Robotic-Assisted Laparoscopic Repair of Petit's Hernia With Preperitoneal Mesh

Abstract

Lumbar hernias are rare abdominal wall hernias that occur in the posterolateral abdominal wall. Intra-peritoneal or extra-peritoneal contents typically protrude through defects in one of two anatomical triangles. The superior lumbar triangle (Grynfeltt-Lesshaft triangle) is an inverted triangle bordered by the 12th rib superiorly, the internal oblique muscle laterally, and the erector spinae muscle medially. The inferior lumbar triangle (Petit's triangle) is an upright triangle bordered by the iliac crest inferiorly, the external oblique muscle laterally, and the latissimus dorsi muscle medially. Surgical repair has been described via open or laparoscopic approach. A 69-year-old male patient presented with right flank pain and swelling. He was involved in a motorcycle accident 10 months prior, which likely resulted in the development of a traumatic lumbar hernia which was demonstrated on the CT scan. The hernia was clinically incarcerated, and the defect contained the cecum and ileocecal valve. The defect was noted just superior to the iliac crest, by definition, making this an inferior lumbar hernia or a Petit's hernia. The hernia was repaired via robotic-assisted laparoscopic transabdominal approach. A peritoneal flap was created exposing the fascial defect. The fascia was primarily repaired with suture. The defect was reinforced with an 11.4 cm round Ventralight ST mesh in the preperitoneal space. The patient tolerated the procedure well with no acute complications. He was discharged the same day as an outpatient with appropriate pain control. Short-term follow-up demonstrated no recurrent hernia present and symptoms resolved. Lumbar hernias are a rare occurrence with no gold standard technique for repair. The benefits of the laparoscopic approach have been described over the open approach. This case report describes utilizing a minimally invasive approach to primarily repair a lumbar hernia defect while also reinforcing the hernia with mesh in the preperitoneal space.

Keywords: general surgery; mesh placement; minimal invasive; petit's hernia; robotic-assisted surgery.

Figure 1. Initial CT of the abdomen/pelvis demonstrating a right lumbar defect containing fat (see blue arrow)

Figure 2. (A) Preoperative CT of the abdomen/pelvis, axial view, demonstrating a right lumbar defect now containing cecum. (B) Same image, structures labeled

Figure 3. Preoperative CT of the abdomen/pelvis, coronal view, demonstrating a right lumbar defect now containing cecum (see blue arrow)

Figure 4. Right inferior lumbar hernia, contents reduced, peritoneum intact

Figure 5. (A) Peritoneum taken down, now exposing fascial defect. (B) Structures labeled: (1) iliac crest, (2) quadratus lumborum, (3) transversalis fascia/transversus abdominis, and (4) upright inferior lumbar triangle defect

Figure 6. (A) Closure of the peritoneal flap; no mesh is exposed. (B) Same view with the suture line highlighted in blue