Pure laparoscopic bilateral arcuate line hernia repair (with video).

An arcuate line hernia is a generally asymptomatic, ascending protrusion of intraperitoneal structures over the linea arcuata. Arcuate line herniae are scarcely reported in the literature. Only a few publications were found. No clear descriptions of the techniques for repair have been published either. We aim to provide diagnostic images and illustrate our method to repair this hernia.

Hernia lumbar de Grynfeltt-Lesshaft / Grynfeltt-Lesshaft lumbar hernias

RESUMEN Las hernias lumbares son defectos infrecuentes de la pared abdominal con pocos casos publicados en la literatura. En la región lumbar existen dos zonas de debilidad, un triángulo superior de Grynfeltt y otro inferior de Petit. Se presenta el caso de una mujer que consultó por dolor y tumoración lumbar derecha. Ante sospecha de hernia lumbar se realizó una tomografía computarizada que informó una hernia de Grynfeltt con contenido de grasa retroperitoneal. Se realizó una plástica protésica por abordaje abierto. No se observaron complicaciones post posoperatorias. Las hernias lumbares pueden ser congénitas o adquiridas, y estas primarias o secundarias. La tomografía computarizada (TC) es el procedimiento de referencia (gold standard) para su diagnóstico. La plástica protésica es el tratamiento de elección. El abordaje abierto y laparoscópico constituyen opciones válidas, y se deben valorar según las características del defecto, el paciente y la experiencia del equipo quirúrgico para su selección.

ABSTRACT Lumbar hernias are rare abdominal wall defects with few cases published in the literature. Two welldefined areas of weakness are identified in the lumbar region, the superior lumbar (Grynfeltt-Lesshaft) triangle and the inferior lumbar (Petit) triangle. We report the case of a female patient who sought medical care due to low back pain and a tumor in the right lumbar region. A lumbar hernia was suspected, and a computed tomography scan was performed, which revealed a Grynfeltt hernia with retroperitoneal fat content. The defect was repaired with mesh placement through an open approach. There were no postoperative complications. Lumbar hernias can be congenital or acquired (primary or secondary). Computed tomography scan is the gold standard for the diagnosis. Mesh repair is the treatment of choice. The open approach and laparoscopy are valid and safe options, and their implementation should be considered based on the characteristics of the defect, the patient, and the experience of the treating team.

Hernia de la línea arcuata, una patología poco difundida

La hernia de la línea arcuata (HLA), es una entidad claramente reconocida, sin embargo, existen escasas publicaciones al respecto. Corresponde a un defecto en la vaina posterior del músculo recto del abdomen, separándose la línea arcuata del musculo, formando un bolsillo, lo que corresponde a un defecto inter-parietal y no una verdadera hernia. Probablemente este subdiagnosticado y sub reportado. Su relevancia es que puede constituir una parte relevante de las consultas en servicio de urgencia por dolor abdominal sin etiología demostrada1. El diagnóstico debe sospecharse ante la presencia de dolor abdominal de tipo orgánico, sin otra etiología demostrada. Se confirma con imágenes, especialmente la tomografía computada. El tratamiento, apoyándose en lo reportado en la literatura, sugiere que la vía laparoscópica sería de elección. A continuación, analizamos la anatomía de la linea arcuata, la presentación clínica de esta afección, sus hallazgos imagenológicos, quirúrgicos, y las diferentes alternativas de tratamiento que se han propuesto en la literatura.

The arcuate line hernia is a clearly recognized entity, but of which little is mentioned. It corresponds to a defect in the posterior wall of the rectus abdominis, separating the arcuate line of the muscle, forming a pocket, which corresponds to an interparietal defect and not a true hernia. It is probably underdiagnosed and underreported. Its relevance is that it can constitute a significant part of the consultations in the emergency department for abdominal pain without proven etiology. The diagnosis should be suspected in the presence of organic abdominal pain, with no other proven etiology. It is confirmed with images, especially computed tomography. The treatment, based on what has been reported in the literature, suggests that the laparoscopic approach should be the choice. We analyze the anatomy of the arcuate line, its clinical presentation, imaging and surgical findings, and the different treatment alternatives that have been proposed in the literature.

Incarcerated left-sided Amyand's hernia and synchronous ipsilateral femoral hernia: first case report.

BACKGROUND: The finding of a vermiform appendix within the peritoneal sac of an inguinal hernia is called Amyand's hernia. The reported incidence of Amyand's hernia and femoral hernia is 1% and 3.8%, respectively. To our knowledge, no cases have been reported in the literature that associate these two entities. We present the first case of incarcerated left-sided Amyand's hernia and synchronous ipsilateral femoral hernia found during emergency surgery. CASE PRESENTATION: A 72-year-old woman was admitted to the Emergency Department for a complicated left inguinal hernia. An inguinotomy was performed that detected a large direct hernial sac and a synchronous femoral hernia. The opening of the inguinal hernia showed the presence of the cecum and the appendix, both without signs of inflammation. The femoral space was evaluated transinguinally, identifying the larger omentum that had slipped into the femoral canal. The primary closure of the posterior wall defect was performed with the McVay technique due to its large size, and then the hernioplasty was completed with a polypropylene mesh. No postoperative complications were reported. CONCLUSIONS: In the context of an incarcerated Amyand's hernia, the decision to perform an appendectomy in addition to hernia repair with or without mesh will depend on intraoperative findings.

Mesh repair for lateral inguinal hernias: a non-evidence-based practice.

INTRODUCTION: The EHS clinical guidelines recommend the use of mesh to repair symptomatic primary inguinal hernias (PIH) in adult males but, in spite of this, it begs the question as to why there is still place for tissue techniques. Lack of stratification of patients according to risk of recurrence in RCTs might be a cause of results disparity, since medial and mixed are hernias with higher risk of recurrence (HRRH), whereas lateral hernias present a lower risk (LRRH). OBJECTIVE: To determine whether the lack of stratification may lead to questionable conclusions regarding the protective effect of mesh techniques and to identify other methodological flaws. METHODS: In the RCTs included in the clinical guidelines that addressed recurrences of PIH after mesh and non-mesh techniques, we assessed the type of hernias classification used, the number needed to treat in LRRH and HRRH and the statistical power. RESULTS: Most of trials were underpowered; five studies classified the hernia types; in the three studies that compared the recurrence rates of LRRH and HRRH the effect of mesh techniques was small; only two trials record data needed to calculate the NNT in LRRH (46 y 84 patients, respectively). CONCLUSION: The idea that mesh techniques reduce the recurrence rate in all PIHs is not supported by high level of evidence. The NNT for pure lateral hernias was very high and should be interpreted taking into account chronic pain rates and costs.

A multicenter, randomized trial comparing pelvic organ prolapse surgical treatment with native tissue and synthetic mesh: A 5-year follow-up study.

INTRODUCTION: The aim of this study was to compare long-term outcomes in patients who underwent either native tissue repair or monofilament macroporous polypropylene mesh. METHODS: This multicenter, randomized trial included-at the end of 5 years follow-up-122 women with severe pelvic organ prolapse, who were randomly assigned to undergo surgical treatment using native tissue repair (native tissue group, n = 59) or synthetic mesh repair (mesh group, n = 63). Cure criterion was when pelvic organ prolapse-quantification (POP-Q) point was ≤0. Quality of life was assessed using the prolapse quality-of-life questionnaire and sexual function with the quality of sexual function. RESULTS: Groups were homogeneous preoperatively with the exception of the previous pelvic surgery variable, which was higher in mesh (P = .019). Cure rate was significantly better for mesh group in the anterior compartment (P = .002) and in the combination of all compartments (P = .001). Native tissue group was significantly better when there was prolapse in the posterior and apical compartment (P = .031). In the quality of life analysis, mesh group showed a significant improvement compared with native tissue group (P = .004). Complications were significantly higher in mesh and recurrence in native tissue. Regarding the reoperation rate, there was no difference between groups, but native tissue had a higher reoperation rate due to recurrence (P = .031). CONCLUSIONS: Outcomes in women with severe POP were better with mesh use than native tissue repair, both in the anterior compartment and in the multicompartmental prolapse after 5-year follow-up. Complications were more common in the mesh group and recurrences were more frequent in the native tissue group.

Petit lumbar hernia--a double-layer technique for tension-free repair.

This report describes an alternative technique for Petit hernia repair. The treatment of lumbar hernias should follow the concept of tension-free surgery, and the preperitoneal space can be the best place for prosthesis placement. An obese patient had a bulge in the right lumbar region, which gradually grew and became symptomatic, limiting her daily activities and jeopardizing her quality of life. She had previously undergone 2 surgical procedures with different incisions. We created a preperitoneal space and attached a mesh in this position. Another prosthesis was placed on the muscles, with a suitable edge beyond the limits of the defect. There were no complications. It has been described as a safe and tension-free repair for Petit hernia. In larger defects, a second mesh can be used to prevent further enlargement of the triangle and also to provide additional protection beyond the bone limits.