REVIEW ARTICLE Controversies in the Current Management of Lumbar Hernias Alfredo Moreno-Egea, MD; Enrique G. Baena, MD; Miquel C. Calle, MD; Jose´ Antonio T. Martı´nez, MD; Jose´ Luis A. Albasini, MD Background: Abdominal wall surgery has changed dra- lyzed. Nine percent of acquired lumbar hernia cases pre- matically in recent years. The current management of lum- sented for emergency surgery, which means that a clinical bar hernias should reflect the development of modern im- diagnosis was completed with computed tomography in aging techniques and new forms of noninvasive treatment. more than 90% of the cases. None of the published clas- sifications has a therapeutic orientation. We present an Objective: To review and update knowledge on lum- original classification based on 6 categories and 4 types. bar hernias. In our study, there was a predominance of incisional her- nias (79%), with no difference with regard to sex or lo- Data Sources: Literature review using MEDLINE with cation but with a predominance in the upper space (47%). the key words “lumbar hernia” for the years 1950 through Laparoscopic treatment accounts for 9% of the publica- 2004. For an analysis prior to this date (1750-1950), we tions’ cases and there is only 1 prospective comparative used cases reported by Thorek. Our own study of 28 pa- tients was also included. study. Study Selection: All articles reporting clinical cases on Conclusions: The use of a complete classification and lumbar hernia. tomography must be standard practice in the preopera- tive protocol of patients with lumbar hernia. The lapa- Data Extraction: Two reviewers analyzed the epide- roscopic approach seems to be the best option for treat- miological, clinical, and treatment data of the articles. ing small or moderate defects; open surgery can be reserved for large defects and to salvage failures with the Data Synthesis: One hundred thirty-five clinical case laparoscopic approach. articles and 8 studies with more than 5 patients, to- gether with our personal experience of 28 cases, were ana- Arch Surg. 2007;142:82-88 UMBAR HERNIA IS A RELATIVELY search for articles published from 1950 to rare defect of the posterior ab- 2004 using the keywords “lumbar hernia.” dominal wall, with approxi- To complete the historical study prior to mately 300 cases reported in 1950(1730-1950),weusedtablespublished the literature. According to by Thorek2 (Figure 1). An analysis was LHafner et al,1 a general surgeon will only made of 135 clinical case articles and 8 stud- have the opportunity to repair 1 lumbar her- ies with more than 5 patients, together with nia case in his or her lifetime. Today, this our personal experience of 28 cases. situation in many centers has changed with the creation of functional units where pa- HISTORICAL NOTES tients can be centralized and surgeons can gain a greater amount of experience in a P. Barbette was the first to suggest the exis- short period of time. Moreover, abdominal tence of these hernias in 1672, but the first wall surgery has changed dramatically over publication was by R.J.C. Garangeot in 1731. the last decade with the introduction of new In 1750, H. Ravaton performed the first sur- diagnostic techniques, the use of prosthetic gical treatment of a strangulated lumbar her- materials, and the development of laparo- nia in a pregnant woman. The description scopic surgery. The current management of the anatomical limits of the inferior lum- Author Affiliations: Abdominal of lumbar hernias should reflect these bar space was made by Petit (1783) and a Wall Unit, Department of changes, but there is still controversy over description of the superior space was made Surgery (Drs Moreno-Egea and the classification of defects, the appropri- by Grynfeltt (1866). In 1890, J. Macready Albasini), Department of Radiology (Drs Baena and ate preoperative diagnosis with or without observed 25 cases. Two of those cases in- Calle), and Department of the use of computed tomography (CT), and volved the superior lumbar space, which he Surgery (Dr Martı´nez), J. M. the treatment of choice for these hernias. called the “triangle of Grynfeltt-Lesshaft.” Morales Meseguer Hospital, In an attempt to address these points of In 1916, Goodman pointed out the pre- Murcia, Spain. controversy, we conducted a MEDLINE dominance of the inferior space as the most (REPRINTED) ARCH SURG/ VOL 142, JAN 2007 WWW.ARCHSURG.COM 82 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 common site of lumbar hernias, but studies after 1920 show that the superior location is more common (Virgilio, 1925; 2 2,3 Thorek Lumbar Hernia Watson, 1948; and Thorek, 1950 ). (1730-1950) (1950-2004) n = 126 APPLIED SURGICAL ANATOMY n = 785 The lumbar region is defined superiorly by the 12th rib, 22 (17%) 104 (83%) Congential Acquired 157 Animals medially by the erector spinae muscle, inferiorly by the crest 282 Disk Hernias of the iliac bone, and laterally by the external oblique muscle. Knowledge of the composition of the abdominal wall at this 49% Spontaneous 488 Human level is important for a correct orientation both during open 24% Traumatic Lumbar Hernias 17% Infection surgery and in the laparoscopic approach: (1) skin; (2) su- 10% Incisional perficial fascia; (3) superficial muscle layer, comprising the n = 162 latissimus dorsi and external oblique; (4) thoracolumbar fascia; (5) middle muscle layer, with the sacrospinal, in- 16 Imaging Studies ternal oblique, and serratus posterior inferior muscles; (6) 08 Studies With >5 Cases deep muscle layer, which contains the quadratus lumbo- 03 Letters to the Editor rum and psoas muscles; (7) transversalis fascia; (8) pre- peritoneal fat; and (9) peritoneum. This area contains 2 well- 135 defined areas of weakness.3 Clinical Cases Superior Lumbar Triangle 24 (18%) 111 (82%) The Grynfeltt-Lesshaft triangle is larger and more con- Congenital Acquired stant than the inferior lumbar space and is probably the most common location for spontaneous hernias. It is an in- 54% Spontaneous verted space bordered at the base by the 12th rib and lower 13% Traumatic 02% Infection edge of the serratus posterior inferior muscle; the poste- 31% Incisional rior side is formed by the sacrospinal muscle; the anterior is formed by the internal oblique muscle; the roof is formed by the external oblique and latissimus dorsi; and the floor Figure 1. Flow diagram of the MEDLINE reference search. consists of the transversalis fascia and aponeurosis of the transversalis muscle of the abdomen. Three areas of weak- dorsi giving rise to a larger triangle base (common in wom- ness can be found in this space: immediately below the rib en with wide hips), tapering of the internal oblique muscle where the transversalis fascia is not covered by the exter- or its not being completely tendinous, and the presence of nal oblique muscle, in the area of fascial penetration of the the Hartmann fissure at the vertex of the triangle. Unlike the 12th dorsal intercostal neurovascular pedicle, and be- superior space, the inferior space is not penetrated by nerves tween the inferior edge of the rib and the ligament of Henle. or blood vessels that weaken the floor. The predisposition to herniation in this space is ex- tremely variable and depends on the following: size and Diffuse Lumbar Hernias form of the triangle; length and angulation of the rib; size and form of the quadratus lumborum and serratus poste- Occasionally the defects assume considerable sizes and rior muscles; insertion of the latissimus dorsi between the are not limited by the previously mentioned spaces. They 11th and 12th ribs; union of the posterior fibers of the latis- are usually the result of surgical incisions or violent trau- simus dorsi and external oblique; variable insertion of the mas, particularly car crashes. In such cases, the lumbar fibers of the external oblique above the 12th rib; and whether spaces usually move into the parietal cicatricial defect and the internal oblique muscle is muscular or aponeurotic at extend beyond the boundaries of the anatomical lumbar its insertion above the 12th rib (a tall, thin person with an- space to invade the edge of the anterior rectus muscle.4 gulated final ribs will have a smaller superior lumbar space than a short, obese person with horizontal ribs). ETIOPATHOGENESIS Inferior Lumbar Triangle Lumber hernias may be congenital and acquired. Con- genital hernias appear during infancy as the origin of a The Petit triangle is smaller and bordered by the crest of the defect in the musculoskeletal system of the lumbar re- iliac bone at the base, the external oblique muscle laterally, gion and are associated with other malformations. Ac- and the latissimus dorsi muscle medially; the floor is formed quired lumbar hernias are usually primary—or sponta- by the lumbodorsal fascia adjacent to the aponeurosis of the neous—and secondary, depending on the existence of a internal oblique and transversalis muscle. Occasionally the causal factor such as surgery, infection, or trauma. Pre- edges of the latissimus dorsi and external oblique muscles disposing factors in spontaneous acquired lumbar her- may be adjoining and close the space. Predisposing factors nia are age, obesity, extreme thinness, chronic debilitat- to herniation in this space may be alterations in the origin ing disease, muscular atrophy, intense slimming, chronic of the external oblique muscle and a more medial latissimus bronchitis, wound infection, and postoperative sepsis. (REPRINTED) ARCH SURG/ VOL 142, JAN 2007 WWW.ARCHSURG.COM 83 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 Table 1. Classification of Lumbar Hernias Into 4 Types Based on 6 Criteria* Characteristic A B C D (Pseudohernia) Size, cm Ͻ5 5-15 Ͼ15 Location Superior Inferior Diffuse Contents EP fat Visceral Visceral Etiology Spontaneous Incisional Traumatic Muscular atrophy No (minor) Mild Severe Severe Recurrence No Yes (open) Yes (laparoscopy) Surgical approach Open approach EP, TEP laparoscopy IP laparoscopy Open approach Open approach (double mesh) Abbreviations: EP, extraperitoneal; IP, intraperitoneal; TEP, total extraperitoneal.