ABSTRACT
The literature has described approximately 300 cases of lumbar hernia. Because of its rarity, the condition is often misdiagnosed, leading to delayed treatment. We report the case of a 65-year-old man who had complained for 5 years of a lump in his left lumbar region. There was no history of prior trauma or surgery. The mass gradually increased in size and was associated with vague dragging pain. The diagnosis of Grynfeltt-Lesshaft lumbar hernia was made based on clinical suspicion and ultrasound findings. The patient underwent open sublay mesh repair and recovered without complications. This case is noteworthy for the 5-year delay in diagnosis and management without computed tomography or magnetic resonance imaging, underscoring the role of high clinical suspicion and ultrasound-based diagnosis in resource-limited settings. Although rare, lumbar hernia should be considered in the differential diagnosis of a lumbar mass. Early diagnosis with ultrasound, contrast-enhanced computed tomography, or magnetic resonance imaging can help prevent complications. This case raises awareness of lumbar hernia and outlines available surgical options for treatment.
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Keywords: Abdominal hernia; India; Lumbosacral region; Resource-limited settings; Surgical mesh; Case reports
INTRODUCTION
Lumbar hernia (LH) is an uncommon surgical disorder, with only about 300 reported cases in the literature. The condition was first described by Garangoet in 1731 [
1,
2]. The lumbar area is bounded inferiorly by the iliac crest, superiorly by the 12th rib, laterally by the external oblique muscle, and medially by the erector spinae muscles. Two weak triangular-shaped areas of the abdominal wall predispose to herniation: the inferior lumbar triangle and the superior lumbar triangle [
3]. A general surgeon may encounter a case of LH only once in a professional lifetime, making diagnosis challenging in the absence of a high index of suspicion [
2]. Because of their rarity and complex anatomical location, LHs present unique diagnostic challenges, beginning with identification and extending to treatment planning. This case report highlights the diagnostic challenge of LH by presenting a case of Grynfeltt-Lesshaft hernia and reviewing relevant anatomy and management approaches [
4].
CASE PRESENTATION
Ethics statement
Informed consent for publication of the research details and clinical images was obtained from the patient.
Patient information
A 65-year-old male farmer presented to the general surgery clinic with a swelling in the left lower back beneath the ribcage, present for 5 years. The swelling began insidiously and gradually increased in size. Over the past 2 months, he had developed vague dragging pain within the swelling. His medical history included chronic obstructive pulmonary disease, for which he had been receiving conservative treatment for 5 years. He was a chronic smoker but had no other significant medical conditions. There was no history of prior surgeries or trauma in the affected area. His bowel and bladder functions were normal.
Clinical and diagnostic findings
The patient’s general condition and vital signs were unremarkable. Local examination revealed a 5×5-cm2 lump in the left lumbar region, located just below the 12th rib. The lump was globular, nontender, nonmobile, nonpulsatile, and reducible, with a well-defined border and smooth surface. The overlying skin was normal, and a cough impulse was visible. Differential diagnoses considered included lipoma, cold abscess, lumbar hematoma, sarcoma, fibroma, abscess, and renal mass.
Laboratory investigations revealed no abnormalities. Initial ultrasonographic examination suggested a lipoma without evidence of an abdominal wall defect. However, after a detailed discussion with the radiologist regarding the anatomy and clinical suspicion of LH, it was determined that the swelling represented a herniated mass extending from the left superior lumbar triangle into the subcutaneous region of the posterolateral abdominal wall, with a 2.5×2.5-cm2 defect. In light of the clinical scenario and ultrasonographic findings, a diagnosis of primary acquired LH arising from the superior triangle of Grynfeltt-Lesshaft was established. Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) were not performed due to financial limitations and lack of availability at the peripheral center.
Therapeutic intervention
Surgical intervention was planned, and the patient underwent surgery under general anesthesia in the right lateral position. A transverse skin incision was made over the swelling. The latissimus dorsi and external oblique muscles were retracted medially and laterally, respectively. The herniated fatty tissue protruding from the superior lumbar triangle was reduced, revealing a 2.5×2.5-cm
2 defect in the thinned fascia transversalis, confirming the diagnosis of Grynfeltt-Lesshaft LH (
Fig. 1). In the preperitoneal space, a polypropylene mesh was placed and fixed to the deep aspect of the fascia (sublay mesh repair). The fascial defect was closed with 2-0 polypropylene sutures.
At the 6-month follow-up, the patient remained asymptomatic.
DISCUSSION
No technical difficulties were encountered during the Grynfeltt-Lesshaft LH repair in this patient. The posterior-transverse incision provided clear visualization of key anatomical landmarks. The patient has remained free of complications after the procedure, and the hernia has not recurred. On this basis, we consider sublay mesh repair to be a safe and effective treatment for Grynfeltt-Lesshaft LH.
LH is a rare condition characterized by protrusion of intraperitoneal or extraperitoneal contents through a defect in the posterolateral abdominal wall [
5]. It typically occurs at one of two anatomical weak points: the superior Grynfeltt-Lesshaft triangle or the inferior Jean-Louis Petit triangle [
1].
The Grynfeltt-Lesshaft triangle, described by Lesshaft in 1870 and Grynfeltt in 1886, is an inverted, avascular, and deeper triangle bounded by the 12th thoracic rib, the serratus posterior inferior muscle, the erector spinae muscle group, and the internal oblique muscle [
3]. Its floor consists of the transversalis muscle aponeurosis, while the roof is formed by the latissimus dorsi and external oblique muscles. Weak points include the area below the 12th rib, the fascial penetration of the twelfth dorsal intercostal neurovascular pedicle, and the region between the rib and Henle’s ligament [
1]. The Petit triangle (
Fig. 2), described in 1783, is upright, more vascular, and superficial, bordered by the latissimus dorsi, external oblique, and iliac crest. Its floor is formed by the internal oblique muscle and its roof by superficial fascia [
1,
2]. Because of the Petit triangle’s robust musculofascial floor, Grynfeltt-Lesshaft hernia is more common [
6].
LH accounts for about 2% of all abdominal hernias. Approximately 20% are congenital, usually due to embryonic defects such as vertebral or rib malformations, while 80% are acquired. Among acquired cases, 55% are primary (spontaneous), and 25% are secondary, related to trauma or surgery [
1,
7,
8]. Risk factors for primary LH include advanced age, obesity, extreme slimness, chronic debilitating diseases, muscular atrophy, chronic bronchitis, infected wounds, postoperative sepsis, and conditions that increase intra-abdominal pressure. Most patients present between the ages of 50 and 70 years [
1,
7].
Diagnosis is challenging because LH can resemble soft tissue swellings such as lipomas, sarcomas, fibromas, cold abscesses, retroperitoneal hematomas, or renal masses [
1,
5]. Initial ultrasound may suggest lipoma, but features such as reducibility, cough impulse, and location in the superior lumbar triangle raise suspicion for LH. Clinical examination is crucial, relying on the detection of a reducible mass with a cough impulse that decreases in the prone position. Diagnosis is particularly difficult in obese patients [
1,
2,
8]. While ultrasound can confirm LH, accurate diagnosis requires an experienced radiologist. CT with multiplanar reconstruction is the preferred modality for diagnosis, as it allows evaluation of muscle and fascial integrity and assessment of hernia contents [
2,
6,
8]. MRI may also be used.
Some LHs are asymptomatic, while others present with dull flank pain that worsens with straining or coughing. Complications include incarceration (25%), strangulation (10%), intestinal obstruction, or volvulus [
8]. When renal contents are involved, hematuria, oliguria, or colicky pain may occur. Bowel obstruction typically presents with nausea, vomiting, and abdominal distension [
5]. Hernia contents may include retroperitoneal fat, colon, kidney, small bowel, omentum, stomach, spleen, ovary, or appendix [
1,
2,
8].
Surgery is the definitive treatment, either open or laparoscopic. Because of LH rarity and the absence of large-scale studies, there is no consensus on the optimal approach [
5,
7,
8]. Open repair, the most widely practiced, involves direct approximation of defect margins and reinforcement with adjacent fascial flaps. Mesh is placed in the preperitoneal region (sublay mesh repair) to overlap the defect margins, followed by fascial closure and muscle approximation [
5,
8]. Laparoscopic repair, either transabdominal or extraperitoneal, provides better visualization, reduced morbidity, shorter hospitalization, less postoperative pain, and faster recovery, but carries higher intraoperative risks [
2,
7,
8].
The choice of treatment depends on hernia size, location, contents, tissue quality, patient finances, and hospital expertise. Open surgery is favored for large defects or failed laparoscopic repairs. During surgery, nerves such as the genitofemoral, ilioinguinal, and lateral femoral cutaneous must be protected to minimize postoperative pain [
5,
8]. Synthetic mesh carries risks of infection, fistula, or obstruction, particularly in elderly patients, smokers, or those with prolonged operations. Biosynthetic materials, such as human acellular dermis, have shown promise in contaminated fields [
5,
7]. In our case, high clinical suspicion combined with ultrasound confirmed a type A LH, based on six criteria (defect size, location, contents, etiology, muscular atrophy, recurrence) [
9], which was successfully treated with sublay mesh repair, without additional mesh reinforcement, thereby reducing the risk of infection.
LH is often misdiagnosed due to its rarity. Accurate diagnosis and appropriate treatment require thorough evaluation. Although CT remains the gold standard for diagnosis, we propose that a high index of clinical suspicion combined with ultrasound performed by an experienced radiologist can be sufficient. Given the high risk of complications, all LHs should be surgically repaired, either laparoscopically or by open mesh repair. While various surgical approaches are available, the open approach remains the most cost-effective, and sublay mesh repair should be considered a safe and effective treatment for Grynfeltt-Lesshaft LH.
ARTICLE INFORMATION
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Author contributions
Conceptualization: all authors; Investigation: all authors; Methodology: ML; Supervision: ML; Visualization: ML; Writing–original draft: all authors; Writing–review & editing: all authors; All authors read and approved the final manuscript.
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Conflicts of interest
The authors have no conflicts of interest to declare.
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Funding
The authors received no financial support for this study.
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Acknowledgments
The authors thank Dr. M. L. Lohiya (Department of General Surgery, Government Medical College, Pali) for his assistance in the surgical management of this case.
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Data availability
Data sharing is not applicable as no new data were created or analyzed in this study.
Fig. 1.Defect noted in the superior lumbar triangle with content reduced.
Fig. 2.Sketch diagram showing boundaries of both lumbar triangles outlined in green.
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