Repair of a Grynfeltt-Lesshaft hernia with the PROCEED™ VENTRAL PATCH: a case report

Lumbar hernias are a very rare cause of abdominal complaints, and there is no standardized surgical strategy. Here, we present the case of a mentally disabled patient with a primary Grynfeltt-Lesshaft hernia with herniation of the ascending colon causing constipation and abdominal pain. Due to the mental disability and the severe symptoms of the hernia, a safe surgical approach with fast postoperative recovery was required.

A review of the literature reveals only a handful of case reports, describing various open and laparoscopic techniques for the closure of lumbar hernias. Due to the rare appearance, there is hardly any evidence supporting one or the other technique [1].

Considering the general condition of our patient and the need for an urgent operation, we decided against laparoscopy, but instead for an open, extraperitoneal, dorsal approach with insertion of a self-expanding, partially absorbable, flexible laminate mesh device, very similar to the approach described by Solaini et al. [2].

The effective use of the PROCEED™ VENTRAL PATCH has been demonstrated for umbilical hernias [3] and likewise small incisional hernias. We could demonstrate that the patch can be also effectively used for closure of hernias in the Grynfellt-Triangle via a dorsal approach.

Up to now, there is no retrospective study or randomized controlled trial analyzing the results of the different surgical techniques for closure of a primary lumbar hernia, and due to the rare appearance, there will probably never be one. Therefore, the surgical approach has been chosen individually for each patient with consideration of the particular situation.

In 2013, Suarez et al. recommended a laparoscopic approach to hernias in the triangle of Grynfellt with the main argument of faster postoperative recovery and less postoperative pain and consumption of pain medication [4]. This recommendation is based mostly on the result of a randomized controlled trial comparing open and laparoscopic repair of secondary lumbar hernias, which reveals beneficial results of the laparoscopic approach [5]. However, this study was carried out with patients suffering from incisional hernias and is therefore not comparable with our case of a primary Grynfeltt-Lesshaft hernia. The trial reports a mean operating time of 71 min, a postoperative morbidity of 86%, and a mean hospital stay of 7 days for the open approach. These figures certainly do not compare to the technique described here.

Our approach is favorable; hence, it requires almost no dissection of the surrounding tissue and muscles and no (laparoscopic) intraabdominal dissection. It can also be performed by any surgeon familiar with more common hernias (e.g., umbilical) even with limited experience with lumbar hernias in a very short time and therefore is very safe. Due to the position and size of the incision and the limited need for dissection, postoperative recovery is fast and incisional pain is acceptable. The overlap of the mesh was about 3 cm to all sides. Due to the small gap and the strong tissue around the hernia, we refrained from further preparation to insert a larger mesh with a wider overlap. We were able to discharge the patient who had a mental disability the next day. A mentally and physically healthy patient could have been presumably treated in an outpatient setting. Our operative technique is certainly a feasible alternative to the laparoscopic approach. In this particular case, it was our chosen approach due to the need for an urgent operation and to guarantee a fast postoperative recovery and prompt hospital discharge.