The Journal of Radiology Case Reports - interactive Radiology case reports and Radiology review articles

Journal of Radiology Case Reports

Incarcerated Grynfeltt-Lesshaft Hernia

Case Report

Max Scheffler1*, Julien Renard2, Pascal Bucher3, Diomidis Botsikas1

Radiology Case. 2015 Apr; 9(4):9-13 :: DOI: 10.3941/jrcr.v9i4.2073

Cite this paper

1. Department of Radiology, Geneva University Hospital, Geneva, Switzerland
2. Department of Urology, Geneva University Hospital, Geneva, Switzerland
3. Department of General and Gastrointestinal Surgery, Clinique La Colline, Geneva, Switzerland

Bookmark and Share


         



  ABSTRACT
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

Superior lumbar triangle hernia, also known as Grynfeltt-Lesshaft hernia, denotes a subtype of abdominal wall hernia, and more specifically of lumbar hernia, occurring between the 12th rib, the internal oblique muscle, and the quadratus lumborum muscle. We report the case of a 92-year-old female patient in which this form of hernia occurred, complicated by incarceration and acute bowel obstruction. The discussion contains a short résumé of the different kinds of abdominal wall hernias.








  CASE REPORT
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

A 92-year-old female with a past medical history of obesity, hypertension, chronic renal failure and chronic obstructive pulmonary disease (COPD) was admitted to our emergency department with right sided abdominal pain, loss of appetite, nausea, and absence of gas and stool for 24 hours.
Physical examination revealed abdominal distension in association with high-pitched bowel sounds. At inspection, a right lumbar scar was noted, without any notion of former abdominal surgery in the patient`s chart.

Imaging findings
Bowel obstruction was suspected and an abdominal plain film requested which showed dilated small bowel loops and cecum (Fig. 1 Preview this figure

Figure 1: Conventional Radiography
Grynfeltt-Lesshaft hernia. Abdominal supine plain radiograph of a 92-year-old woman with clinical bowel obstruction shows multiple dilated small bowel loops as well as distended cecum (C). The remaining colon is not aerated.
). The patient then underwent unenhanced abdominal computed tomography (CT). One single acquisition with 2 mm thick slices was performed on a multi-detector row CT scanner (Mx800 IDT 16; Philips Medical Systems, Best, The Netherlands). Multiplanar images were reconstructed using OsiriX medical imaging software (Pixmeo, Bernex, Switzerland). The CT showed a herniation of a segment of the ascending colon and surrounding fat into the posterior abdominal wall, with the herniation sac located just below the right 12th rib (Fig. 2 Preview this figure
Figure 2: Computed Tomography
Grynfeltt-Lesshaft hernia in a 92-year-old woman. Axial (a, b) and coronally reconstructed (c) unenhanced abdominal computed tomography images show right posterolateral abdominal wall mass, consistent with incarcerated Grynfeltt-Lesshaft hernia containing right colon. (a) Hernia (squiggly arrow) is shown with afferent loop (straight arrow) in continuity with proximally dilated cecum (C). Note dilated small bowel loops (*). (b) Image slice at a slightly more cranial level shows efferent loop (arrow) leaving hernia sac. (c) Coronal reconstruction shows hernia sac in right abdominal wall (arrow). Right 11th rib is seen (arrowhead). Note also fat stranding next to hernia (*). Technical parameters: Philips Mx8000 IDT 16 CT scanner; tube voltage, 120 kVp; tube current 396 mA; slice thickness, 2 mm.
). The cecum and small bowel loops proximal to the hernia were dilated, suggesting bowel obstruction, and there was an area of fat stranding around the hernia sac. Intraperitoneal free fluid was present but no signs of bowel perforation.

Management
The patient underwent emergency abdominal laparoscopic surgery with reduction of the hernia and closure of the abdominal wall defect, with deployment of a nonabsorbable polypropylene mesh prosthesis. No intestinal resection was necessary.

Follow-up
The patient was discharged from the hospital ten days later. No radiological or clinical follow-up took place at our institution.

  DISCUSSION
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

Etiology & demographics
Abdominal wall hernias, also called external hernias develop in 1.5% of the population and signify a protrusion of abdominal structures through a defect in the abdominal wall, usually implicating a site of congenital or acquired weakness [1,2]. Herniating structures may be peritoneum, fat (properitoneum, greater omentum), hollow visceral organs including the gall bladder [3], solid organs (for example parts of the liver or kidney), or the urinary bladder. Their etiology may be congenital, traumatic, constitutional, or post-operative. The latter are designated as incisional hernias and may occur in up to 5% of patients after abdominal surgery, typically within the first year [2]. Parastomal hernia is a subtype of incisional hernia. A small percentage of incisional hernias may be clinically occult [2]. Their formation may be precipitated by factors associated with increased intra-abdominal pressure, such as abdominal mass, ascites, physical exertion, pregnancy, constipation or COPD [1].

Among the different hernia subtypes, groin hernias are common, constituting over half of all operated abdominal wall hernias [4]. Differentiation is made between indirect and direct inguinal hernias and femoral hernias. Direct inguinal hernias are located medially to the inferior epigastric vessels, whereas indirect inguinal hernias commence laterally of them. Femoral hernias protrude inferior to the inguinal ligament, remain usually located lateral to the pubic tubercle and may compress the femoral vein [5]. Femoral hernias are more common in females, with a ratio of 1.8:1 [1,6].

In a more posterior position, protruding between the adductor muscles is the rare obturator hernia.

Among the anterior, or ventral, hernias should be mentioned umbilical hernias, the second most commonly operated hernia, prevailing in women [6]. Other ventral midline hernias may be due to rectus abdominis muscle diastasis at the linea alba aponeurosis, with epigastric, paraumbilical, or hypogastric locations. Antero-lateral defects in the linea semilunaris, between the aponeuroses of the transverse and oblique abdominal muscles are called Spigelian hernia.

Lumbar hernias finally are more common in elderly men and have a predilection for the left side [7]. The most common age at presentation is 50-70 years [7]. As of 2008, about 300 cases had been described in the literature [1]. They are divided into two subtypes, depending on their anatomic location. When herniation is present through the lower lumbar triangle, bordered by the iliac crest, the external oblique muscle, and the latissimus dorsi muscle, it is called Petit hernia. Petit hernia has been described after iliac bone graft donation or non consolidated iliac fracture [7]. When the defect lies in the upper lumbar triangle, bordered by the 12th rib, the internal oblique muscle, and the quadratus lumborum muscle, it is called Grynfeltt-Lesshaft hernia. The upper lumbar triangle is covered internally by the transversalis fascia and externally by the external oblique muscle. It may also be covered by the latissimus dorsi muscle, but this muscle does not provide sufficient anatomical support for it [8]. Grynfeltt-Lesshaft hernia has first been described by Joseph Grynfeltt in Montpellier in 1866 [9] and then independently by Petr Lesshaft in Leipzig in 1870 [10]. It is more common than Petit hernia, the Petit triangle having a stronger musculofascial floor [11,12]. Very rarely, Grynfeltt-Lesshaft hernia may be congenital [13]. It may appear spontaneously [8], after trauma, or as an incisional hernia, the latter having accounted for 26% of reported Grynfeltt-Lesshaft hernias [11]. About 25% of lumbar hernias lead to bowel incarceration, and 10% result in strangulation [1].

Clinical & imaging findings
Abdominal wall hernias cause discomfort or a dragging or painful sensation [7] and may be clinically detected as an bulging mass, but sometimes prove difficult to diagnose on physical examination, particularly in obese or postoperative patients, as it was the case in our patient [2,4,7,13]. Lumbar hernias may simulate different parietal masses on physical examination, such as hematoma, abscess, seroma, lipoma, hemangioma, or fibroma [1,6]. Strangulation (compromise in vascularization) may be associated as well as incarceration (non reducibility) or volvulation. If bowel obstruction is present, typical clinical signs include nausea, vomiting and abdominal distention. In fact, hernias are the second most common cause of small bowel obstruction after adhesions. Intercostal neuralgia may also result from abdominal wall hernia [7].

Plain radiography has a limited role in showing signs of bowel obstruction, rarely may air be detected within the parietal hernia sac. Barium-enhanced radiographic studies are nowadays less commonly performed. For uncomplicated groin hernias real-time sonography is the imaging technique of choice [14], and multi-detector row CT for other kinds of abdominal wall hernia. CT should comprise multiplanar reconstructions and allows for detailed anatomic analysis of implicated muscular and fascial structures. As opposed to the case here presented, CT should generally be performed with intravenous injection of iodinated contrast media, in order to evaluate for vascular compromise [6]. Imaging acquisition under Valsalva`s maneuver may help detect subtle and non incarcerated hernias [6]. Contrast-enhanced CT is also sensible for signs of intestinal suffering associated with an incarcerated hernia, namely wall thickening, lacking wall enhancement, fat stranding, and free fluid in the herniation sac or elsewhere in the peritoneal cavity [6].

Our patient revealed a previous right lumbar flank incision, for unknown reasons (the right kidney was present), at the site of her lumbar hernia. She had a history of COPD, a know risk factor for abdominal wall hernias. Having excess weight, she presented an example for a clinically difficult to detect abdominal wall hernia, not palpable in her case, and several other causes would have been conceivable for the signs of bowel obstruction she presented.

Treatment & prognosis
Even if asymptomatic, abdominal wall hernias should be surgically repaired with mesh-graft deployment, to prevent further complications such as incarceration with obstruction, or strangulation. A simple surgical technique has been described by Solaini et al. [15]. Surgical complications comprise infection, sterile fluid collections with symptomatic mass effect, fibrosis around mesh graft. Hernia recurrence may also occur.
Differential Diagnoses
None in imaging. Clinically abdominal wall tumor may be suspected, such as lipoma, hemangioma or fibroma, as well as other mass lesions like hematoma, seroma, or abscess.

  TEACHING POINT
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

Grynfeltt-Lesshaft hernia designates a superior lumbar triangle hernia, a quarter of which are of postincisional origin. It is a subtype of abdominal wall hernia that may be difficult to detect clinically or simulate other parietal masses, the diagnosis is usually posed by CT.








  FIGURES
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

Display figure 1 in original size

Figure 1: Grynfeltt-Lesshaft hernia. Abdominal supine plain radiograph of a 92-year-old woman with clinical bowel obstruction shows multiple dilated small bowel loops as well as distended cecum (C). The remaining colon is not aerated.

Figure 1: Conventional Radiography (Open in original size)
Grynfeltt-Lesshaft hernia. Abdominal supine plain radiograph of a 92-year-old woman with clinical bowel obstruction shows multiple dilated small bowel loops as well as distended cecum (C). The remaining colon is not aerated.

Back Back


Display figure 2 in original size
Figure 2: Grynfeltt-Lesshaft hernia in a 92-year-old woman. Axial (a, b) and coronally reconstructed (c) unenhanced abdominal computed tomography images show right posterolateral abdominal wall mass, consistent with incarcerated Grynfeltt-Lesshaft hernia containing right colon. (a) Hernia (squiggly arrow) is shown with afferent loop (straight arrow) in continuity with proximally dilated cecum (C). Note dilated small bowel loops (*). (b) Image slice at a slightly more cranial level shows efferent loop (arrow) leaving hernia sac. (c) Coronal reconstruction shows hernia sac in right abdominal wall (arrow). Right 11th rib is seen (arrowhead). Note also fat stranding next to hernia (*). Technical parameters: Philips Mx8000 IDT 16 CT scanner; tube voltage, 120 kVp; tube current 396 mA; slice thickness, 2 mm.

Figure 2: Computed Tomography (Open in original size)
Grynfeltt-Lesshaft hernia in a 92-year-old woman. Axial (a, b) and coronally reconstructed (c) unenhanced abdominal computed tomography images show right posterolateral abdominal wall mass, consistent with incarcerated Grynfeltt-Lesshaft hernia containing right colon. (a) Hernia (squiggly arrow) is shown with afferent loop (straight arrow) in continuity with proximally dilated cecum (C). Note dilated small bowel loops (*). (b) Image slice at a slightly more cranial level shows efferent loop (arrow) leaving hernia sac. (c) Coronal reconstruction shows hernia sac in right abdominal wall (arrow). Right 11th rib is seen (arrowhead). Note also fat stranding next to hernia (*). Technical parameters: Philips Mx8000 IDT 16 CT scanner; tube voltage, 120 kVp; tube current 396 mA; slice thickness, 2 mm.

Back Back


Display figure 3 in original size
Figure 3: Summary table of Grynfeltt-Lesshaft hernia.

Figure 3: Table (Open in original size)
Summary table of Grynfeltt-Lesshaft hernia.

Back Back


Display figure 4 in original size
Figure 4: Differential diagnosis table for Grynfeltt-Lesshaft hernia.
Clinically, an abdominal wall tumor may be suspected, such as lipoma, sarcoma or hemangioma, as well as entities like abscess, seroma, or hematoma. On ultrasound or CT, these masses are characterized by the absence of a wall defect and a hernia neck, as no communication exists between the parietal mass and the peritoneal or retroperitoneal space.


Figure 4: Table (Open in original size)
Differential diagnosis table for Grynfeltt-Lesshaft hernia.
Clinically, an abdominal wall tumor may be suspected, such as lipoma, sarcoma or hemangioma, as well as entities like abscess, seroma, or hematoma. On ultrasound or CT, these masses are characterized by the absence of a wall defect and a hernia neck, as no communication exists between the parietal mass and the peritoneal or retroperitoneal space.


Back Back


Display figure 5 in original size
Figure 5: Differential diagnosis table for parietal hernia.

Figure 5: Table (Open in original size)
Differential diagnosis table for parietal hernia.

Back Back


  REFERENCES
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion



1. Gore RM, Levine MS. Textbook of gastrointestinal radiology. 3rd ed Philadelphia, PA: Saunders Elsevier, 2008; 2156-2165 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

2. Miller PA, Mezwa DG, Feczko PJ, Jafri ZH, Madrazo BL. Imaging of abdominal hernias. RadioGraphics 1995;15:333-347 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

3. Rosenblum JK, Dym RJ, Sas N, Rozenblit AM. Gallbladder torsion resulting in gangrenous cholecystitis within a parastomal hernia: findings on unenhanced CT. J Radiol Case Rep 2013;7:21-25 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

4. Aguirre DA, Casola G, Sirlin CB. Abdominal wall hernias: MDCT findings. AJR Am J Roentgenol 2004;183:681-690 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

5. Suzuki S, Furui S, Okinaga K, Sakamoto T, Murata J, Furukawa A, Ohnaka Y. Differentiation of femoral versus inguinal hernia: CT findings. AJR Am J Roentgenol 2007;189:W78-W83 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

6. Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics 2005;25:1501-1520 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

7. Baker ME, Weinerth JL, Andriani RT, Cohan RH, Dunnick NR. Lumbar hernia: diagnosis by CT. AJR Am J Roentgenol 1987;148:565-567 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

8. Walsh M, Springfield DS. Spontaneous lumbar hernia. J Bone Joint Surg 2004;86:1526-1527 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

10. Lesshaft P. Die Lumbalgegend in anatomisch-chirurgischer Hinsicht. Archiv für Anatomie, Physiologie und wissenschaftliche Medicin Leipzig 1870;37:264-300. Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

11. Orcutt TW. Hernia of the superior lumbar triangle. Ann Surg 1971;173:294-297 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

12. Virgilio F. L`ernia lombare. Arch Ital Chir 1825;14:337-417. Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

13. Shiki S, Kuwata Y, Kashihara E, Ueda U, Fuchimoto S, Orita K. A case of superior lumbar hernia. Jpn J Surg 1991;21:696-699 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

14. Whalen HR, Kidd GA, O`Dwyer PJ. Femoral hernias. BMJ Brit Med J 2011;8:d7668 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

15. Solaini L, Di Francesco F, Gourgiotis S, Solaini L. A very simple technique to repair Grynfeltt-Lesshaft hernia. Hernia 2010;14:439-441 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

Back Back

  ABBREVIATIONS
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

COPD = chronic obstructive pulmonary disease
CT = computed tomography
MRI = magnetic resonance imaging









  MORE IMAGES
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

Find more cases and images for:

Abdominal wall hernia at Radiolopolis or Radiology Search
Incisional hernia at Radiolopolis or Radiology Search
Grynfeltt-Lesshaft hernia at Radiolopolis or Radiology Search
Upper lumbar triangle hernia at Radiolopolis or Radiology Search
Computed tomography at Radiolopolis or Radiology Search









  YOUR OPINION
Top
Abstract
Case Report
Discussion
Teaching Point
Figures
References
Abbreviations
More Images
Your opinion

Let us know what you think!












Cite this paper


©2020 Journal of Radiology Case Reports :: www.RadiologyCases.com :: Published by EduRad