Laparoscopic Transabdominal Hernioplasty of a Lumbar Hernia of the Grynfelt – Lesshaft Triangle

Juan D Hernandez, MD. Fundacion Santa Fe de Bogota, Universidad de los Andes

We present the case of a 51 years old lady with a reproduced right lumbar hernia. The first intervention was planned for a lumbar lipoma, but a hernia of the Grynfelt- Lesshaft triangle was found and repaired.
After two years the mass reappeared accompanied by abdominal pain and an episode of bowel obstruction. CT scan shows the hernia, marked by an arrow, with a large sac containing omentum.

At Laparoscopy it can be seen the omentum retracted over the ascending colon.
The procedure is started by dissecting the hernia sac to free the omentum and pull it out of the cavity.
A large amount of omentum was contained in the hernia causing pressure over the ascending colon, causing the episodes of obstruction. The hernia sac was inspected. Remaining adhesions are cut.
The edges of the defect are dissected to create an extraperitoneal space where the mesh is going to be placed.
On the superior aspect of the orifice, this dissection requires the inferior pole of the right kidney to be mobilized anteriorly. Dissection of the lateral and posterior peritoneum is completed on a wide enough area to place a mesh extending five centimeters from the edge of the aponeurotic defect. Anterior edge is dissected with the same goal.

Once completed, the exposure allows seeing the psoas major muscle medially and adjacent to it, the quadratus lumborum muscle as the medial border of the hernia.

The Mesh is introduced through a 12 mm trocar and extended to cover the defect leaving adequate margins. It is also checked its position in the extraperitoneal space.
Mesh is tucked behind the kidney and extended making sure no wrinkles are left.
Next, mesh is fixed to the muscles to make sure it remains in position.
Additional tackers are placed around the defect to secure it.
Finally, the peritoneum is closed over the mesh, leaving the kidney in its original position.