Case Report

A 39-year-old farmer by profession reported dull pain (3–4/10 on the Visual Analogue Scale) in the left lumbar area for one year. An orthopaedic surgeon had previously examined him, ruling out any conditions that would have caused pain. Occasionally, he would use over-the-counter pain relievers. There was no other medical or surgical history of significance in the past. On examination, there was no spinal or lumbar deformity, and the renal angles were not tender. The cough impulse over and inferior to the left renal angle was, however, barely palpable.

Figure 1: Ultrasound (USG ) image showing defect in posterior fascia (red arrows) leading to fatty left lumbar hernia (blue arrows).

An ultrasound study of the left lumbar area revealed a defect in the posterior fascia with herniation of extraperitoneal fat (Figure 1), which increased with the Valsalva manoeuvre. The neck of the hernia measured approximately 13mm. There was no herniation of bowel loops or other viscera. There was no defect on the right side. A diagnosis of Grynfelt-Lesshaft hernia was made, and due to a lack of management experience with this rare condition, the patient was attached to the services of a tertiary healthcare facility, where further imaging by MRI and open hernioplasty with mesh implantation were successfully undertaken. At the three-year follow-up, the patient was satisfied and symptom-free.

Figure 2: Schematic diagram of anatomy of lumbar area depicting superior lumbar triangle (red colour) and inferior lumbar triangle (blue colour)

Discussion

Grynfelt-Lesshaft hernia appears along the posterolateral abdominal wall in the superior lumbar triangle (shown in red in Figure 2), which is located posterior to the lower pole of the left kidney. Posterior (superficial) to this hernia is the latissimus dorsi muscle, medial to it is the quadratus lumborum muscle, and superior relation is formed by the 12th rib [1]. In contrast, the inferior lumbar triangle (shown in blue in Figure 2) is bounded by the latissimus dorsi posteriorly, the external oblique aponeurosis anteriorly, and the iliac crest inferiorly [1].

It is a rare condition, with only about 300 cases published in the peer-reviewed literature, and most physicians are not exposed to it during their training [2]. As a result, physicians frequently fail to recognize this hernia or misdiagnose it as a lipoma, which causes treatment delays and an increase in morbidity [3]. Barbette had suggested the possibility of lumbar hernias in 1672, and the first case was reported by Garangeot in 1731. The boundaries of the inferior and superior lumbar triangles were delineated by Petit and Grynfeltt in 1783 and 1866, respectively [4].

On the basis of origin, lumbar hernias have been classified as congenital (20%) or acquired (80%). The congenital hernias are believed to form during embryologic development, when the invasion of the somatopleure by the aponeuroses of the layered abdominal muscles results in the creation of potentially weak areas If acquired, the hernias may be either primary (55%) or else secondary (25%) [4]. The most common cause of primarily acquired lumbar hernias is increased intra-abdominal pressure, with predisposing factors such as old age, chronic lung disease, extremes of weight, muscular atrophy, and professions that involve lumbar constraints. Secondarily acquired lumbar hernias are associated with trauma, prior surgical incisions, and infection or abscess formation [1,4].

The patient may be asymptomatic or else present with discomfort, dragging sensations, flank swelling, and, rarely, gut obstruction. These hernias may grow to huge dimensions and have an inherent tendency of getting larger over time. Retroperitoneal fat, kidney, colon, or, less frequently, small bowel, omentum, ovary, spleen, or appendix, may be contained in the hernia [4]. Impulses on coughing may be visible or palpable over the hernia, and if it contains bowel loops, auscultation may reveal audible bowel sounds over it.

In the presented case, the hernia was documented by ultrasonography, though this modality may fail to detect the hernia due to the presence of body fat in this region and a lower index of suspicion [4]. CT-scan and MRI studies can lead to accurate diagnosis by proper delineation of the anatomy and identification of defects in the muscular and fascial layers [4]. These imaging modalities can also distinguish a hernia from other differential diagnoses, such as hematoma, abscess, or soft-tissue tumour [5].

Surgical repair of these hernias should be undertaken as early as possible to avoid incarceration and strangulation [4]. Bowel incarceration is reported in 25% of cases, though strangulation is rare due to the wideness of the hernial neck [4]. Eliminating the defect and building a sturdy, elastic abdominal wall that can sustain the strain of regular physical activity are the two main objectives of hernia repair [4]. Due to the rarity of this hernia, there is no clear consensus on the type of repair, but the classic repair published in the literature uses the open surgical approach, where tension-free closure of the defect is performed either directly or using prosthetic mesh [6]. A transabdominal or extraperitoneal laparoscopic approach are the alternatives. It is advantageous for the mesh to be positioned extra-peritoneally since no bony anchorage is required. The sound physiological principle of diffusion of the entire intra-abdominal pressure on each square inch of the implanted mesh serves as the foundation for laparoscopic transabdominal preperitoneal mesh repair, which has also been documented in the literature [7]. It is a tensionless repair that offers the patient rapid recuperation and improved cosmesis.

There is a proposal by some experts to base the surgical approach on a classification that takes into account six characteristics of the hernia: size, location, content, aetiology, muscular atrophy, and the existence or otherwise of a recurrence [8]. If the patient reports bowel obstruction and there is doubt about the viability of the bowel, laparotomy has been suggested as a surgical approach to allow resection of the non-viable bowel and adequate peritoneal lavage [9].

Acknowledgements

The patient's consent to the publication of this case study and its accompanying images is gratefully acknowledged by the author.

References

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