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Original Report |
1
Department of Radiology, Shock Trauma Center, University of Maryland Medical
System, 22 S. Greene St., Baltimore, MD 21201-1595.
2
Department of Radiology, Ottawa Hospital, Civic Campus, 1053 Carling Ave.,
Ottawa, Ontario K1Y 4E9, Canada.
3
Department of Radiology, Riverside Regional Medical Center, 500 J. Clyde
Morris Blvd., Newport News, VA 23601.
Received May 18, 1999;
accepted after revision October 11, 1999.
Address correspondence to K. L. Killeen.
Abstract
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CONCLUSION. CT can reveal traumatic lumbar hernia and show both the anatomy of disrupted muscular layers and the presence of herniated intraabdominal viscera or retroperitoneal fat.
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Traumatic abdominal wall hernias are easily missed in patients with multiple injuries because abdominal wall tenderness and ecchymosis may be the only findings. Historically, diagnosis has been made at exploratory laparotomy performed for other reasons because the overall incidence of additional intraabdominal injuries in patients with traumatic abdominal wall hernias is approximately 30% [2]. However, diagnosis of these injuries before surgery will become more common as the use of CT for the detection of intraabdominal injuries increases in patients suffering from blunt trauma. Because bowel incarceration and strangulation can occur in up to 25% of patients [3], it is crucial that intraabdominal injuries are recognized.
We describe 15 patients with traumatic abdominal wall hernias occurring in the lumbar triangle identified on CT before surgery. Fourteen patients had traumatic hernias through the inferior lumbar (Petit's) triangle, which is an upright triangle bordered by the iliac crest inferiorly, the external oblique muscle anteriorly, and the latissimus dorsi muscle posteriorly. One patient had a traumatic hernia through the superior lumbar (Grynfeltt-Lesshaft) triangle, which is an inverted triangle bordered by the 12th rib superiorly, the internal oblique muscle anteriorly, and the erector muscle of the spine posteriorly. Both triangles are areas of relative weakness in the posterolateral abdominal wall. We review the CT findings of traumatic abdominal wall hernia occurring in the lumbar triangle, and we discuss the mechanisms of injury and treatment.
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In fourteen patients, CT was performed on a helical scanner (Somatom Plus 4; Siemens Medical Systems, Iselin, NJ), and in one patient, CT was performed on another helical scanner (PQ-2000; Picker Medical Systems, Highland Heights, OH). In all patients, CT was performed with 8-mm collimation and pitch of 1:1 from the dome of the diaphragm to the public symphysis after administration of 150 ml of iohexol (Omnipaque 240; Winthrop-Breon Pharmaceuticals, Barcolenta, Puerto Rico) in 12 patients or 150 ml of iohexol (Omnipaque 300; Winthrop-Breon Pharmaceuticals) in two patients. One patient received IV contrast material but extravasation occurred around the IV line. All 15 patients received oral contrast material before undergoing CT.
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Fourteen patients had traumatic hernias through Petit's triangle. Of these 14 patients, 10 had right-sided hernias and four had left-sided hernias. Three patients had herniation of the colon through Petit's triangle (Fig. 1), two had herniated small bowel and colon, and nine had herniation of retroperitoneal fat (Fig. 2). Associated abdominal injuries were identified in nine patients, including injuries to the liver (n = 3), spleen (n = 3), mesentery (n = 5), small bowel (n = 1), kidney (n = 3), pancreas (n = 1), rectum (n = 1), ureteropelvic junction (n = 1), and adrenal artery (n = 1). Five patients had no additional intraabdominal injuries. Of the 14 patients, only one had clinical signs of a hernia, with a focal reducible mass in the right lower quadrant.
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Five patients with hernias through Petit's triangle underwent exploratory laparotomy for their injuries, during which three of the hernias were surgically confirmed and repaired. One patient underwent surgery for intraabdominal injuries, but the lumbar hernia was not addressed (Fig. 3). This patient subsequently developed a bowel obstruction 1 week later, and herniation of the sigmoid colon, mid ileum, and the left fallopian tube was found at exploratory laparotomy. Another patient underwent surgery for a rectal injury but the hernia was not addressed. The remaining nine patients were treated without surgery. One patient had a traumatic hernia through the Grynfeltt-Lesshaft triangle, with herniation of the ascending colon (Fig. 4). No additional intraabdominal injuries were identified in this patient at exploratory laparotomy, and the defect was repaired.
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Acute traumatic lumbar hernia is a rare type of abdominal wall hernia, occurring in either the Grynfeltt-Lesshaft triangle or in Petit's triangle. Both are areas of relative weakness in the posterolateral abdominal wall. Most hernias through these areas [4] occur either spontaneously or after surgical procedures, such as flank incisions or iliac bone graft procedures [5].
Acute blunt abdominal trauma is a rare cause of acquired lumbar hernia [6]. Our literature search discovered fewer than 20 cases of traumatic lumbar hernias. In those cases, the mechanism of injury was assumed to be seat belt use [3, 7,8,9], which allows exposure of the abdominal wall musculature to full deceleration forces. The increased intraabdominal pressure associated with seat belt injuries more commonly causes a diaphragmatic hernia; however, both increased pressure and deceleration forces applied to the abdominal muscles can cause avulsion injuries that may occur with or without herniation of peritoneal or retroperitoneal contents [7, 10]. Use of shoulder belts in combination with lap belts was suggested as a way to avoid such injuries [7]; however, improper use of the three-point restraint was a cause of a similar injury [9].
Delivery of a force sufficient to disrupt abdominal wall musculature commonly creates additional visceral or solid organ injuries, especially in patients exhibiting abdominal wall contusion (seat belt sign) [11]. Delayed diagnosis of traumatic lumbar hernia is therefore common because hernias are easily overlooked while other injuries are being addressed. Physical examination may reveal a reducible mass associated with pain and bruising just superior to the iliac crest. Auscultation over the area may reveal bowel sounds. However, initial physical examination findings may be normal, and diagnosis may not be made until exploratory laparotomy. If not recognized, traumatic lumbar hernias will typically increase in size [4], resulting in long-term morbidity ranging from chronic lower back pain to bowel incarceration in 25% and strangulation in 10% of patients [3]
Esposito and Fedorak [3] reported that the presence of an acute traumatic lumbar hernia alone is an indication for laparotomy because of the high incidence of associated hollow viscus and mesenteric injuries. Other researchers advocate clinical treatment of asymptomatic impalpable lumbar hernias identified on CT [6]. Repair of nontraumatic or congenital lumbar defects has generally been performed from the retroperitoneal approach, but in the setting of acute trauma, the approach is usually transperitoneal to allow identification of associated abdominal injuries. However, because CT can allow detection of additional injuries and because treatment of solid organ injuries without surgery is becoming more common, primary repair of traumatic lumbar hernias can be performed through the retroperitoneum. For larger defects, use of muscle or fascial flaps or prosthetic material has been advocated [3].
Previously, conventional radiology was useful for diagnosis, with lateral or oblique abdominal radiographs showing gas-filled loops outside of the abdominal cavity [12]. More recently, CT has been useful in some cases [3, 6, 8]; however, our study is the largest series in which the diagnosis was first suggested by CT examination. CT can accurately show the anatomy of the disrupted musculature layers, show the presence of herniated intraabdominal viscera or retroperitoneal fat, and show associated intraabdominal injuries.
As more patients suffering from serious blunt abdominal trauma undergo CT examination, traumatic lumbar hernia will be more commonly identified as an unsuspected finding before surgery. Careful attention should be given to the abdominal wall and muscular insertions when reviewing CT images, particularly in patients with a history of seat belt restraint or CT evidence of subcutaneous contusion caused by seat belt use. Additionally, CT can be useful in the examination of patients suspected clinically of having traumatic lumbar hernias. It can reveal the muscular and fascial layers, show the presence of defects, and reveal the contents of the hernia before repair. It can also allow differentiation of a hernia from hematoma or abscess, both common entities after blunt trauma.
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