Editor’s note: The 14 ACS Advisory Councils, which serve as liaisons in the communication of information to and from surgical societies and the Regents, periodically submit articles on notable initiatives taking place in their respective specialties.
This week’s issue features a submission from the Advisory Council for Plastic and Maxillofacial Surgery.
Abdulaziz Elemosho, MD, and Jeffrey E. Janis, MD, FACS
Post-traumatic non-iatrogenic lumbar/flank hernias (PTLFHs) are rare, composing less than 1.5% of all hernias. These hernias specifically develop following blunt or penetrating abdominal trauma and belong to the broader category of secondary lumbar/flank hernias (LFHs), which also includes iatrogenic hernias resulting from surgical incisions. In contrast, primary LFHs—constituting over 75% of all LFH cases—occur spontaneously or due to congenital causes.
LFHs typically develop in the lumbar triangles and are classified accordingly. Inferior lumbar hernias, or Petit’s hernias, arise in the inferior lumbar triangle (Petit’s triangle), while superior lumbar hernias, or Grynfeitt-Lesshaft hernias, originate in the superior lumbar triangle. A minority of patients may present with hernias spanning both triangles, termed diffuse-type LFHs.
Most reported PTLFHs result from motor vehicle crashes, falls from heights, or handlebar injuries. Inferior PTLFHs are significantly more common, accounting for more than 80% of cases, reflecting the typical distribution of traumatic forces during blunt abdominal trauma.
Classification of this LFH generally can be challenging. In fact, the utility of the European Hernia Society classification for LFH is limited, as it does not allow full characterization of the hernia. Moreno-Egea classification remains the well-applied classification LFHs and most PTLFHs fall into B-Type.
Early diagnosis and management of PTLFHs are crucial due to their predisposition to incarceration and strangulation. Mesenteric avulsion, a frequently reported and potentially fatal complication, often indicates the presence of additional intraabdominal injuries. This "bucket-handle" tear of the mesentery—characterized by detachment of bowel loops from their vascular supply—commonly occurs in high-velocity deceleration events such as motor vehicle collisions or falls and may lead to bowel ischemia, necessitating prompt surgical intervention.
Therefore, recognizing the clinical implications of PTLFHs and their association with visceral injuries is critical for guiding appropriate diagnostic strategies and treatment planning.
Diagnosis
Diagnosing PTLFHs can be challenging due to their atypical presentation. In the acute trauma setting, life-threatening injuries and other distracting injuries often take precedence, leading to missed or delayed diagnoses. A low index of suspicion for PTLFHs further contributes to underdiagnosis at the time of presentation.
Computed tomography (CT) is the gold standard for diagnosing PTLFHs. All patients with blunt abdominal trauma should undergo thorough radiologic evaluation to rule out PTLFHs. Patients undergoing CT imaging at the time of presentation are typically diagnosed earlier than those who do not.
While CT scans may not have high sensitivity for detecting mesenteric avulsions, they can identify predictors of mesenteric injuries, such as bowel wall perfusion defects, interloop fluid, intra-mesenteric bleeding, and hernia defect dimensions. Hernia defects larger than 8 cm or associated with flank hematomas, with or without seatbelt signs, warrant close evaluation for bowel and other intraabdominal organ injuries.
Management
Management of PTLFHs depends on several factors, including trauma severity, patient age, and hernia defect size. An algorithm guiding flow of management from diagnosis to definitive management has been described.
Hernia defect <8 cm is typically repaired using a minimally invasive laparoscopic approach with mesh, while defects ≥8 cm are repaired via open mesh repair. In pediatric patients, open primary suture repair without mesh is preferred, as mesh use is generally avoided in this population. For adult patients undergoing mesh repair, fixation of the mesh to the iliac crest may provide additional support.
PTLFHs diagnosed acutely can be repaired either acutely or electively, depending on the patient’s condition. Hemodynamically unstable patients or those with life-threatening injuries should be stabilized before undergoing elective repair. Patients undergoing exploratory laparotomy for intraabdominal injuries may have concurrent hernia repair.
Given the high risk of incarceration and strangulation, PTLFH repair should be prioritized as soon as feasible. However, non-operative management has been reported in a few cases. Finally, mesh repair is not contraindicated in patients with high risk of abdominal contamination (for example, perforated bowel or at risk). Management of this patient subset should be individualized.
