GRYNFELT'S HERNIA

• DOI: 10.22533/at.ed.1592242215056

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• Abstract:

  Introduction: Lumbar hernias are characterized by posterolateral defects of the abdominal wall. When present in the superior lumbar triangle, it is called Grynfelt's hernia, being a diagnosis not commonly remembered. The report aims to demonstrate the importance of diagnosing this alteration in patients without indicative factors for the diagnosis.

  Case report: Female patient, 78 years old, presenting a bulge of approximately 6 cm in the left dorsal region. Diagnosed as a lipoma by ultrasound (USG). She underwent open surgical correction. The patient was positioned in the right lateral decubitus position, a lumbocostal incision was made, in the topography of the bulge. After dissection and dieresis, Grynfelt's hernia was identified with a hernia sac, which protruded through the muscle gap of approximately 3 cm. The hernia was reduced, the failure was synthesized with vicryl® 0 and a tension-free polypropylene mesh was fixed over the herniorrhaphy. The patient evolved well in the postoperative period and remains asymptomatic. 

  Discussion: Lumbar hernias represent about 2% of abdominal wall hernias, the majority being unilateral, on the left and in men between 50 - 70 years of age. Grynfelt's hernia forms in the superior lumbar triangle, in places of anatomical fragility: exit points of the posterior branches of the lumbar nerves and vascular structures. There is discontinuity of the posterolateral abdominal wall due to the presence of a failure in the transversalis fascia or in the aponeurosis of the transversus abdominis muscle. In general, it is asymptomatic, being diagnosed by high suspicion in the abdominal examination - presence of soft, reducible and asymptomatic swelling in the lumbar region - and confirmed by the computed tomography exam. About 25% of the cases present incarceration and up to 18% present strangulation, therefore, the accurate diagnosis is essential, being the main differential diagnoses to be considered: lipoma, hematoma, abscess after trauma or surgery and renal tumors. Treatment must be performed as early as possible to avoid complications, with open surgical correction being the treatment of choice. In the case reported, because it was a female and asymptomatic patient, we opted for investigation by US, being diagnosed as a lipoma. Surgical excision was chosen, but intraoperatively, Grynfelt's hernia was evidenced, and herniorrhaphy and repair with synthetic mesh were then performed. Simple herniorrhaphy, without repair with synthetic mesh, in these cases increases the recurrence rate due to the difficulty in making a simple suture without tension in this location. In view of the above, it is important to highlight that, despite being rare, Grynfelt's hernia needs to be a diagnosis to be remembered and investigated not only in symptomatic patients who are more prone to change, but in all patients with significant lumbar bulging. 

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