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J Ped Surg Case Reports 2 (2014) 101e103

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Journal of Pediatric Surgery CASE REPORTS

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Laparoscopic repair for a congenital lumbar hernia with free fascialata graft reinforcement

Keiichi Morita*, Go Miyano, Hiroshi Nouso, Koji Fukumoto, Masaya Yamoto,Hiromu Miyake, Masakatsu Kaneshiro, Naoto UrushiharaDepartment of Pediatric Surgery, Shizuoka Children’s Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka 420-8660, Japan

a r t i c l e i n f o

Article history:Received 10 January 2014Received in revised form3 February 2014Accepted 3 February 2014Available online 26 February 2014

Key words:Congenital lumbar herniaFascia lataLaparoscopyLumbocostovertebral syndrome

* Corresponding author. Tel.: þ81 54 247 6251; fax:E-mail address: keimorita1209@gmail.com (K. Mor

2213-5766 � 2014 The Authors. Published by Elsevierhttp://dx.doi.org/10.1016/j.epsc.2014.02.007

a b s t r a c t

Congenital lumbar hernias are rare, and the optimal surgical procedures for hernia repair are stillcontroversial. A 13-month-old girl with a left-sided, 7 cm � 7 cm, congenital lumbar hernia underwentlaparoscopic repair with autologous free fascia lata graft reinforcement. At 6 months, she was doing wellwith no recurrence of the hernia. Laparoscopic repair with free fascia lata graft reinforcement is a safeand feasible surgical option for the treatment of large congenital lumbar hernias.

� 2014 The Authors. Published by Elsevier Inc.Open access under CC BY-NC-ND license.

Congenital lumbar hernias are rarely seen in infancy and child-hood, and only about 60 cases have been reported in the Englishliterature [1]. Less than 35 cases of congenital lumbar hernias wererelated to the lumbocostovertebral syndrome [2]. The lumbocos-tovertebral syndrome was defined as the association of congenitallumbar hernia, costal defects, and vertebral anomalies by Toulou-kian [3]. Because of the rarity of congenital lumbar hernia, appro-priate surgical procedures for repair are still controversial, andlaparoscopic repair has been reported in only a few cases. Thelaparoscopic repair of a congenital lumbar hernia related to thelumbocostovertebral syndrome with free fascia lata graft rein-forcement is reported.

1. Case report

A 2.49-kg female infant was born vaginally at 40 weeks’ gesta-tion. The Apgar score was 9 at 5 min. Immediately after birth, shewas noted to have a left-sided, 3 cm � 3 cm, lumbar hernia.Computed tomography demonstrated a left-sided lateral lumbarmuscular layer defect characterized by ipsilateral 9th to 11th rib

þ81 54 247 6259.ita).

Inc.Open access under CC BY-NC-ND

agenesis. Furthermore, malformation of the right 1st to 3rd and 8thto 10th ribs and the left 6th to 8th and 12th ribs, Th10 and Th11hemivertebrae, and a sinistral convex scoliosis were seen. Magneticresonance imaging revealed a lateral meningocele and a tetheredcord. She was referred to our hospital for further treatment at 10months of age. The lumbar hernia protruded considerably withcrying, and it was reducing spontaneously (Fig. 1). The hernialdefect enlarged to 7 cm � 7 cm, and the hernia sac contained thestomach, spleen, and colon (Fig. 2). Since the hernia sac was adja-cent to the lateral meningocele, the meningocele had been previ-ously repaired at 12 months of age. At 13 months of age, the lumbarhernia was repaired laparoscopically.

Under general anesthesia, the patient was placed in a semi-lateral position on her right side. A 5-mm trocar was insertedumbilically, and CO2 was insufflated to a pressure of 8 mm Hg.Under visual 45� 5-mm laparoscopic guidance, the other two tro-cars (5 and 12mm)were then placed along themidclavicular line inthe right upper and left lower quadrants. The hernia sac in the leftlumbar wall was inspected, and a peritoneal flap was raised. Sincethe hernia bulged outward with pneumoperitoneum, the edges ofthe hernia defect were well identified (Fig. 3). The ventral side ofthe defect was closed by approximation of the surroundingmuscular layers. 2-0 non-absorbable sutures were passed percu-taneously through the superior muscular edge of the hernia defectinto the peritoneal cavity with a Lapa-Her-Closure needle (Hakko,Nagano, Japan) and passed through the inferior muscular edge of

license.

Fig. 1. Photograph of the patient demonstrating the left-sided lumbar hernia.

Fig. 3. Laparoscopic view of the hernial defect (arrows) after raising a peritoneal flap(arrow head).

K. Morita et al. / J Ped Surg Case Reports 2 (2014) 101e103102

the hernia defect, and then taken out through the abdominal wall,exiting at the entry point. All the sutures were tied within thesubcutaneous plane. On the dorsal side, since the postero-superiorborder of the defect was the rib, the tension to close directly wasstrong. Therefore, the dorsal defect was repaired with free fascialata graft reinforcement. A transverse incision approximately 3-cmlong was made on the lateral side of the left thigh, and a piece offascia lata measuring 5 cm � 4 cm was harvested. The fascia latagraft with three stay sutures was inserted into the abdominal cavityand positioned (securing the stay sutures to the cardinal points ofthe hernial edges using a Lapa-Her-Closure needle inserted throughthe abdominal wall into the abdominal cavity). The ventral sutureline and the dorsal defect were covered with a fascia lata graft, andthe graft was secured to the surrounding muscular layers with

Fig. 2. Radiograph showing the hernia sac with the gastric air bubble and air-filledloops of bowel, costovertebral anomalies, and scoliosis.

interrupted 3-0 non-absorbable sutures (Fig. 4). The peritoneal flapwas replaced to cover the patch with interrupted 4-0 absorbablesutures.

There were no perioperative complications. The patient wasdischarged on postoperative day 14, and she showed no recurrenceof the hernia (Fig. 5) or functional deficit of the left lower limb 6months after surgery.

2. Discussion

Lumbar hernia is defined as the protrusion of organs through acongenital defect in the posterolateral abdominal wall [4]. Lumbarhernias classically occur in three spaces of the lumbar wall: the

Fig. 4. The dorsal hernial defect is reinforced with a fascia lata graft (arrow). Theperitoneal flap (arrow head) is visible in the left part of the image.

Fig. 5. Photograph 3 months after surgery showing no recurrence of the hernia.

K. Morita et al. / J Ped Surg Case Reports 2 (2014) 101e103 103

superior triangle (Grynfeltt hernia), the inferior triangle (Petithernia), and diffusely in the lumbar area [4]. Congenital lumbarhernias associated with the lumbocostovertebral syndrome havevarious forms different from the previous noted classical threetypes. In the present case, the hernia occurred through the inter-costal space between the left 8th and 12th ribs, and it was moresuperior and more lateral than the Grynfeltt hernia. The presentfindings are similar to those reported by Akçora [1] and Sengar [2].The etiology of lumbar hernia in these cases may be associated withthe agenesis of ipsilateral multiple ribs and defects of musclesinserted on those ribs [1,2].

Elective surgical repair of a congenital lumbar hernia is sug-gested at any early age to prevent incarceration and strangulation[5,6]. Furthermore, operative repair before 12 months of age isrecommended because the hernia defect may enlarge with growth,as in the present case, making primary direct closure with sur-rounding tissue difficult [7]. Because of the rarity of congenitallumbar hernia, appropriate surgical procedures are still controver-sial. Open repair has been performed in most patients [1e3,5e7],and, to the best of our knowledge, laparoscopic repair has beenreported in only two patients [8,9]. In the present case, the hernialdefect was large, and surrounding abdominal wall muscles werehypoplastic. Therefore, the edges of the muscular layer defect werenot clear under general anesthesia. Since the hernia bulged out-ward with pneumoperitoneum, the edges of the muscular layerdefect were identified easily and exactly. From the viewpoint ofcertain hernial defect closure, we consider that laparoscopic repairis effective for a large hernial defect. The laparoscopic intra-corporeal suture technique for direct closure of the hernia defect istechnically demanding and doubtful [8]. Placement of full-thick-ness muscular layer stitches with a Lapa-Her-Closure needle andextracorporeal knot tying in the subcutaneous tissue allowmaximum strength of repair. Furthermore, in reinforcing thehernial defect with a fascia lata graft laparoscopically, completecovering of the defect is necessary to prevent recurrence. Initialfixation of the graft with stay sutures and a Lapa-Her-Closureneedle enabled correct reinforcement of the hernia defect in thepresent case.

In patients with large hernial defects, reinforcement withprosthetic materials, such as a polypropylene mesh [5,8], is gener-ally performed. However, prosthetic materials may lead to infec-tion, local growth disorders, or recurrences in pediatric patients.Therefore, in the present case, reinforcement with an autologous

free fascia lata graft was chosen. Because the fascia lata is one of thestrongest fascial layers in the body, it has often been used for therepair of abdominal defects in adult patients [10]. A free fascia latagraft remains viable after implantation, and it is revascularizedwithin 3 weeks [11]. Since the autologous materials are expected togrow with the patient, we consider that the risk of growth disorderor recurrence after the repair with autologous fascia lata is less thanthat after repair with prosthetic materials in the long term. Afunctional deficit of the donor site due to fascial harvest is animportant consideration in the pediatric age group. The posteriorcondensation of the iliotibial tract should be preserved to minimizethe risk of lateral knee instability [10]. In our institution, the freefascia lata graft has been used in three pediatric patients (two pa-tients with recurrence of tracheoesophageal fistula, one patientwith recurrence of congenital diaphragmatic hernia [12]). All threepatients showed no functional deficit of the donor site after fascialata harvesting.

3. Conclusion

Since congenital lumbar hernias associated with the lumbo-costovertebral syndrome have various forms, determining theappropriate surgical procedures for individual patients is chal-lenging. Laparoscopic repair with free fascia lata graft reinforce-ment is a safe and feasible surgical option for large congenitallumbar hernias associatedwith the lumbocostovertebral syndrome.

Consent

Written informed consent was obtained from the patient’sparents for publication of this case report and accompanying im-ages. A copy of the written consent is available for review by theEditor-in-Chief of this journal on request.

Conflict of interest statementThe authors have no conflict of interest to disclose.

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