What is the recommended treatment for a lumbar hernia?

Repair of Lumbar Hernia

Surgical repair with mesh placement is the recommended treatment for lumbar hernias, with laparoscopic approach preferred for most cases due to superior visualization of the defect and ability to place mesh deep into the defect where intraabdominal pressure holds it in position. 1, 2

Indications for Surgery

• All confirmed lumbar hernias should be repaired once diagnosed due to 25% risk of incarceration and 8% risk of strangulation 1
• Surgery is indicated regardless of hernia size, as these hernias tend to grow progressively over time 1

Diagnostic Approach

• CT scan is the gold standard for diagnosis, as it delineates muscular and fascial layers, detects defects, evaluates herniated contents, differentiates muscle atrophy from true hernia, and excludes tumors 2
• Ultrasound can serve as an adjunct to reveal the abdominal wall defect and hernia contents 3
• Clinical examination typically reveals a protruding semispherical bulge in the back with slow growth 2

Surgical Approach Selection

Laparoscopic Repair (Preferred)

Laparoscopic approach is the ideal treatment option for most lumbar hernias, particularly for:

• Larger hernias 3
• Hernias with suspected visceral involvement 3
• Cases requiring precise anatomic localization 1

Key advantages of laparoscopic repair include: 1, 2

• Exact localization of the anatomic defect
• Mesh placement deep into the defect with intraabdominal pressure holding it in position
• Ability to identify the entire lumbar area
• All standard benefits of minimally invasive surgery (smaller incisions, faster recovery)
• Can be performed as major ambulatory surgery 4

Open Repair (Alternative)

Open anterior approach with synthetic mesh is appropriate for: 5, 3

• Smaller hernias where precise defect borders are easily identified
• Cases suitable for loco-regional anesthesia
• When better cosmetic effect is desired for small defects

Technical considerations for open repair: 5

• Synthetic mesh placed in extraperitoneal space below muscular layers
• Tension-free technique
• Mean hospital stay approximately 2-3 days
• Return to normal activities within 15 days

Mesh Placement Technique

• Synthetic mesh is the standard for repair in both open and laparoscopic approaches 5, 3
• Mesh should be placed in the extraperitoneal space using tension-free technique 5
• In laparoscopic repair, mesh is positioned deep into the defect where intraabdominal pressure maintains position 1
• For open repair, mesh is placed below muscular layers in the extraperitoneal space 5

Anatomic Considerations

Lumbar hernias occur in two primary locations: 3, 2

• Superior triangle (Grynfeltt): More common location
• Inferior triangle (Petit): Less common location
• 95% of lumbar hernias occur in these two triangles, with 5% being diffuse 2

Expected Outcomes

Both approaches demonstrate excellent results: 5

• No recurrence in long-term follow-up (median 25 months)
• Minimal complications (subcutaneous hematoma being most common)
• No postsurgical sequelae such as chronic pain or muscular weakness
• Safe and effective repair with proper technique

Common Pitfalls to Avoid

• Do not delay surgery once diagnosis is confirmed due to significant risk of incarceration (25%) and strangulation (8%) 1
• Avoid attempting primary suture repair without mesh, as this leads to high recurrence rates given the difficulty in defining borders and bone margin involvement 4
• Do not overlook the need for CT imaging when clinical diagnosis is uncertain, as it prevents misdiagnosis (e.g., lipoma) and guides surgical planning 2
• Ensure adequate mesh overlap of the defect borders to prevent recurrence 5