Lumbar Hernia: An Unusual Presentation of Bear Maul 453
Ultrasonography may fail to demonstrate the hernia due
to low index of suspicion and presence of fat. CT scan
can accurately distinguish the muscular and fascial layers,
detect the presence of a defect in these layers, visualize
herniated fat or viscera and differentiate a hernia from a
hematoma, abscess or soft-tissue tumor [5,6]. The goal of
hernia repair is to eliminate the defect and to constru ct an
elastic and firm abdominal wall that will withstand the
stress of daily physical activities. A lumbar hernia sho uld
be repaired surgically, as it is prone to both obstruction
and strangulation [7,8].
Techniques for repair include anatomical closure,
overlapping of the aponeurosis, use of musculofascial
flaps, prosthetic meshes and laparoscopic mesh repair in
case of uncomplicated lumbar hernias [4]. Currently,
extraperitoneal mesh repair is considered the optimal
treatment for isolated unilateral lumbar hernia. The Rives
Stoppa approach, wherein, a large rectangular mesh is
fashioned to be placed in the pre-peritoneal space ex-
tending from umbilicus to retropubic space and between
the two anterior superior iliac spines, appear to be the
most promising open technique for bilateral lumbar her-
nia, recurrent hernias or multiple site hernias with com-
paratively low recurrence rates [8]. Extra- peritoneal po-
sition of the mesh is advantageous as no bony anchorage
is essential. The weight of the intraperitoneal contents is
an additional support to maintain the mesh in correct
position in the early postoperative period. Laparoscopic
transabdominal preperitoneal mesh repair for lumbar
hernia confers all the benefits of minimal access surgery
to the patient. It is a tensionless repair. It follows the
current principle of hernia surgery and is based on the
sound physiological principle of diffusing the total intra-
abdominal pressure on each square inch of the mesh im-
planted [9,10].
4. Review of Literature
Post traumatic lumbar hernias have been reported but till
date no case of lumbar hernia following an attack by a
bear has been reported. Agarwal N and his colleagues
[11] have reported a case of traumatic abdominal wall
hernia in a 40-year-old female from North India who was
hit by a bull. Al Sarela et al. [12] have reported a case of
lumbar hernia which had developed following blunt ab-
dominopelvic trauma. Burick et al. [13] reported a case
of acute lumbar hernia as a direct result of blunt trauma
which was explored and repaired laparoscopically. Mo-
reno-Egea et al. [14] studied open versus laparoscopic
lumbar hernia repairs. They concluded that outcomes did
not differ with respect to morbidity and recurrence rate
after long-ter m follow-up and that laparoscop ic approach
for lumbar hernia is safe, effective, and more efficient
than open repair and can be considered the procedure of
choice. Links and Berney [15] report the use of bone
suture anchors placed in the iliac crest during transperi-
toneal laparoscopy for mesh fixation to repair a recurrent
traumatic lumbar hernia.
5. Conclusion
Both acute and long-standing post-traumatic lumbar her-
nias are rare but ch allenging cond itions, which require an
appropriate index of suspicion and investigations for di-
agnosis and a well planned surgical repair. These hernias
increase in size and become symptomatic. The corrective
surgical procedure becomes more complex as hernial
defect enlarges. Reconstruction is a challenging aspect of
lumbar hernia surgery.
REFERENCES
[1] W. T. Swartz, “Lumbar Hernia,” In: L. M. Nyhus and R.
E. Condon, Eds., Hernia, 2nd Edition, Lippincott, Phila-
delphia, 1978, pp. 409-426.
[2] J. E Skandilakis and J. B. Flament, “The Surgical Clinic s
of North America,” Vol. 80, 2000, pp. 388-391.
[3] W. P. Geis and G. T. Hodakowski, “Lumbar Hernia,” In:
L. Nyhus and R. Condon, Eds., Hernia, 5th Edition, Lip-
pincott, Philadelphia, 2001, pp. 425-427.
[4] B. Devlin and A. N. Kingsnorth, “Management of Ab-
dominal Hernias,” 2nd Edition, Edward Arnold, London,
1998, pp. 330-334.
[5] M. E. Baker, J. L. Weinerth, R. T. Andriani, et al., “Lum-
bar Hernia: Diagnosis by CT,” American Journal of Ro-
entgenology, Vol. 148, No. 3, 1987, pp. 565-567.
http://dx.doi.org/10.2214/ajr.148.3.565
[6] K. L. Killeen, S. Girard, J. H. Demeo, et al., “Use of CT
to Diagnose Traumatic Lumbar Hernia,” American Jour-
nal of Roentgenology, Vol. 174, No. 5, 2000, pp. 1413-
1415. http://dx.doi.org/10.2214/ajr.174.5.1741413
[7] G. E. Leber, J. L. Garb, A. l. Albe rt and W. P. Ree d, “Long-
Term Complications Associated with Prosthetic Repair of
Incisional Hernias,” Archives of Surgery, Vol. 132, 1998,
pp. 1141-1144.
[8] A. K. Meinke, “Totally Extraperitoneal Lapar oendoscopic
Repair of Lumbar Hernia,” Surgical Endo scopy and Other
Interventional Techniques, Vol. 17, No. 5, 2003, pp. 734-
737. http://dx.doi.org/10.1007/s00464-002-8557-8
[9] B. T. Heniford, D. A. Iannitti and M. Gagner, “Laparo-
scopic Inferior and Superior Lumbar Hernia Repair,” Ar-
chives of Surgery, Vol. 132, No. 10, 1997, pp. 1141-1144.
http://dx.doi.org/10.1001/archsurg.1997.01430340095017
[10] P. K. Chowbey, A. Sharma, R. Khullar, et al., “Laparo-
scopic Ventral Hernia Repair,” Journal of Laparoendo-
scopic & Advanced Surgical Techniques, Vol. 10, No. 2,
2000, pp. 79-84. http://dx.doi.org/10.1089/lap.2000.10.79
[11] N. Agarwal, S. Kumar, M. K. Joshi and M. S. Sharma,
“Traumatic Abdominal Wall Hernia in Two Adults: A
Case Series,” Journal of Medical Case Reports, Vol. 3,
2009, p. 7324.
http://dx.doi.org/10.4076/1752-1947-3-7324
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