Controversies in the current management of lumbar hernias
Alfredo Moreno-Egea1, Enrique G Baena, Miquel C Calle
1Abdominal Wall Unit, Department of Surgery, J. M. Morales Meseguer Hospital, Avenida Primo de Rivera 7, 30008 Murcia, Spain. moreno-egea@ono.com
Background:
Abdominal wall surgery has changed dramatically in recent years. The current management of lumbar hernias should reflect the development of modern imaging techniques and new forms of noninvasive treatment.
Objective:
To review and update knowledge on lumbar hernias.
Data Sources:
Literature review using MEDLINE with the key words "lumbar hernia" for the years 1950 through 2004. For an analysis prior to this date (1750-1950), we used cases reported by Thorek. Our own study of 28 patients was also included.
Study Selection:
All articles reporting clinical cases on lumbar hernia.
Data Extraction:
Two reviewers analyzed the epidemiological, clinical, and treatment data of the articles.
Data Synthesis:
One hundred thirty-five clinical case articles and 8 studies with more than 5 patients, together with our personal experience of 28 cases, were analyzed. Nine percent of acquired lumbar hernia cases presented for emergency surgery, which means that a clinical diagnosis was completed with computed tomography in more than 90% of the cases. None of the published classifications has a therapeutic orientation. We present an original classification based on 6 categories and 4 types. In our study, there was a predominance of incisional hernias (79%), with no difference with regard to sex or location but with a predominance in the upper space (47%). Laparoscopic treatment accounts for 9% of the publications' cases and there is only 1 prospective comparative study.
Conclusions:
The use of a complete classification and tomography must be standard practice in the preoperative protocol of patients with lumbar hernia. The laparoscopic approach seems to be the best option for treating small or moderate defects; open surgery can be reserved for large defects and to salvage failures with the laparoscopic approach.