Management of giant inferior triangle lumbar hernia (Petit's triangle hernia): A rare complication following delayed breast reconstruction with extended latissimus dorsi myocutaneous flap

Abstract

Introduction: Lumbar triangle hernia after breast reconstruction with latissimus dorsi flap (LDMF) is a very rare complication and few cases were previously described. Muscle mobilization and iatrogenic fascia defect are related etiologic factors.

Presentation of case: The authors describe a rare case of lumbar hernia in a 58-year-old woman who underwent delayed left breast reconstruction with LDMF. Two months after surgery, a progressive symptomatic lower left lumbar bulge was observed. The CT scan confirmed the diagnosis and delineated an 18cm lumbar defect filled with lower and large bowel. At operation, the defect was exposed and the hernia sac reduced. In order to obtain stability, the remained local muscle and fascia flaps were mobilized into the defect. Additional strength was achieved with a two-layer closure of prosthetic mesh (intra/extra peritoneal). The patient is currently in the 10th postoperative year of hernia repair and satisfactory lumbar wall contour was achieved. Neither the recurrence of lumbar hernia nor symptoms compliance was noted.

Discussion: Lumbar hernia is an uncommon complication of LDMF harvest. Although it is a rare disease, general and plastic surgeons must be on alert to avoid complications and misdiagnosis. Seroma differential diagnosis is important in order to avoid bowel perforation due to aspiration. Defect reconstruction is necessary with a muscular and fascia flaps mobilization and synthetic mesh in order to obtain a stable repair.

Conclusion: The knowledge of this rare post-operative complication following delayed breast reconstruction is crucial to its surgical management. Early surgical intervention is warranted in order to avoid severe complications.

Keywords: Breast reconstruction; Complication; Hernia; Lumbar triangle; Myocutaneous flap.

Fig. 1

(A–D) Preoperative view/surgical planning of a delayed left breast reconstruction with left LDMF and silicone implant in a 58-year-old patient (A–C). Intraoperative view the left LDMF before transposition to the left anterior thorax (D).

Fig. 2

(A–D) Postoperative appearance 2 months following reconstruction (A) showing lower left lumbar bulge (B). Abdominal CT transverse section showing a lumbar hernia and delineated an 18 cm triangle lumbar defect with lower and large bowel filled hernia sac (C). Intraoperative view of the hernia sac containing the remaining lumbar fascia, peritoneum and small and large bowel dissected free from the adjacent thoracic wall structures (D).

Fig. 3

(A–D) Intraoperative view of the lumbar region. Strength was achieved with a two-layer closure of prosthetic mesh. In the deep layer (intra-peritoneal), the sheet of polypropylene mesh (15 cm × 15 cm) is sutured to the defect borders (A). The second layer is a running reinforcing suture of the sheet of mesh (25 cm × 25 cm) to the remaining transverses abdominis and internal oblique muscles, costal cartilages and iliac crest (B). Postoperative appearance 2 months following hernia repair showing satisfactory contour (C). The patient is currently in the 10th postoperative year of lumbar hernia correction and the breast reconstruction (D).

Fig. 4

Abdominal CT transverse section after hernia repair showed resolution of the left lumbar hernia trough inferior triangle (Petit's).