The Retroperitoneoscopic Repair of a Lumbar Hernia of

Acta chir belg, 2004, 104, 330-334
The Retroperitoneoscopic Repair of a Lumbar Hernia of Petit
Case report and Review of Literature
A. Grauls*, B. Lallemand*, M. Krick**
Department of Surgery, St Joseph Hospital*, Liège and O.L.V. Hospital**, Asse, Belgium.
Key words. Hernia ; Petit ; inferior lumbar triangle ; retroperitoneoscopy ; Marlex.
Abstract. In this paper, we comment on a patient who consulted us because of his «lower backpain» together with the
appearance of a small swelling at the left side. Anamnesis and clinical examination were suggestive and further simple
diagnostic methods confirmed the exceptional diagnosis of a «lumbar hernia of Petit». We describe the retroperitoneoscopic approach of this hernia, its reduction and the fixation of a polypropylene mesh at the surrounding structures with
a Tacker. This approach provided a good postoperative comfort, a shorter hospital stay and an early recovery of autonomy and activity.
Furthermore, we give a review of the literature concerning lumbar hernias and the evolution of the different reconstruction techniques.
With only 250 to 300 cases reported in the literature (13), lumbar hernias are rare defects that involve the
extrusion of retroperitoneal fat or viscera through a
weakness in the posterolateral abdominal wall (1).
Within this region there are two anatomically defined
weaker triangles, «the triangle of Petit» and «the triangle of Grynfelt-Lesshaft» (7-8). The “triangle of Petit”
or “the inferior lumbar triangle” is an upright triangle
bound by the crista ilica, the musculus obliquus externus
and the musculus latissimus dorsi (Fig. 7 and Fig. 8).
The superior lumbar triangle is an inverted triangle bordered by the 12th rib, the musculus serratus posterior
inferior, the musculus quadratus lumborum, the musculus erector spinae and the musculus obliquus internus (1,
4-6, 8).
The most common clinical sign presenting a lumbar
hernia is a posterior protruding bulge found by the
patient. It may be asymptomatic, associated with a sense
of discomfort, or the cause of notable localized tenderness (1, 5-6). -We distinguish a reducible from a nonreducible hernia ; 25% of the spontaneous lumbar hernias have an incarcerated content, with an overall stangulation risk of 8% (1). Because lumbar hernias are rare,
the differential diagnosis must be made with a lipoma, a
soft tissue tumour, a haematoma, an abcess, an atheromatous cyst, a renal tumour, a panniculitis and a muscle
Repairing these lumbar hernias is often difficult
because of the weakness of the surrounding structures
(1, 10-12). Many different «open» surgical techniques
have been used to repair the defect and since several
years the laparoscopic approach has been successful (13, 8, 10, 12). We repaired a lumbar hernia of Petit
Case Report
A 49-year old man of Iraqui origin had a history of lower
backpain of 3 days duration. The pain was localized on
lumbar level, radiating to the left flank and increasing by
lifting heavy objects. Herewith the patient felt a small
swelling in the left flank, which was slightly painful at
night when lying on that side. The patient reported that
the soreness was accentuated with hard physical efforts.
His medical history was notable for the resection of an
atheromatous cyst of the back in 1996, acute backache
treated with a support bandage in 1998, and the resection of an abscess of the back on 08-02-1999. The
patient smoked one packet of cigarettes a day and he was
obese. By clinical examination, we found a visible
swelling in the left flank, at the triangle of Petit, with a
diameter of 2.5 cm. By percussion, we found dullness
over the swelling and palpation revealed a supple, well
defined and reducible mass, increasing by Valsalva and
reducing while lying down. In spite of a suggestive
anamnesis and clinical examination, we made an ultrasound of the lumbar region, because of the rareness of
lumbar hernias. This way we could differentiate the lumbar hernia from other pathologies. Excluding vertebral
pathologies, we made X-rays of the lumbar and thoracic
The Retroperitoneoscopic Repair
Fig. 1
CT-scan with double contrast at the level of the triangle of
Petit : visualization of a lumbar hernia, containing intraperitoneal fat (arrow).
vertebrae, on which we could not visualize any relevant
anomalies. We made a contrast CT-scan of the abdomen
(Fig. 1), in order to visualize the contents of the hernial
sack and the relation with the surrounding structures. A
lumbar hernia, containing intraperitoneal fat, with a
maximal diameter of 5 cm, was visualized at the level of
the triangle of Petit.
Under general anaesthesia we performed a retroperitoneoscopic repair of the defect, with a polypropylene
Marlex prosthesis, one month after the first consultation.
The patient was placed in a semilateral position, on
his right side, which optimized exposure and allowed the
viscera to fall away from the operative field (Fig. 2). A
small incision was made under the tip of the 12th rib to
accommodate a 12 mm distention balloon, placed into
the retroperitoneal space. By insufflation, the retroperitoneal space could be dissected. The distention balloon
was replaced by a 10 mm structural trocar, and with an
extra 5 mm trocar near the 11th rib, the retroperitoneal
dissection was continued towards the lateral border of
the left rectus sheath. A 10 mm trocar was introduced at
the umbilicus and a final 5 mm trocar at the left fossa
iliaca (Fig. 3). The camera was displaced to the 10 mm
trocar at the umbilicus. After dissection of the posterior
part of the retroperitoneal space, the defect, with a
maximal diameter of 5 cm, was visualized (Fig. 4). The
hernia, containing intraperitoneal fat, was reduced and
the borders of the opening were cleared. A 15 15 cm
Marlex mesh was used to occlude the defect, and it was
fixed with the Tacker at the crista iliaca, the musculus
quadratus lumborum and the musculus transversus
abdominis (Fig. 5). A redon drainage was placed.
The postoperative sequelae were uneventful, and the
patient was discharged on the 5th postoperative day. Six
weeks later he could resume work, without any com-
Fig. 2
Position of the patient during the operation : the semilateral
position, on the right side, optimized the exposure and allowed
the viscera to fall away from the operative field.
plaints. During 24 months of follow-up, neither recurrence of hernia nor any related complaints were recorded. Both the ultrasound examinations and the CT-scan,
performed after 12 months (Fig. 6), were negative.
Our patient had a reducible, non incarcerated lumbar
hernia at the triangle of Petit. The ultrasound and the
CT-scan could confirm the suggestive anamnesis and
clinical examination. We successfully performed a
retroperitoneoscopic repair of the defect, which provided good postoperative comfort, a short hospital stay and
an early recovery of autonomy and daily activities.
There are several classifications on lumbar hernias,
made according to the origin, the anatomical localization
and the contents of the hernia. We distinguish a congenital hernia from an acquired form, which can arise primary or secondary after surgery, infection or trauma. On
localization we differentiate diffuse lumbar hernias from
the hernias localized within the superior or inferior lumbar triangle. Furthermore, lumbar hernias differ from
each other by the contents of its hernial sac (1, 8, 13).
Because lumbar hernias seldom cause strangulation,
the prognosis is often good. However, their volume
increases progressively and they become more symptomatic. The larger the hernia, the more difficult the operation. That is why most of the hernias should be operated
as soon as the diagnosis has been made (1-5). After the
hernial sac and its contents are identified and reduced,
the recontruction of the defect can be performed. This
reconstruction is difficult because of the weakness of the
surrounding tissues and because of the complicated
anatomical boundaries (1, 8, 10-12). A preoperative CTscan should be made, with attention to the colon and the
urinary tract (1, 4, 6-7, 9, 13).
Fig. 3
Position of the 4 trocars : 1 : at the tip of the 12th rib ; 2 : cranial and anterior from the 11th rib ; 3 : at the umbilicus ; 4 : at
the left fossa iliaca.
Fig. 4
Endoscopic visualization of the anatomical defect, bounded by
the crista iliaca and the musculus quadratus lumborum.
Over the years, several reconstruction techniques for
lumbar hernias have been described. Primary closure has
been tried, but was often inadequate for repair. Probably
the most cited and certainly an adequate repair in most
lumbar hernias is the classical reconstruction technique
described by DOWD in 1907 (4, 8) (Fig. 9).
DOWD turned up a flap from the fascia lata and the
aponeurosis of the musculus gluteus maximus and
sutured it to the lumbar fascia, the musculus obliquus
externus and the musculus latissimus dorsi. WARBASSE
modified DOWD technique by undercutting the transversalis so that it could be imbricated without tension
(Fig. 10). RISHMILLER split the musculus latissimus dorsi
and slid it over the defect as a flap. He reinforced the
repair by approximating the musculus obliquus externus
and the musculus latissimus dorsi (Fig. 11). Probably the
first use of free fascial grafts in lumbar repair was made
A. Grauls et al.
Fig. 5
Endoscopic visualization of the Marlex mesh, fixed with the
Fig. 6
CT-scan at the level of the triangle of Petit, performed
12 months postoperatively : No recidive hernia can be detected. We notice the Tacker fixation points at the musculus quadratus lumborum (red arrow) and the musculus transverses
abdominis (blue arrow)
by RAVDIN in 1923. He closed the transversalis defect
and reinforced it with a free fascia graft, taken from the
fascia lata. In 1954, SWARTZ described the use of free fascia lata strips to approximate and close the defect in
small and moderate-sized lumbar hernias (Fig. 12).
KOONTZ described mobilization of massive flaps of fascia lata and lumbar fascia to reinforce massive
defects (8).
Because all these methods required large planes of
dissection and had the potential disadvantage of creating
flaps with compromised vascularization, the use of prosthetic meshes was introduced. But this technique also
required a large incision, dissection and exploration (2,
4, 8, 13).
The Retroperitoneoscopic Repair
Fig. 9
DOWD technique included mobilization of a flap of the musculus. gluteus maximus and the fascia lata, approximation of the
musculus obliquus externus and the musculus latissimus dorsi
and reinforcement with a facial flap from the musculus latissimus dorsi. Many subsequent techniques are modifications of
this original procedure (8).
Fig. 7
Inferior lumbar triangle : LD : musculus latissimus dorsi ; EO :
musculus obliquus externus ; IC : crista iliaca ; GM : musculus
gluteus maximus ; ILT : inferior lumbar triangle ; B : crosssectionpoint of Figure 8.
Fig. 10
WARBASSE modified DOWD repair by imbricating the transversalis and covering the defect with a flap turned up from the fascia lata and the m. gluteus maximus (8).
Fig. 8
Inferior lumbar triangle, section across point B of Figure 10 :
Above : normal anatomy. Under : hernia. PS : musculus
psoas ; QL : musculus quadratus lumborum ; SS : musculus
sacrospinalis ; LDF : lumbodorsal fascia ; P : peritoneum ;
TF : transversal fascia ; TA : musculus transversus abdominis ;
IO : musculus obliquus internus ; EO : musculus obliquus
externus ; LD : musculus latissimus dorsi ; HS : hernial sac.
Fig. 11
RISHMILLER slid over a flap from the free border of the musculus latissimus dorsi and reinforced the repair by approximating
the musculus latissimus dorsi and the musculus obliquus externus (8).
Since several years, lumbar hernias have been successfully repaired laparoscopically. This approach
allows an exact visualization of the anatomical defect so
that damage to boundary structures, such as the ureter
and nerves, can be avoided. It is minimal invasive, with
less postoperative pain, a minimal morbidity, a shortened hospital stay, better cosmetic results and minimal
lifestyle intrusion (1-2, 4, 10-12).
Since this transabdominal approach needs a strong
transmuscular fixation of the intraabdominal mesh we
looked for another approach, avoiding transmuscular
stitches and direct contact between the mesh and the
intraperitoneal content (1-2, 4).
We used this retroperitoneoscopic technique without
entering the peritoneal cavity, and we fixed a Marlex
mesh with a Tacker, as seen in preperitoneal inguinal
hernia repair.
We could conclude that this technique is safely feasible, with an excellent postoperative result. Our patient
had little or no pain and 24 months of follow-up could
not reveal recurrence.
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A. Grauls
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