According to hernia classification as acquired and secondary, incisional lumbar or posteromedial hernias always present a history of incisions like lumbotomy for nephrectomy, approach for abdominal aorta aneurisms, access to spine corrections, or iliac crest graft material collection and, at a lower ratio, history of trauma and infection.
Though lumbar incisional hernias could occur in healthy individuals, several factors may contribute to their occurrence, including old age, undernourishment, obesity, chronic obstructive pulmonary disease (COPD)/Asthma, and surgical time. 
The scarce number of publications, mostly Case Reports, the lack of significant statistical serial data and the great number of repair techniques that have been described in the literature make lumbar/posterolateral incisional hernias a challenge for the surgeon. These circumstances underlie the fact that neither a gold standard surgical procedure nor recommendations have been identified [3, 7].
A CT scan is routinary in our practice after the clinical diagnosis, in order to assess ring size, relation to neighboring organs, possible content and, above all, to rule out the presence of a bulge by denervation as the only cause of clinical manifestation. It is important to see the differences: when there is an incisional hernia, disruption of the three layers of the flat muscles creates a passage of abdominal content outwardly. When there is only denervation, though the three layers become thinner, there is no interruption .
The importance of this detailed examination lies in the fact that the denervation bulge or pseudohernia, as expressed by its name, is not a hernia and, as such, should not to be treated by laparoscopic surgery .
Without clear recommendations as to which technique is the most efficient for its treatment, there are two methods for approach and surgical correction. The first one, direct open approach through skin incision where the hernia is located, and the second one, the minimally invasive videolaparoscopic approach .
As regards the open approach, apart from the difficulty to define the defect scope, it is necessary to perform large incisions and soft tissue dissection to go beyond bone structure margins, like costal arch and iliac crest . This, in turn, increases wound complications, such as hematomas, seromas and infection, postoperative pain and a longer hospital stay .
The significant postoperative morbidity and the long postoperative recovery caused by a large dissection as mentioned above make us prefer the videolaparoscopic approach.
Burick and Parascandola , in 1996 published the first traumatic lumbar hernia repair by transabdominal laparoscopic approach.
Moreno-Egea et al  in 2005 published a non-randomized prospective study comparing both approaches: videolaparoscopic vs open. This study revealed fewer complications in the laparoscopic group, as well as all the other known benefits of this minimally invasive technique. That is, shorter hospital stays, lower postoperative pain, early mobilization and return to normal living. Besides, it proved to be more cost-effective, considering the higher incidence of subsequent hospital admissions in the open approach group.
Thus, the International Endohernia Society Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias  established at a 2b Level that laparoscopic repair with a mesh is superior to open repair with a mesh in terms of morbidity and, recommends laparoscopic repair with a grade B taking into account its lower morbidity compared to the open technique.
The development of minimally invasive techniques is advantageous for ventral hernia repair. TAPP, eTEP and IPOM approaches are the most widely used techniques for lumbar hernias due to their significant benefits [15, 16]. Mention should also be given to TAPE method, as well as the replicability of all of these procedures by robotic approaches.
Although the TAPP and eTEP methods show a strong theoretical advantage, like the mesh location far from the peritoneum and below the abdominal wall muscles, the series presented fall short and currently follow-up is limited, which still makes it difficult to find statistically significant and clear advantages over the IPOM procedure [17, 18].
Based on our experience, IPOM Plus is the preferred method, as it is simple to be performed by laparoscopic surgeons and has shown good results both for the short and the long terms regarding relapse and complications [19, 20].
Following EHS classification, incisional lumbar hernias cannot be classified exclusively as L4, which is possible for congenital hernias, considering that for the retroperitoneal approach most surgeons’ incisions go beyond that anatomical site towards L3.
So, incisional hernia features differ completely from primary lumbar hernias, as the latter always present with their ring in the retroperitoneum, making them extraperitoneal and more suitable for TAPP because the flap is simpler to perform in the area surrounding extraperitoneal spaces. However, in incisional hernias, lumbotomy extension, which always includes lateral abdominal muscles, makes the ring lie completely or almost completely in the abdominal cavity, ventral to the colonic frame.
Thus, in our daily practice, with the treatment of midline incisional ventral hernias, it was not difficult to extend the IPOM Plus indication to lumbar incisional hernias which, based on our experience, have two advantages over the first one. As in posterolateral incisional hernias there is no lateral traction exerted by the Flat Muscles as it occurs in the midline, this allows the indication for incisional hernias with larger rings as these present less tension in the suture line. Besides, they rarely present difficulty to release adhesions since their presence is not frequent. We found two cases of empty sacs once the patient was positioned on its lateral decubitus on the hernia opposite side. Even when present, adhesions tend to be lax.
The lumbar hernia laparoscopic approach offers some advantages, such as the easiness to locate the defect and the perfect anatomical sight of the region, which avoids excessive dissection of the lumbar region through large incisions .
Based on our experience, the transabdominal approach enables accessing the retroperitoneum from the cavity since there is always colon medialization in order to expose the defect completely and to suture it. This is always done to enable a field clearance that could allow for a 5-cm overlap as well as to get an adequate and safe position to perform tacker mesh fixation to muscle tissue and/or Cooper ligament, avoiding vessels, nerves or urinary organs damage .
Because of this, in most cases, the mesh remains covered, partly by the peritoneum. Nevertheless, we cannot consider it a TAPE procedure because, in this case, the peritoneum is sutured or fixed with tackers to the mesh.
In our series of 10 cases, after a follow-up that ranged from 4 to 85 months, there was a case of partial relapse in the medial margin of an incicsonal hernia which extended up to a rectus abdominis diastasis. We believe this condition was overlooked and probably the mesh overlap should have exceeded the midline. The rest of the scar presents no sign of protrusion and is well contained.
The average length of hospital stay was 40,3 hours and there were no peri-operatory complications, like seromas, readmissions, or chronic pain. There was only one postoperative case of acute pain which extended the length of hospital stay to 64 hours and presented a hematoma near a port, which was solved by non-surgical means.
By analyzing mid-sized hernias, whose ring area averages 46 cm2, comorbidities low index and ASA classification, patients were low risk, which would explain the low number of complications and relapse.
Sample heterogeneity, the absence of case series with significant statistical value and of randomized prospective studies make it difficult to reach to conclusions; however, we can state that our experience matches other authors’ in that the lumbar incisional hernia laparoscopic approach is a safe and convenient method, which offers all the advantages of the minimally invasive procedure, for small and medium-sized hernias with low index of comorbidity, leaving the open approach is for the large ones [4, 9, 10, 11, 12, 13, 15,16, 20, 21].
Our experience in the chronological use of the technique IPOM Plus, using it firstly for primary midline hernias, then for incisional midline and lateral hernias, and finally, for lumbar incisional hernias, makes this procedure a valid tool available today as a minimally invasive therapeutic option for the treatment of posterolateral incisional hernias.