The lumbar hernia: A clinical conundrum

Lumbar hernias are rarely encountered as compared to other ventral abdominal wall hernias and are often misdiagnosed and overlooked. They account for less than 1.5% of all abdominal hernias. Fewer than 300 cases have been reported over the past 300 years. A lumbar hernia is defined as a protrusion of intra-abdominal contents through a weakness or rupture in the posterior abdominal wall. It must be distinguished from a lipoma, cold (tuberculous) abscess or a pseudo-hernia due to local muscular paralysis. Presenting a case of 65-year-old female who came to surgery OPD with complaint of a swelling in the right lumbar area since 5 years. On examination, a smooth and non-tender swelling measuring approximately 4 x 3 cm was evident in right lumbar region. We proceeded with a lumbar ultrasound which confirmed the presence of the hernia in posterior abdominal wall. Later, the patient was admitted for surgery under spinal anaesthesia. An open approach was performed and intraoperative findings revealed retroperitoneal fat, intermuscular lipoma and a small hernia sac as contents of swelling. It is very unusual to find lumbar hernias presenting with a lipoma, as in our case, the clinical findings alone can be very confusing and increase the chances of incorrect diagnosis and subsequent treatment. Inability of clinical examination and ultrasonography alone in making an adequate diagnosis of lumbar hernia in preoperative setting mandates a routine CT/MRI for all such patients, to ensure surgeons have a correct diagnosis before proceeding for surgery. Ideal management is just like other hernias, i.e., with mesh hernioplasty either laparoscopically or through an open approach.