Hernia of the Superior Lumbar Triangle

THOMAS W. ORCUTr, M.D.

LUMBAR hernias are rare. DeGarangeot 10 toid, trapezoid, or polyhedral shape,37 one
reported the first known case in 1731, the must retract both the latissimus dorsi and
hernia being reduced at autopsy; Petit, in the serratus posterior inferior muscles. If
1783,37 described a strangulated hernia a triangle is present, it is inverted, the base
emerging through the inferior lumbar tri- being formed by the lower border of the
angle which now bears his name; and in 12th rib and the portions of the serratus
1750, Ravaton37 reported a strangulated posterior inferior. The anterior border is
lumbar hernia with operation and cure. A formed by the internal oblique and the
century later, Grynfeltt'16 described a her- posterior border is the quadratus lum-
nia through the superior lumbar triangle, borum; these borders are easily remem-
distinguishing it from the inferior lumbar bered if the area is thought of as the lum-
triangle. In 1870, Lesshaft 24 independently bocosto-abdominal triangle.27 The floor of
confirmed the existence of a separate supe- the triangle is the transversalis fascia which
rior lumbar triangle and reported a similar is a portion of the fusions of the lumbo-
case. By 1890, Macready had collected dorsal fascia which continues anteriorly as
25 cases, two of which were through the the aponeurosis of the transversus abdomi-
superior lumbar triangle which was named nis muscle and posteriorly splits into three
the space of Grynfeltt-Lesshaft. In 1925, layers which include the quadratus lum-
Virgilio 36 collected 109 cases and found borum and the sacrospinalis.
that the Grynfeltt-Lesshaft hernia was The size and shape of the space depend
more frequent than the Petit's hernia. upon the development of the bordering
muscle masses, the length and position of
Anatomy the 12th rib and the position of its muscle
A lumbar hernia may occur anywhere attachments, and the position of attach-
in the lumbar region which is bounded ment of the overlying latissimus dorsi.
above by the 12th rib, below by the crest Weak points in the superior lumbar tri-
of the ilium, in front by a line drawn verti- angle are immediately beneath the 12th
cally downward from the anterior extrem- rib where the transversalis fascia is not
ity of the 12th rib to the crest of the ilium, covered by the external oblique and where
and behind by the vertebral column and it is perforated by the 12th dorsal inter-
the erector spinae muscles. The two main costal neurovascular bundle.27
areas of lumbar herniation are the superior The inferior lumbar triangle is.normally
lumbar triangle (Grynfeltt-Lesshaft) and present in adults, occasionally present in
the inferior lumbar triangle (Petit). children. It is usually triangular shaped
Goodman and Speese,15 in dissections of with the base being the iliac crest. The
76 cadavers, found the superior lumbar tri- posterior border is the free edge of the
angle present in greater than 93 per cent latissimus dorsi and the anterior border is
of the specimens. To expose the "triangle," the external oblique. The musculofascial
which sometimes takes a quadrilateral, del- floor is much stronger than that of the su-
Submitted for publication February 26, 1970. perior lumbar triangle, being composed of
294
Volume 173 HERNIA OF THE SUPERIOR LUMBAR TRIANGLE 295
Number 2

Transversa;s
a
FIG. 1. A. Anatomical Fasciae
relationships of the infe- Superior Lumbar
Triongl1e Peritoneum
rior and superior trian- .\N. \
gles. A portion of the Transvers'l,s Fascia Psoas 1.
fatissimusdorsi has been IZ . ..
removed to fully expose External Oblque
the deeper superior lum- Internal Oblique
bar triangle. B. Trans-
verse section through
kidney inferior to 12th
rib.

the lumbodorsal fascia with underlying fect immediately beneath the 12th rib. High liga-
internal oblique and transversus abdominis. tion was performed with 2-0 silk, and the defect
in the transversalis fascia was closed with inter-
The superior lumbar triangle is larger and rupted Mersilene sutures. The fascia of the inter-
more constant than the inferior lumbar tri- nal oblique, quadratus lumborum, and serratus
angle, possibly accounting for the greater posterior were imbricated. A pressure dressing was
frequency of hernias in this area. firmly applied. The postoperative course was
smooth and sutures were removed on the 7th
Case Report postoperative day. Six months postoperatively the
patient is asymptomatic and engaged in heavy
R. D., a 47-year-old man, was admitted to the work.
Nashville Veterans Administration Hospital with
a chief complaint of a "knot" in his side of 3 to
4 weeks' duration. The mass first appeared after
Discussion
he had strained himself while loading heavy boxes Twenty per cent of reported lumbar her-
onto a truck. The mass was painful and enlarging. nias are congenital. These are rarely bi-
His bowel habits had remained unchanged and lateral and are usually associated with
he had no other abdominal pain.
other congenital abnormalities.1 4, 6, 11, 14, 23
On examination, there was a 3 X 3 cm. round,
smooth, soft mass in the posterior axillary line All congenital hernias reported have
immediately beneath the 12th rib on the right been through the inferior lumbar triangle.
side. No bowel sounds were heard over the mass Acquired traumatic lumbar hernias com-
which was slightly tender, not increased in tem- prise about 26 per cent of reported lumbar
perature, could not be totally circumscribed by
the examiner's fingers, and was easily reducible. hernias and are probably more frequent in
A transmitted impulse could be felt in the mass the superior lumbar triangle because of
when the patient coughed. operations performned in this area and be-
The laboratory values and radiographic ex- cause it is the thinnest point in the lateral
aminations were normal. and posterior abdominal wall. This hernia
Under endotracheal anesthesia, the patient was results from direct trauma, penetrating
placed in the left lateral decubitus position and wound, abscess, or flank incision.27 Mas-
the operating table was angulated to achieve the
same effect as a kidney rest. The mass which had sive lumbar hernias have been reported fol-
been marked with indelible ink preoperatively lowing removal of bone from the iliac crest
could not be palpated with the patient in this for autogenous bone grafting.3 28 Kretsch-
position. An incision was made over the mass mer20 reported 13 renal hernias through
paralleling the intercostal nerves. When the latis- lumbar triangles, in 11 of which prior renal
simus dorsi was retracted medially, a 3 x 5 cm.
mass of herniated fat was sharply dissected to ex- operations had been performed, and of
pose its incarcerated neck caught in a 1 cm. de- the other two, one was a true congenital
 ORCUTT Annals of Surgery
296 February 1971
hernia are rare, but occasionally heaviness
in the flank or back is associated with back
pain. Frazer13 described his own lumbar
pain which persisted for 6 years after an
automobile accident. After extensive exami-
nations, lumnbar herniorrhaphy was per-
formed with complete relief of symptoms.
Several reports 2, 7, 8, 9, 12, 19, 31, 34 emphasize
the necessity to exclude lumbar hernia as
a cause of back pain. Most instances were
not hernias through either of the lumbar
triangles but were small adipose hernias
through superficial fascial layers.
Most authors agree that once formed,
these hernias progressively enlarge until
they either cause symptoms or attain enor-
mous proportion.27 All lumbar hernias
should be repaired except in the poor risk
patient. Lee and Mattheis 23 advise wait-
ing until after the age of 6 months to re-
pair hernias in children.
FiG. 2. Incision may be either oblique as shown A strong overlapping reconstruction, em-
or vertical for adequate exposure. A. Identification
of defect and ligation of fat-containing sac after ploying intrinsic fascia and aponeurosis,
inspection of contents. B. Closure of defect uti- is preferable to artificial splints such as
lizing periosteum of 12th rib. C, D. Obliteration
of triangle with internal oblique, serratus posterior tantalum mesh or skin. Upper gastrointes-
inferior and quadratus lumborum. tinal and barium enema roentgenograms,
renal hernia through the inferior lumbar bowel preparation with mechanical cleans-
triangle, the other was the aftermath of ing, and weight reduction preoperatively
goring by a bull. are recommended. A kidney rest is utilized
Spontaneous lumbar hernias constitute to increase the distance between the 12th
about 54 per cent of the reported cases. rib and iliac crest, and the entire buttock
Such predisposing factors as age, emaci- and thigh are prepared to the knee in case
ation, and debilitating disease may be con- a flap of gluteus maximus fascia or fascia
tributing factors since loss of fat which lata is required.27 Langan 22 emphasized
normally pads the neurovascular orifices the helpfulness of marking the hernia with
(found only in superior lumbar triangle) an indelible marker preoperatively.
facilitates the rupture.35 Watson found 8 The objectives of operation for hernia
per cent of 186 lumbar hernias were stran- are to reduce the hernia, to remove the sac
gulated, the majority of these being spon- if it is large or simply reduce it within
taneous hernia following lifting.37 the hernial ring if the sac is small, and to
Although most authors believe that a reconstruct the defect.32 In lumbar hernias,
sac is present most of the time, statistics a sac is rarely adherent to the skin, being
are lacking. Marmisse 26 described fatty separated from it by either fat or muscle.
hernias without sacs as early as 1862. The The sac should be identified, the neck dis-
most frequently reported contents of the sected, and if the content of the sac is pro-
hernias are omentum, small intestine, peritoneal or perirenal fat, its pedicle is li-
colon, Iddney, stomach, ovary, spleen, and gated and the mass excised.27
appendix.27 Reconstruction of the defect may be ac-
Symptoms of an uncomplicated lumbar complished in a variety of ways. The ana-
Volume 173 HERNIA229
OF THE SUPERIOR LUMBAR TRIANGLE 297
Number
tomical arrangement in the superior lum- 9. Dal Lago, H. and Vera, R. A.: Fat Hernias
bar triangle and the usual small defect lend with Necrotic Lesions as Cause of Lumbago.
Rev. Ortop. y Traumatol., 20:160, 1950.
themselves to simple closure with inter- 10. DeGarangeot, R. J. C.: Traite des Operations
rupted sutures and overlapping of the adja- de Chirurgie, 1:369, 1731.
11. Dowd, C. N.: Congenital Lumbar Hernia at
cent fascial structures. If the defect is the Triangle of Petit. Ann. Surg., Vol. 45,
large, multiple fascial flaps reinforced by 1907.
12. Floarra, B. J.: Pannicular Lumbosacro-iliac
some type of artificial splint may be neces- Hernia. Arch. Surg., 70:229, 1955.
sary. Several methods are available for the 13. Frazer, E. H.: A Case of Lumbo-Dorsal Her-
nia with Some Unusual Features. Med. J.
reconstruction of hernia of the inferior Aust., 1:60, 1968.
lumbar triangle and are described else- 14. Galeano, F. et al.: Bilateral Lumbar Hernia.
Prensa Med. Argent., 47:1195, 1960.
where.3, 5, 11, 17, 18, 21, 29, 30, 33, 37 15. Goodman, E. H. and Speese, J.: Lumbar Her-
nia. Ann. Surg., 63:548, 1916.
Summary 16. Grynfeltt, J.: La Hernie Lombaire. Montpel-
lier Med., 16:329, 1866.
Lumbar hernias are rare; scattered re- 17. Hafner, C. D., Wylie, J. H., Jr. and Brush,
B. E.: Petit's Lumbar Hernia: Repair with
ports of hernias of both superior and infe- Marlex Mesh. Arch. Surg., 86:180, 1963.
rior lumbar triangles have appeared in 18. Hancock, T. H.: Report of a Case of Trau-
both the English and foreign literature matic Hernia in Petit's Triangle. So. Med.
J., 13:521, 1920.
since the collection of 186 cases in 1948 19. Herz, R.: Herniation of Fascial Fat and Low
reported by Watson,37 the total now being Back Pain. JAMA, 128:921, 1945.
20. Kretschmer, H. L.: Lumbar Hernia of the
about 220. Hernia of the superior lumbar Kidney. J. Urol., 65:944, 1951.
triangle is most commonly associated with 21. Koontz, F. R.: An Operation for Massive Inci-
sional Lumbar Hernia. Surg. Gynec. Obstet.,
either straining or direct trauma in the 101:119, 1955.
lumbar region. The diagnosis is relatively 22. Langan, F. G.: A Grynfeltt-Hernia-A Rare
Lumbar Hernia. Med. J. Aust., 1:1089, 1967.
easy if there is a reducible mass beneath 23. Lee, C. M., Jr. and Mattheis, H.: Congenital
the 12th rib which transmits a cough im- Lumbar Hernia. Arch. Dis. Childhood,
32:42, 1957.
pulse. An additional case of spontaneous 24. Lesshaft, P.: Die Lumbalgegend in Anat. Chi-
hernia of the superior lumbar triangle with rurgischer Hinsicht. Arch. f. Anat. u. Physiol.
u. Wissensch., Med. Leipzig, 37:264, 1870.
a method of successful repair is reported. 25. Macready, J.: A Treatise on Ruptures. Lon-
don, Griffin, 1893.
26. Marmisse, G.: Hernie Ventrale. Gaz. de Hop.,
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