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Table of Contents
CASE REPORTS
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 125-127

Recurrence lumbar lipoma: Misdiagnosis of a Grynfelt-Lesshaft hernia: Case report


Department of Surgery, Morales Meseguer University Hospital, IMIB-Arrixaca, Murcia, Spain

Date of Submission19-Jan-2021
Date of Decision08-Feb-2021
Date of Acceptance05-Mar-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Dr. Sergio Annese
General Surgery Service, Morales Meseguer University Hospital, Av Marqués de los Vélez, s/n, 30008, Murcia.
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_5_21

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  Abstract 

Lumbar hernias of the lateroposterior abdominal wall have a low prevalence, being described in the scientific literature as sporadic cases or short series. Initially, they manifest as a painless tumor that can be confused with other more frequent pathologies such as soft-tissue tumors, lipomas, hematomas, or abscesses. We present the case of a 72-year-old female patient who, after removal of a lumbar lipoma by dermatology, was referred to our clinic for recurrence of tumor. An ultrasound scan showed a recurrence of the lipoma. The anamnesis and physical examination suggested lumbar hernia. Computerized axial tomography scan confirmed the clinical diagnosis, and surgery was indicated.

Keywords: Grynfelt’s hernia, infrequent hernias, lumbar hernia


How to cite this article:
Liron R, Annese S, Baeza M, Betoret L. Recurrence lumbar lipoma: Misdiagnosis of a Grynfelt-Lesshaft hernia: Case report. Int J Abdom Wall Hernia Surg 2021;4:125-7

How to cite this URL:
Liron R, Annese S, Baeza M, Betoret L. Recurrence lumbar lipoma: Misdiagnosis of a Grynfelt-Lesshaft hernia: Case report. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Dec 6];4:125-7. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/3/89/327068




  Introduction Top


Barbette in 1672 first suggested the existence of lumbar hernia and Garangeot published the first case in 1731. Anatomically described by Petit (1783) Grynfelt (1866) and Lesshaft (1870),[1] Fewer than 300 cases have been described worldwide due to their rarity. They are currently a challenge diagnosis. We present a case of Grynfeltt’s hernia misdiagnosed as a recurrence lipoma, highlighting the role of proper clinical examination.


  Case Report Top


A 72-year-old female medical background of depressive syndrome in treatment. Surgical history: Bilateral inguinal hernioplasty and removal of a left lumbar lipoma by dermatology (pathological anatomy confirms the diagnosis). Consultation due to persistence of postoperative left lumbar tumor. Initially asymptomatic, but after a few weeks she presented increased volume and occasional colicky abdominal pain. Physical examination: body mass index: 29.34. Bipedent: left lateral lumbar tumor below the 12th rib, soft, painless, not very mobile and increasing with Valsalva maneuvers. Prone position: the tumor disappears. Clinical history and exploratory findings suggest Grynfelt’s lumbar hernia. Abdominal computed tomography (CT) confirms our clinical suspicion [Figure 1].
Figure 1: (a) Hernia axial reconstruction. (b) Green: internal oblique muscle, Red: hernial orifice, Yellow: fat with hernial sac, Black: 12th rib, Purple: quadratus lumborum muscle

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Marking the tumor: right lateral decubitus. General anesthesia. Transverse incision, opening of the latissimus dorsal with extrusion of retroperitoneal fat and hernia sac through a 3–4 cm hole, invagination of the content, hernia orifice closure with continuous monofilament suture, placement of 8 cm × 6 cm polypropylene mesh over the sutured orifice with cranial loose stitches fixation on the 12th rib, lateral on the internal oblique and medial on the quadratus lumborum [Figure 2] and closure by planes. Operation time: 35min. Postsurgery: Hospital discharge after 48 hours. Postoperative review at 6 months without any complications.
Figure 2: (a) Lipoma and hernial sac content. (b) Prosthetic mesh repair

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  Discussion Top


Lumbar hernias develop in a large anatomical space, superiorly limited by the 12th rib, inferiorly by the iliac crest, medially by the vertebral canal muscles, and laterally by the external oblique muscle. Divided into two triangles: Grynfelt’s superior, more frequent, deep, large, inverted, and constant, limited by the 12th rib, quadratus lumborum and internal oblique; and Petit’s inferior, less frequent, vertical and superficial, limited by the iliac crest, latissimus dorsi muscle and external oblique muscle.[1],[2] Three areas of anatomic weakness have been described in hernias of the superior triangle: (1) immediately below the 12th rib, where the transverse fascia does not carry oblique muscle reinforcement; (2) vasculonervous penetration orifice of the 12th rib; and (3) inferior border of the 12th rib attached to the ligament of Henle.[2],[3] In the literature review, little information is found due to their low incidence; Hafner et al.: state that many experienced surgeons will be able to operate on only one lumbar hernia during their professional practice.[4] Congenital in 20% (musculoskeletal defect in the lumbar region and/or associated with other congenital malformations) or acquired (80%) divided into primary (anatomical weakness, age, obesity, etc.,) and secondary (infections, trauma, previous surgeries, etc.,) which are the most frequent nowadays.[4],[5] Usually, unilateral, between fifth and sixth decades, more frequent in men, appear as a painless tumor, although they sometimes cause unspecific local pain, with reduction or disappearance of the tumor on prone decubitus, increasing with exertion or Valsalva and are usually reducible.[5],[6] We highlight the importance of a thorough anamnesis, a correct physical examination and knowledge of this anatomical area as potentially herniogenic. The infrequency of presentation is a factor that hinders diagnostic suspicion.

Presentation as incarceration or strangulation is infrequent, and differential diagnosis should be made with abscesses, hematomas, tumors (lipomas, soft tissue, and renal), which are more common pathologies in this location.[6],[7] We emphasize that a detailed anamnesis will guide us in this differential diagnosis. Our case shows that ultrasound is not the recommended imaging technique, despite having been performed by a medical ultrasound expert, who in our case identified the hernia content of retroperitoneal fat as a lipoma. Gold standard diagnostic is the abdominal CT with oral and intravenous contrast, more sensitive, and specific, which allows: delimitation of muscular planes, differentiation of muscular atrophy (pseudohernia), identification of content, and ruling out tumors. An imaging classification has been created according to the size of the hernial orifice, Type I: small, <5 cm; Type II intermediate, 5–15 cm; Type III large, >15 cm; Type IV: absence of triangle. Thorek classifies them according to their content: (1) without peritoneal sac (extraperitoneal); (2) slipped (paraperitoneal); and (3) sac surrounding the visceral content (intraperitoneal).[8] We believe that the Moreno-Egea classification, which distinguishes 4 types of hernias of increasing clinical complexity (A, B, C, and D) based on six criteria (size, location, content, origin, existence of muscular atrophy, and previous recurrence) may be useful for therapeutic purposes [Table 1]. Surgical treatment is mesh repair, abandoning the use of myoplasty. Currently, the transabdominal or extraperitoneal laparoscopic approach is preferable for small hernias, but in the case of larger defects, open repair with mesh or double mesh is recommended.[9] The main reason for open surgery was the lack of experience of the surgical team in this type of hernia, also the case could be resolved with a small incision that allowed correct closure of the hernial orifice and placement of the mesh, avoiding possible intra-abdominal access.
Table 1: Classification of lumbar hernias into 4 types based on 6 criteria*

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Moreno-Egea A. Hernia y Eventración Lumbar: Manejo Quirúrgico. In: Carbonell F, Moreno-Egea A. Eventraciones y otras hernias de la cavidad y pared abdominal. Valencia: Grafiques Vimar; 2012.  Back to cited text no. 1
    
2.
Kadler B, Shetye A, Patten DK, Al-Nowfal A. A primary inferior lumbar hernia misdiagnosed as a lipoma. Ann R Coll Surg Engl 2019;101:e96-8.  Back to cited text no. 2
    
3.
Ploneda-Valencia CF, Cordero-Estrada E, Castañeda-González LG, Sainz-Escarrega VH, Varela-Muñoz O, De la Cerda-Trujillo LF, et al. Grynfelt-Lesshaft hernia a case report and review of the literature. Ann Med Surg (Lond) 2016;7:104-6.  Back to cited text no. 3
    
4.
Cesar D, Valadão M, Murrahe RJ. Grynfelt hernia: Case report and literature review. Hernia 2012;16:107-11.  Back to cited text no. 4
    
5.
Sarwal A, Sharma A, Khullar R, Soni V, Baijal M, Chowbey P. Primary lumbar hernia: A rare case report and a review of the literature. Asian J Endosc Surg 2019;12:197-200.  Back to cited text no. 5
    
6.
Satorras-Fioretti AM, Vázquez-Cancelo J, Pigni-Benzo L, Salem A and Ramos-Ardá A Hernias of the abdominal wall of rare location. Cir Esp 2006;79:180-183.  Back to cited text no. 6
    
7.
Macchi V, Porzionato A, Morra A, Picardi EEE, Stecco C, Loukas M, et al. The triangles of Grynfeltt and Petit and the lumbar tunnel: An anatomo-radiologic study. Hernia 2017;21:369-76.  Back to cited text no. 7
    
8.
Martín J, Mellado JM, Solanas S, Yanguas N, Salceda J, Cozcolluela MR. MDCT of abdominal wall lumbar hernias: Anatomical review, pathologic findings and differential diagnosis. Surg Radiol Anat 2012;34:455-63.  Back to cited text no. 8
    
9.
Moreno-Egea A, Baena EG, Calle MC, Martínez JA, Albasini JL. Controversies in the current management of lumbar hernias. Arch Surg 2007;142:82-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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