LARGE LUMBAR HERNIA: A DIFFICULT AND UNCOMMON PROBLEM

Objectives: A lumbar hernia is either a congenital or acquired lateral abdominal wall hernia, and it is defined based on whether it occurs in the superior or inferior lumbar triangle. Repair is accomplished using mesh with either open or laparoscopic approach. While uncommon, understanding the options for repair is critical for optimal patient outcome. In this case, we present a patient with a large lumbar hernia that was repaired successfully with a complex open approach.
A 59-year-old obese female was initially admitted to the Trauma Service after motor vehicle collision. The patient was noted to have a complex right lower abdomen laceration and subcutaneous degloving injury adjacent to the iliac crest consistent with seat belt injury. Computed topography (CT) scan revealed an 8.8cm traumatic right-sided lumbar hernia without other intraperitoneal pathology. The abdominal wall wound was treated with negative-pressure wound therapy. The lumbar hernia was not repaired acutely to allow for healing of the overlying wound. The patient elected for remote outpatient repair. She lost 60 pounds in preparation for her elective repair. Repeat CT obtained for pre-operative planning demonstrated that the original defect enlarged to 10 cm and contained fat, colon, and small bowel.
The patient was positioned supine with a 30° bump and a midline laparotomy was performed. After mobilization of the right colon, an 11cm x 5cm hernia defect was encountered beginning at the iliac crest and ending just inferior to the lower pole of the right kidney. The hernia sac and contents were reduced. A retrorectus plane was created from below the right iliac crest and superiorly to the ribs by releasing the transversalis fascia laterally. A polypropylene mesh was placed in the retrorectus space overlying the iliac crest and costal margin. The hernia sac was then tacked to the borders of the defect to cover the polypropylene mesh. A biologic mesh underlay mesh was placed to further bolster the repair. Two closed Blake drains were placed in the retrorectus space to help control potential seroma. Post-operatively, the patient progressed well and at follow-up, has had no complications from the hernia repair. She continues to have no recurrence and is doing well.
Lumbar hernias are rare and can be challenging to repair. This case demonstrates a complex, open surgical approach to repair a large traumatic lumbar hernia not amenable to laparoscopic repair.

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