Perforated sigmoid diverticulitis in a lumbar hernia after iliac crest bone graft - a case report
- Florian S Frueh†1, 2,
- Raphael N Vuille-dit-Bille†1, 3,
- Dimitri A Raptis4,
- Hanspeter Notter1Email author and
- Brigitte S Muff1
© Frueh et al.; licensee BioMed Central Ltd. 2014
Received: 9 March 2014
Accepted: 18 July 2014
Published: 22 July 2014
The combination of perforated diverticulitis in a lumbar hernia constitutes an extremely rare condition.
We report a case of a 66 year old Caucasian woman presenting with perforated sigmoid diverticulitis localized in a lumbar hernia following iliac crest bone graft performed 18 years ago. Emergency treatment consisted of laparoscopic peritoneal lavage. Elective sigmoid resection was scheduled four months later. At the same time a laparoscopic hernia repair with a biologic mesh graft was performed.
This case shows a very seldom clinical presentation of lumbar hernia. Secondary colonic resection and concurrent hernia repair with a biologic implant have proven useful in treating this rare condition.
KeywordsPerforated diverticulitis Lumbar hernia Iliac crest bone graft Laparoscopic hernia repair Mesh
Hinchey classification of diverticulitis
Pericolic abscess or phlegmon
Pelvic, intra-abdominal or retroperitoneal abscess
Generalized purulent peritonitis
Lumbar hernias and especially those following iliac crest bone graft are extremely rare. Only about 300 cases have been reported in the literature . Strategies of surgical lumbar hernia repair include primary repair, local tissue flaps, open mesh repair or laparoscopic mesh repair . None of these methods has yet been defined or accepted universally.
Here, we describe an extremely rare combination of perforated diverticulitis in a lumbar hernia.
Lumbar hernias may arise in the superior and inferior lumbar triangle. The superior lumbar triangle hernia, first described by Grynfeltt and so named as Grynfeltt’s hernia, is bordered by the 12th rib, the erector spinae muscle and the internal oblique muscle. Similarly, the inferior lumbar triangle hernia is referred to as Petit’s hernia and is bordered by the latissimus dorsi muscle, the iliac crest and the external oblique muscle [5, 6, 8]. Both types of hernias may be divided into congenital and acquired lumbar hernias with the latter occurring after full-thickness iliac crest harvest or following nephrectomy. Risk factors for lumbar hernias include advanced age, female gender, obesity, and poorly developed abdominal muscles . Similarly to other abdominal wall hernias, optimal treatment of lumbar hernias requires surgical repair. But the approach to the posterior abdominal wall defect is challenging and the absence of a musculoaponeurotic layer, the weak posterior abdominal wall muscles and the limiting bony structures complicate dissection and fixation of a mesh . Different methods for hernia closure have been described including primary closure, rotational and onlay fascial flaps, prosthetic material, or straightening the iliac crest . Whereas primary closure is often inadequate for lumbar hernia repair due to high tension in the suture, rotational flaps need extensive tissue dissections and bear the risk of compromised vascularization. Prosthetic mesh placement displays a safe and effective method reducing the tension especially where there is significant separation of the margins. Open surgery brings the drawback of a large incision to clearly define the defect. A laparoscopic approach seems to be favorable due to less postoperative pain and earlier hospital discharge. For laparoscopic repair the literature recommends a semi-prone position with 45° elevation of the affected side in order to improve exposure by placing the intestine to the reverse side pursuant to gravity. Placement of trocars is endorsed subxiphoidly, periumbilically and suprapubicly . In the present case, the surgeon chose supine patient positioning allowing mesh placement and sigmoid resection with adequate overview without changing the position of the patient.
Standard procedures for purulent or fecal peritonitis (Hinchey III and IV) consist of Hartmann’s procedure or colonic resection with primary anastomosis in the acute phase, with or without protective ileostomy formation . Outcomes are amendable with about 10 per cent of patients showing stoma-related complications following Hartmann’s procedure and up to 14 per cent of patients showing anastomotic leakages following primary anastomosis . Furthermore, the stoma is never reversed in about two third of patients following Hartmann’s procedure .
Emergency laparoscopic lavage followed by colonic resection and anastomosis in a second procedure represents a relatively new strategy in the management of perforated diverticular disease. It was initially recommended for selected patients with Hinchey I and II perforated diverticulitis . More recently, several authors have reported laparoscopic lavage as a treatment option also for Hinchey III disease  providing adequate control of the acute inflammatory episode in most patients. Of course, laparoscopic lavage is to be reserved for patients with purulent peritonitis and abscesses not accessible to percutaneous image-guided drainage. Nevertheless, the Hinchey classification refers to intra-operative findings. Hence one advantage of laparoscopy is exploration of the peritoneal cavity in order to categorize patients. A further advantage is the relatively short operation time [10, 11].
Combination of perforated diverticulitis and lumbar hernia
The described clinical presentation represents an extremely rare finding. If the patient did not have a lumbar hernia and was suffering from perforated diverticulitis only, a laparoscopic drainage would have been performed due to free bowel perforation as reported in the CT scan. As laparoscopic mesh repair is the recommended treatment option for secondary lumbar hernia repair by many authors [5, 6, 8, 9], we decided to combine these two procedures. Of course, it is imperative that implanting foreign material, even biological, should be avoided in an acute infection. Hence, laparoscopic hernia reduction was combined with laparoscopic peritoneal lavage and mesh repair was performed simultaneously with secondary colonic resection and anastomosis. The advantage of this “two-step” procedure is the avoidance of a third general anesthesia (including possible peri- and postoperative complications), but of course, the combination of elective colorectal surgery and mesh implantation brings the risk of foreign material contamination with colonic bacteria. Whereas some authors found that concomitant mesh repair and colorectal surgery showed reasonable outcomes in most patients [12, 13], others stated a clearly increased risk of infectious and noninfectious complications  and requested a critical case-by-case patient selection for simultaneous surgery. According to the decision model for biologics by the Italian Biological Prosthesis Work-Group (IBPWG), a high resistance to mechanical stress and to protease enzyme action favors the use of cross-linked biological prostheses in circumstances of high infection probability and/or large tissue defects . Due to the high possibility of bacterial contamination upon concomitant colorectal surgery and because of the size of the defect (5x5 cm) a cross-linked biological prosthesis was chosen for the present patient.
If perforated, diverticulitis may be treated by laparoscopic lavage (i.e. not in Hinchey IV disease). Concurrent laparoscopic hernia reduction displays a feasible treatment option. Secondary colonic resection and primary anastomosis in the infection-free interval may be combined with the closure of the hernia defect. Laparoscopic mesh implantation may exhibit the most convenient method for lumbar hernia repair, but the surgeon should avoid mesh repair in the infectious state and should be careful with simultaneous elective colorectal surgery and foreign material implantation.
Informed consent was obtained from the patient for publication of this case report and all images.
Body mass index.
We kindly thank Ian Foster, PhD, Institute of Physiology, University of Zurich for critically reading the manuscript. There was no funding.
Source of funding
There was no funding to the present study.
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