Totally extraperitoneal laparoendoscopic repair of lumbar hernia

Background: The repair of congenital and acquired lumbar hernias has remained a significant surgical challenge for over three centuries. Transperitoneal laparoendoscopic techniques have been reported that have achieved success in repairing these difficult hernias using a variety of synthetic mesh. Careful review of the surgical literature addressing the repair of lumbar hernia reveals that only fourteen successful cases have been reported using minimally invasive techniques. All of these cases elected a transperitonal approach to repair. Encouraged by established success in the repair of inguinal hernia using an extraperitoneal approach, the repair of a large inferior triangle lumbar hernia was attempted using overlapping synthetic mesh technique while remaining entirely in an extraperitoneal plane. Methods: A seventy-eight-year-old patient presented for repair of a large symptomatic right lumbar hernia, one year following iliac bone harvest for lumbar laminectomy/fusion. Under general anesthesia, the patient was placed in a lateral decubitus position with lumbar roll in place. Using a muscle splitting dissection through the lateral abdominal musculature, a plane was developed bluntly between the transversalus muscle and the peritoneum. Using a three trocar technique, the plane was matured posteriorly, achieving an ample working space to identify the hernia and complete a synthetic mesh (PTFE) repair. Results: A large inferior triangle lumbar hernia was successfully repaired using overlapping synthetic mesh technique while remaining entirely in an extraperitoneal plane. Eighteen month reevaluation including physical examination and computer tomographic (CT) study confirms successful repair without recurrence of symptoms. Conclusions: A totally extraperitoneal approach to the identification, mobilization, and repair of lumbar hernia can be successfully accomplished using established laparoendoscopic surgical techniques.