International Journal of Clinical Medicine, 2013, 4, 451-454 Published Online October 2013 (
Lumbar Hernia: An Unusual Presentation of Bear Maul
Mubashir Ahmad Shah1, Aakib Hamid Charag1*, Adil Pervaiz Shah1, Haroon Rashid Zargar2
1Department of General & Minimal Access Surgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India; 2Department of
Plastic & Reconstructive Surgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India.
Email:, *,,
Received July 1st, 2013; revised August 5th, 2013; accepted September 1st, 2013
Copyright © 2013 Mubashir Ahmad Shah et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction: Typical lumbar hernias are very rare surgical conditions. Lumbar hernias can be congenital or acquired.
About 25% of all lumbar hernias have a traumatic etiology. Case-Report: We here reported a case of a 55-year-old
male who was mauled by a bear. The patient developed an atypical lumbar hernia after 6 months of sustaining craniofa-
cial and abdominal trauma. Open hernioplasty, which was a very challenging job, was done in this patient. Conclusion:
Post traumatic lumbar hernias h ave been reported but till toda y no case of lumbar hernia following an attack by a bear
has been reported in literature. Both acute and long-standing post-traumatic lumbar hernias are rare but challenging
conditions. The corrective surgical procedure becomes more complex as hernial defect enlarges. Reconstruction is a
challenging aspect of lumbar hernia surgery.
Keywords: Lumbar; Hernia; Trauma; Bear Maul
1. Introduction
Typical lumbar hernias are very rare surgical conditions.
Lumbar hernias can be congenital or acquired. About
25% of all lumbar hernias have a traumatic etiology [1].
The trauma may be post surgical due to the blunt and
penetrating trauma to the flank. We report the case of a
male patient who presents with a lumbar hernia, 6 months
following a bear maul.
2. Case Report
A 55-year-old male patient presented with history of be-
ing attacked by bear about 6 months back with trauma
face and abdomen. Apart from the facial trauma, the pa-
tient had a healed lumbar laceration. Facial trauma was
managed by the department of plastic surgery. Lumbar
laceration was closed primarily at the time of presenta-
tion after ruling out intra-abdominal injury. After six
months on follow up of plastic and reconstructive sur-
gery patient presented with a swelling in left lumbar re-
gion associated with a dragging pain. Patient was re-
ferred to the department of general surgery for the man-
agement of same.
On examination, there was a 20 × 15 cm non-tender,
non-pulsatile and reducible swelling in the left lumbar
region with an expansile cough impulse, with palpable
gut loops within it. There was about 10 × 8 cm palpable
defect under the swelling getting more prominent after
reducing the hernia. There was a scar of old repaired lac-
eration visible on the swelling. The examination of rest
of the abdomen, right flank, back was normal. Plain ra-
diograph of the abdomen revealed gas shadows (gut
loops) within the swelling (Figure 1). Ultrasonography
revealed a 15 × 13 cm ill-defined mass in the left lumbar
region with areas of mixed echogenicity within the
swelling. Computed tomography (CT) scan of the abdo-
men was carried out which confirmed the presence of left
lumbar hernia containing gut loops part of transverse
colon and small gut with a bony defect in left ilium (Fig-
ure 2). A diagnosis of a reducible post traumatic (bear
maul) left lumbar hernia was made and patient was taken
up for surgery. The patient was placed in a right lateral
position. The swelling was explored through a left flank
incision. The contents of the hernia were reduced back
into peritoneal cavity. Fractured ilium and loss of at-
tachment of abdominal muscles from the iliac crest was
noted (Figure 3). Defect in the peritoneum was closed
using absorbable suture. A prolene mesh was fashioned
as inlay prosthesis and was placed in the extra peritoneal
space through the defect in the muscle layer (Figure 4).
The mesh was secured with prolene sutures and rest of the
wound was closed in layers. The immediate postoperative
period was uneventful. Oral feeds were started on the
second postoperative day. The patient was discharged on
Copyright © 2013 SciRes. IJCM
Lumbar Hernia: An Unusual Presentation of Bear Maul
Figure 1. Erect abdominal radiograph showing herniated
bowel loops in left lumbar re gion.
Figure 2. CT scan showing broken left ilium with bowel
loops lateral to it.
Figure 3. Intra operative picture showing broken ilium with
loss of muscle attachments.
Figure 4. Placement of prolene mesh.
third post operative day. During the follow-up visit after
one month, and three months the operation scar was
found to be well healed and the patient was absolutely
asymptomatic, with no recurrence.
3. Discussion
Lumbar hernias are relatively rare. These occur more
commonly in males and are twice as common on the left,
than on the right side. Patients are usually between 50 to
70 years old. These hernias can occur anywhere within
the lumbar region but are more common through the su-
perior lumbar triangle (of Grynfeltt-Lesshaft), an in-
verted triangle bounded by 12th rib, erector spinae and
the posterior border of the internal oblique muscle. The
inferior lumbar triangle (of Petit), bounded by iliac crest,
posterior border of external oblique and the anterior bor-
der of latissimus dorsi is the next most frequent site [2].
Lumbar hernias have been classified as congenital (20%)
or acquired (80%). If acquired, they may be primary
(55%) or secondary following trauma, surgery or in-
flammation (25%). These hernias have a natural history
of a gradual increase in size over time and may assume
large proportions [3].
The differential considerations at this stage include li-
poma, soft tissue tumors, hematoma or abscess. The her-
nia may contain retroperitoneal fat, kidney, colon or less
commonly small bowel, omentum, ovary, spleen or ap-
pendix. On auscultation, bowel sounds may be audible
over the swelling if the hernia contains bowel loops.
Bowel incarceration occurs in 25% but strangulation is
rare because of wide hernial neck [4]. Lateral or oblique
radiograph of the lumbar region may show gas filled
loops of the bowel lying outside the abdominal cavity.
Upper or lower gastrointestinal contrast studies are useful
in delineating the herniated bowel segment. In addition,
an intravenous urogram may be performed to visualize
any displacement of the kidney or ureter into the hernia.
Copyright © 2013 SciRes. IJCM
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.
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