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Gooseman MR, Rawashdeh M, Mattam K, Rao JN, Vaughan PR, Edwards JG. Unifying classification for transdiaphragmatic intercostal hernia and other costal margin injuries. Eur J Cardiothorac Surg 2020; 56:150-158. [PMID: 30770701 DOI: 10.1093/ejcts/ezz020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/10/2018] [Accepted: 12/22/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Taxonomy of injuries involving the costal margin is poorly described and surgical management varies. These injuries, though commonly caused by trauma, may also occur spontaneously, in association with coughing or sneezing, and can be severe. Our goal was to describe our experience using sequential segmental analysis of computed tomographic (CT) scans to perform accurate assessment of injuries around the costal margin. We propose a unifying classification for transdiaphragmatic intercostal hernia and other injuries involving the costal margin. We identify the essential components and favoured techniques of surgical repair. METHODS Patients presenting with injuries to the diaphragm or to the costal margin or with chest wall herniation were included in the study. We performed sequential segmental analysis of CT scans, assessing individual injury patterns to the costal margin, diaphragm and intercostal muscles, to create 7 distinct logical categories of injuries. Management was tailored to each category, adapted to the individual case when required. Patients with simple traumatic diaphragmatic rupture were considered separately, to allow an estimation of the relative incidence of injuries to the costal margin compared to those of the diaphragm alone. RESULTS We identified 38 patients. Of these, 19 had injuries involving the costal margin and/or intercostal muscles (group 1). Sixteen patients in group 1 underwent surgery, 2 of whom had undergone prior surgery, with 4 requiring a novel double-layer mesh technique. Nineteen patients (group 2) with diaphragmatic rupture alone had a standard repair. CONCLUSIONS Sequential analysis of CT scans of the costal margin, diaphragm and intercostal muscles defines accurately the categories of injury. We propose a 'Sheffield classification' in order to guide the clinical team to the most appropriate surgical repair. A variety of surgical techniques may be required, including a single- or double-layer mesh reinforcement and plate and screw fixation.
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Affiliation(s)
- Michael R Gooseman
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, South Yorkshire, UK
| | - Majd Rawashdeh
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, South Yorkshire, UK
| | - Kavitha Mattam
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, South Yorkshire, UK
| | - Jagan N Rao
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, South Yorkshire, UK
| | - Paul R Vaughan
- Department of Cardiothoracic Surgery, St Georges Hospital, London, UK
| | - John G Edwards
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, South Yorkshire, UK
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Posttraumatic transdiaphragmatic intercostal hernia: report of a case and review of the literature. Int Surg 2016; 100:444-9. [PMID: 25785325 DOI: 10.9738/intsurg-d-13-00272.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Intercostal hernias are rare, and usually occur following injuries of the thoracic wall. The scope of this report is to present a case of a 53-year-old obese patient that developed a transdiaphragmatic intercostal hernia. The patient presented with a palpable, sizeable, reducible mass in the right lateral thoracic wall, with evident bowel sounds in the area, 6 months after a motor-vehicle accident. On computed tomography (CT), the hernia sac contained part of the liver and part of the ascending colon. A surgical repair of the defect was performed, using a prosthetic patch. The patient's postoperative course was uneventful and she remains recurrence free at 12 months after surgery. Intercostal hernias should be suspected following high-impact injuries of the thoracic wall, and CT scans will facilitate the diagnosis of intercostal hernia. We consider the surgical repair of the defect, with placement of a prosthetic mesh, as the treatment of choice to ensure a favorable outcome.
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Akça AH, Sarzep H. Posttraumatic pulmonary hernia in child. Am J Emerg Med 2015; 34:760.e1-2. [PMID: 26375663 DOI: 10.1016/j.ajem.2015.08.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/08/2015] [Indexed: 11/30/2022] Open
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Acquired abdominal intercostal hernia: a case report and literature review. Case Rep Surg 2014; 2014:456053. [PMID: 25197605 PMCID: PMC4150516 DOI: 10.1155/2014/456053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 07/09/2014] [Indexed: 11/30/2022] Open
Abstract
Acquired abdominal intercostal hernia (AAIH) is a rare disease phenomenon where intra-abdominal contents reach the intercostal space directly from the peritoneal cavity through an acquired defect in the abdominal wall musculature and fascia. We discuss a case of a 51-year-old obese female who arrived to the emergency room with a painful swelling between her left 10th rib and 11th rib. She gave a history of a stab wound to the area 15 years earlier. A CT scan revealed a fat containing intercostal hernia with no diaphragmatic defect. An open operative approach with a hernia patch was used to repair this hernia. These hernias are difficult to diagnose, so a high clinical suspicion and thorough history and physical exam are important. This review discusses pathogenesis, clinical presentation, complications, and appropriate treatment strategies of AAIH.
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Affiliation(s)
- Jean-Stephane David
- Trauma and Emergency Surgery Unit, Department of Anesthesia and Critical Care, Lyon Sud Hospital, , Hospices Civils de Lyon, Pierre Benite, France
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Abstract
Intercostal herniation is very rarely and sporadically reported in the literature. Intercostal hernia can occur following blunt trauma and may be associated with rib fractures. We present a case of a patient who presented with rib fractures, diaphragmatic rupture, and intrathoracic herniation of abdominal contents with subsequent herniation of both lung and abdominal contents through an intercostal defect. The patient was successfully treated with primary surgical repair of the diaphragm and intercostal hernia. The presentation, pathophysiology, and management of this rare clinical entity are discussed.
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Yodonawa S, Kobayashi K, Yoshida S, Ogawa I, Ito H, Kato A, Kubokawa R, Tokoshima E. Transdiaphragmatic intercostal hernia following blunt trauma. Gen Thorac Cardiovasc Surg 2012; 60:459-61. [PMID: 22544425 DOI: 10.1007/s11748-012-0020-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2011] [Accepted: 07/07/2011] [Indexed: 11/25/2022]
Abstract
We report a rare case of traumatic transdiaphragmatic intercostal hernia (TDIH) in an 85-year-old women who was transported to our hospital by ambulance after blunt trauma caused by the involvement in a motor vehicle accident. Chest and abdominal computed tomography (CT) revealed a left diaphragmatic rupture with a chest wall hernia involving loops of small intestine. An emergency operation was performed and led to a diagnosis of TDIH. Surgery via a thoracoabdominal incision in the left side was performed to reduce the hernia contents, and the diaphragmatic and intercostal defects were reconstructed by direct suture. CT scans were very helpful in detecting TDIH in this case.
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MESH Headings
- Accidents, Traffic
- Aged, 80 and over
- Female
- Hernia, Diaphragmatic, Traumatic/diagnostic imaging
- Hernia, Diaphragmatic, Traumatic/etiology
- Hernia, Diaphragmatic, Traumatic/surgery
- Herniorrhaphy
- Humans
- Multiple Trauma/diagnostic imaging
- Multiple Trauma/etiology
- Multiple Trauma/surgery
- Tomography, X-Ray Computed
- Treatment Outcome
- Wounds, Nonpenetrating/diagnostic imaging
- Wounds, Nonpenetrating/etiology
- Wounds, Nonpenetrating/surgery
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Affiliation(s)
- Satoshi Yodonawa
- Department of Surgery, Ibaraki Seinan Medical Center Hospital, Ibaraki, Japan.
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Lanier ST, Wetterau M, Smith-Singares E, Bilfinger T, Vosswinkel J, Shapiro MJ, Dagum AB. Management of pulmonary hernia through a flail segment in closed thoracic trauma using open reduction, internal fixation and pectoralis major flap reconstruction: A case report. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2011. [PMID: 23204887 DOI: 10.1177/229255031101900408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The present article reports on the successful management of a large flail chest with traumatic pulmonary herniation in a patient who could not be weaned from mechanical ventilation following a course of conservative management. Surgical intervention involved open reduction and internal fixation with tubular plates to stabilize the flail segment, followed by a pectoralis major myocutaneous flap to repair the chest wall defect. Following surgical intervention, the patient was able to be weaned from mechanical ventilation and showed remarkable improvement in pulmonary function parameters. To the authors' knowledge, the present report is the first to describe the use of open reduction and internal fixation of the chest wall and flap reconstruction to treat lung herniation with a flail chest segment.
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Affiliation(s)
- Steven T Lanier
- School of Medicine, Stony Brook University Medical Center, Stony Brook
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Biswas S, Keddington J. Soft right chest wall swelling simulating lipoma following motor vehicle accident: transdiaphragmatic intercostal hernia. A case report and review of literature. Hernia 2008; 12:539-43. [PMID: 18293055 DOI: 10.1007/s10029-008-0342-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Accepted: 01/11/2008] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Intercostal herniation of abdominal contents through a diaphragmatic defect is rare. We report a case of transdiaphragmatic intercostal hernia secondary to blunt trauma, initially misdiagnosed as lipoma, later confirmed by CT scan. METHODS We present a case of a 77-year-old who was involved in a motor vehicle accident and sustained a hand fracture. Later that year his wife noticed an egg-shaped soft swelling on his right chest wall. He was seen in the minor operative clinic, and a lipoma excision was attempted when it was found to be an intercostal hernia. Colon was seen in the hernial pouch. RESULTS Anatomically, the chest wall is weak from the costochondral junction to the sternum because of lack of external intercostal muscle support, and from the costal angle posteriorly to the vertebrae because of lack of internal intercostal musculature. The integrity of the thoracic cage is disrupted by tears of the intercostal musculature between fractured ribs. This defect leads to separation of the ribs and development of a potential weakened space for hernia. This chest wall muscular weakness can occur anywhere and can be more pronounced if it occurs at anatomically weakened areas. In the presence of associated diaphragmatic rupture, there is herniation of abdominal viscera. The treatment includes immediate surgical repair either by abdominal or thoracoabdominal approach. CONCLUSIONS A thorough physical examination may suggest the diagnosis, but confirmation by chest radiograph, CT scan, and sometimes by gastrointestinal contrast studies is often helpful for preoperative planning. A high index of suspicion for diaphragmatic injury or intercostal herniation during the initial evaluation, coupled with chest and abdominal diagnostic testing once the patient is stable, can avert undue delay in diagnosis and catastrophe from incarceration of a hernia.
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Affiliation(s)
- S Biswas
- Department of General Surgery, Stanford University Medical Center, 300 Pasteur Dr., H3591, Stanford, CA 94305-5641, USA.
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Unlu E, Temizoz O, Cagli B. Acquired spontaneous intercostal abdominal hernia: case report and a comprehensive review of the world literature. ACTA ACUST UNITED AC 2007; 51:163-7. [PMID: 17419863 DOI: 10.1111/j.1440-1673.2006.01661.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Intercostal hernias develop most often as a result of a blunt or penetrating thoracoabdominal trauma. We know of no prior report of a spontaneously occuring intercostal hernia. This study presents a review of the published literature that deals with this uncommon phenomenon, along with a discussion of our patient's clinical presentation and imaging findings.
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Affiliation(s)
- E Unlu
- Department of Radiology, Trakya University School of Medicine, Edirne, Turkey.
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Patel MB, Nathan JD, Frush DP, Rice HE. Nonoperative Management of Asymptomatic Traumatic Pulmonary Hernia in a Young Child. ACTA ACUST UNITED AC 2007; 62:234-5. [PMID: 17215762 DOI: 10.1097/01.ta.0000246947.19359.3e] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Mayur B Patel
- Department of General Surgery, Duke University Medical Center, Durham, North Carolina 27707, USA
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Sharma OP, Duffy B. Transdiaphragmatic intercostal hernia: review of the world literature and presentation of a case. THE JOURNAL OF TRAUMA 2001; 50:1140-3. [PMID: 11426131 DOI: 10.1097/00005373-200106000-00026] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- O P Sharma
- Trauma Services, The Toledo Hospital, 2142 North Cove Boulevard, Toledo, Ohio 43606, USA
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Hruska LA, Corry D, Kealey GP. Transdiaphragmatic intercostal hernia resulting from blunt trauma: case report. THE JOURNAL OF TRAUMA 1998; 45:822-4. [PMID: 9783630 DOI: 10.1097/00005373-199810000-00039] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- L A Hruska
- Division of General Surgery, The University of Iowa Hospitals and Clinics, Iowa City 52242-1086, USA
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Abstract
Lung hernia is an uncommon entity usually resulting from trauma or inadequate healing from recent or remote thoracic surgery. A small percentage may be congenital. Four cases are reported, each demonstrating lung herniation resulting from either accidental or postsurgical trauma. Most of the previous cases have been reviewed in various surgical and radiological journals with only rare mention in the emergency medicine literature. Because emergency physicians may be the most immediate contact for patients who develop a lung herniation, they should be cognizant of this entity as a possible delayed complication to chest wall injury. Awareness of the clinical and radiological appearance of lung hernia will help to avoid its confusion with other conditions such as subcutaneous emphysema, chest tumor, pneumothorax, or a focus of infection.
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Affiliation(s)
- C Glenn
- Department of Radiology, University of California, Davis, USA
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Sonett JR, O'Shea MA, Caushaj PF, Kulkarni MG, Sandstrom SH. Hernia of the lung: case report and literature review. Ir J Med Sci 1994; 163:410-2. [PMID: 7982766 DOI: 10.1007/bf02975039] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Hernia of the lung is an uncommonly encountered clinical entity. The majority of reported hernias are acquired traumatic thoracic hernias. A case report of an acquired spontaneous lung hernia is presented. A literature review of the classification, diagnosis, treatment and current incidence is discussed.
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Affiliation(s)
- J R Sonett
- Medical Center of Central Massachusetts, Worcester 01605
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Abstract
A 72-year-old man was seen with cough-induced rib fractures, a diaphragmatic tear, and an intercostal hernia containing abdominal contents. A review of the literature of this rare problem is presented, and techniques of repair are discussed.
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