An 86-year-old female presented with a swelling over the back in left lateral aspect since 5 years, which was initially small in size, reducible, painless, and gradually increased. The swelling had become irreducible and associated with pain since last 2 months. There was no other significant history in the form of trauma, previous surgery, and chronic infections like tuberculosis or altered bowel habits. On examination at admission, there was 15 x 12 x 10 cm, non-tender, non-pulsatile, irreducible swelling, soft in consistency in the left lumbar region with an expansile cough impulse. There was congenital right scoliosis [Figure 1].
Examination of right flank, rest of the abdomen and other hernial orifices was normal. Plain radiograph of the abdomen revealed a gas shadow within the swelling. Ultrasonography revealed well-defined, elongated and rounded mixed echogenic masses of about 3.7 x 2.2 x 1.4 cm and about 2 cm diameter in the left lumbar region, which appeared most probably to be herniated bowel loops. Computed tomography (CT) scan of the abdomen revealed 3 cm defect in the left lumbar region at the level of L3 vertebra, with a hernial sac containing large bowel loops, confirming the presence of left lumbar hernia containing large bowel. A diagnosis of irreducible left lumbar hernia was made and the patient was taken up for the surgery after she was examined for anesthetic fitness. The patient was placed in the right lateral decubitus position and the operating table was angulated to achieve the same effect as a kidney rest. The left flank incision was given over the swelling for exploration. The sac was herniating through the superior lumbar triangle and was covered by the muscles forming the boundaries of the triangle [Figure 2]. There were dense adhesions around the sac which had made it irreducible. There were no features of strangulations.
The dense adhesions were released meticulously and the sac was reduced completely and intact. A sheet of polypropylene mesh was fashioned as inlay prosthesis and was placed in the extraperitoneal space by umbrella placement technique through the defect in the muscle layer [Figures 3 and 4]. The defect was repaired with prolene continuous suturing and the rest of the posterior abdominal wall was closed in layers.
The immediate postoperative period was uneventful. Oral sips were started after 4 hours of operation. The patient was discharged after removal of sutures on 10th postoperative day, with a healed scar. On follow-up visit after 2 weeks, the patient was absolutely asymptomatic with a well-healed operation scar.