Jean-Louis Petit ‘ S Hernia : Report of 03 Cases at Kara Teaching Hospital ( Togo )

Lumbar hernia are rare. Their diagnosis is difficult but facilited par the Computed Tomography. The best treatment is the use of the mesh by laparoscopy. The aim of this study is to report three cases of Jean-Louis Petit hernia and to do literature review.


Introduction
Lumbar hernias are rare entities among abdominal wall diseases. Two forms can be distinguished depending on the localization: the lowest and lateral form is that of Jean-Louis Petit while the highest and medial is that of Grynfelt. They often pose the problem of their diagnosis because of their rarity and their topography. But in case undoubtedly, the imaging represented by the ultrasound and especially the computed tomography helps in the diagnosis [1]. The objective of this study is to report three cases of Jean Louis-Petit's hernia and then to review the literature.

Case 1
A 75-year-old farmer who consulted for a large left lumbar swelling associated with constipation that had progressed for about three years. His only antecedent was unmonitored hypertension. The clinical examination had made it possible to note a good general condition, a low right lumbar swelling overhanging the painless left iliac crest, soft, renitent, impulsive to coughing and reducible with gurgling sounds (Figure 1). The diagnosis of a hernia of Jean-Louis petit not strangled was evoked. As the ultrasound and the CT scan were available, an X-ray of the abdomen without preparation was performed showing the mass which was slightly opaque containing digestive clearances. The diagnosis was therefore confirmed. Our patient undergone lombotomy showing the hernia bag. After dissection of the bag, we push it back and put the mesh forward the muscles and backward the bag in extraperitoneal space. The outcomes were good after surgical procedure.

Case 2
61-year-old patient, housewife, with no particular pathological history, admitted for a right lumbar swelling that progressed for years. The physical examination noted apyrexia; a good general condition; a soft, painless swelling, reducible and impulsive to cough (Figure 4). The diagnosis of an unstrangled right Jean-Louis Petit's hernia was suggested and confirmed by an ultrasound. The patient undergone lombotomy showing the hernia bag. After dissection of the bag, we push it back and put the mesh forward the muscles and backward the bag in extraperitoneal space (Figures 5 and 6). She had good outcomes after surgical procedure.   50-year-old female patient, housewife, with no specific history admitted for left lumbar pain that has been evolving for around a few months. The clinical examination had made had noted a good general condition, a low left lumbar swelling overhanging the left iliac crest painless, impulsive to the cough and reducible. The diagnosis of Jean-Louis Petit's hernia was evoked and confirmed on ultrasound. She also received repair of the hernia with mesh as the previous patients. She had good outcomes.

Discussion
Lumbar hernias are rare, explaining the small number of published cases [1][2][3]. In the literature, Jean-Louis Petit's hernia is less frequent than that of Grynfelt [4,5]. In general, two out of three lumbar hernias in males [1]. There are several causes of hernias among which we have: congenital hernias (newborns, children, sometimes bilateral, associated with other anomalies); acquired hernias: adults (without trauma or incision); posttraumatic hernias; postoperative hernias (after operation on the iliac crest, nephrectomies) which are incisional hernia [1]. The diagnosis of a hernia is essentially clinical. However, the difficulty of the diagnosis of lumbar hernias is explained by their rarity and their localization requires imaging [1,6]. Computed tomography is still the best exam to show the hernia with all of its features, although ultrasound can sometimes help in the diagnosis [7]. In one of our cases, an unprepared x-ray of the abdomen alone was sufficient to confirm the diagnosis. It could therefore contribute to diagnosis in front of any suspicion of lumbar hernia especially in the poorly equipped centers. As any hernia, the management of the Jean-Louis Petit hernia is surgical. Two therapeutic approaches could be used: laparoscopy and laparotomy with a superiority of the first [5,8]. For hernias of small sizes cure without mesh could be used unlike large hernias where the mesh is required to avoid recurrence as in our Cases [1,9].

Conclusion
Jean-Louis Petit's hernia is a rare variety of hernia. Its diagnosis is facilitated today by the contribution of the computed tomography.The repair of the hernia with mesh by laparoscopy is currently the gold standard treatment.