Editing Lumbar hernia

== '''Anatomy/pathophysiology''' ==

* Lumbar region in general boundaries: 
** Superiorly 12th rib
** Inferiorly iliac crest
** Medially erector spinae
** Laterally external oblique
* Lumbar hernias occur in either the superior or inferior lumbar triangle
*



== '''Risk factors''' ==

* Inferior - more lateral insertion of external oblique and more medial insertion of latissimus dorsi into iliac crest, making the space bigger
* Superior - length and angle of the 12th rib, and size of quadratus lumborum and serratus posterior muscles. A short, obese person with more horizontal ribs is at risk.

== '''Presentation''' ==

* 80% acquired
** Primary (spontaneous)
*** Usually occur in superior lumbar space
*** Caused by conditions that increase intra-abdominal pressure - chronic cough, pregnancy, obesity
** Secondary (trauma/incisional)
*** Often occur in inferior lumbar space - shearing force of weakened lumbar muscles against iliac crest
* 20% congenital
** Generally appear in infancy
* Only about 10% will present in emergency, mostly elective

== '''Workup''' ==

* CT scan best way to diagnose - 98% sensitivity

== '''Management''' ==

* Generally need mesh coverage due to immobile bony margins
* Both open and laparoscopic possible, but both can be technically challenging
* Cameron's says laparoscopy should be preferred to open technique for initial repair
* Contraindications to laparoscopy:
** Very large defect (>10-15cm)
** Concern for bowel strangulation
** Shock

== '''Technique''' ==

* Open
** Prone
** Incise over mass, at least 2cm below 12th rib, parallel to intercostal nerves
** Reduce sac, open if indicated
** Invaginate sac with absorbable
** Close transversalis fascia
** Synthetic mesh secured to surrounding muscle layers
** Cover mesh with overlying muscle
** Larger defects may require rotational flap repair
* Laparoscopic
** 45 degree decubitus position (see diagram below)
** Umbilical entry
** 5mm ports in ipsilateral upper and lower quadrants
** Reduce sac, reapproximate muscle layers with transfascial suturing device
** IPOM
*** 3-5cm mesh coverage
** TAPP 
*** Three-sided peritoneal flap raised starting 5-7cm anteriorly from the hernia defect




^rotational flap for inferior lumbar hernia using gluteal fascia

[[Category:Abdo wall and retroperitoneum]]