Novel Fixation Technique for the Surgical Repair of Lung Hernias

Traumatic thoracic rib cage and chest wall hernias: A review and discussion of management principles

Traumatic thoracic or chest wall hernias are relatively uncommon but highly challenging injuries that can be seen after a variety of injury mechanisms. Despite their description throughout history there remains scant literature on this topic that is primarily limited to case reports or series. Until recently, there also has been no effort to create a reliable grading system that can assess severity, predict outcomes, and guide the choice of surgical repair. The purpose of this article is to review the reported literature on this topic and to analyze the history, common injury mechanisms, likely presentations, and optimal management strategies to guide clinicians who are faced with these challenging cases. We also report a modified and updated version of our previously developed grading system for traumatic chest wall hernias that can be utilized to guide surgical management techniques and approaches.

Surgical Repair of the Postoperative Lung Hernia by Combining Mesh Interposition and Chest Wall Stabilization by Using Synthes Plates: A Novel Technique

Several technical points for postoperative lung hernia repair are still not fully elucidated. We present an original technical solution to deal with this complication. In a 68-year-old female, the lung hernia was confirmed 5 months after the partial left-sided chest wall and scapula angle resection with primary Mersilene mesh reconstruction for elastofibroma. The patient refused the proposed surgical correction, being only slightly limited in daily activities. The symptoms persisted under analgetic therapy till the moment when patient's daily activities became critically limited, 22 months after surgery. The repeated chest CT showed a slight increase in hernia size with no signs of tumour recurrence, so that reoperation was planned. After the exposure of the mesh region, a lung protrusion (4 × 3 cm) along the anterolateral edge of the mesh was confirmed. By careful dissection, the mesh was separated from a firmly adherent lung and removed. After adhaesiolysis and complete lung liberation, a wedge resection of the afunctional lung tissue of the lingula was done, just in the region of contact with the mesh. After the chest tube insertion, the chest wall defect was reconstructed by using a Mersilene mesh, and the final chest wall stabilization was done by the fixation of two Synthes plates (DePuy Synthes J&J) over the 5th and 6th ribs. The postoperative course was uneventful. One year after the operation, the patient was in good general condition, without the need for analgesics. To the best of our knowledge, the described technique is the original way of dealing with postoperative lung hernia. We find it efficient as a prevention of potential serious hernia-related complications.

Traumatic herniation of the lung

We present a relatively rare clinical presentation of herniation of lung parenchyma. In our case, the patient suffered multiple rib fractures, with an intercostal herniation of lung tissue after a trauma. We opted for a conservative treatment, given the clinical presentation, and the absence of incarceration or strangulation of the pulmonary tissue. In the absence of clear guidelines for this rare presentation, current treatment can be conservative or surgical, depending on the clinical presentation.

Repair of lung herniation with titanium prosthetic ribs and Prolene mesh

We present a rare case of intercostal lung herniation due to blunt trauma. A 40-year-old man was admitted to our hospital with lung herniation due to falling off a donkey. Computed tomography demonstrated a fracture of the 8th left rib, a comminuted fracture of the 9th rib, and lung herniation into the 8th intercostal space. The herniation was repaired using a titanium prosthetic rib, a rib plate, and Prolene mesh via a thoracotomy.

A new technique of pulmonary hernia surgical repair using intramedullary titanium implants

Introduction

In this paper we present a new method of pulmonary hernia surgical treatment. Pulmonary hernia is a rare pathology. The first description of pulmonary hernia was made by Roland in 1499. The world literature describes only a little more than 300 cases of pulmonary hernia. Pulmonary hernia is defined as the projection of the lung tissue covered by the parietal pleura beyond the normal boundaries of the pleural cavity, through the pathological holes in the chest wall. During our work as thoracic surgeons, we have used different ways of thoracic chest wall reconstructive operations and anastomoses of the broken ribs.

Aim of the study

To search for optimal methods of pulmonary hernia surgery and to evaluate a new technique of pulmonary hernia surgical repair using intramedullary titanium implants.

Material and methods

In 2013 in our clinic, we diagnosed and cured two patients with idiopathic pulmonary hernia. We performed a reconstructive operation of the chest wall with anastomosis of the broken ribs using titanium intramedullary stabilization implants – splints.

Results

To date, the annual observation has revealed no recurrence of pulmonary hernia or postoperative complications. At present, the patients demonstrate full life activity.

Conclusions

So far, in the world literature, we have not encountered any information about using such methods to repair pulmonary hernia. We regard our method as safe, easy to use and giving good therapeutic results.

[Lung hernia provoked by a cough fit]

Lung hernias are rare and their pathogenesis is few described. They are defined as the protrusion of lung parenchyma through the chest wall: intercostal space, inter-costo-clavicular, supra-clavicular or diaphragmatic hiatus. Lung hernias are classically divided into congenital and acquired hernias. Those are usually post-traumatic or post-surgical but can be provoked by cough. Clinical diagnosis is often evident but is confirmed by chest radiograph and especially computed tomography. Major risks are lung incarceration and necrosis but also ventilatory distress due to paradoxical respiration, in case of large defect. Treatment is first and foremost surgical but debated and should consider the localization, the size, the length of evolution and the possible infectious context. We report the case of a right basi-thoracic lung hernia induced by a cough fit, in a patient with chronic bronchitis.

Primary and Prosthetic Repair of Acquired Chest Wall Hernias: A 20-Year Experience

BACKGROUND

Chest wall herniation has been described after thoracotomy, trauma, and violent coughing episodes. Few studies have examined risk factors associated with chest wall herniation or predictors of complications after surgical repair.

METHODS

A divisional database identified all patients who underwent chest wall herniorrhaphy between 1992 and 2011. Data were collected on patient age, sex, body mass index (BMI), cause and location of hernia, comorbidities, duration and technique of herniorrhaphy, postoperative complications, and hospital length of stay. Risk factors for chest wall herniation were then examined, and primary repair was compared with prosthetic repair for differences in postoperative morbidity.

RESULTS

Twenty-seven consecutive patients underwent chest wall herniorrhaphy. Hernias most commonly occurred on the right side, in the fifth intercostal space, contained lung, and were chronic in nature. Pain was the presenting symptom in all but 4 patients. The most frequently observed comorbidities were obesity, chronic obstructive pulmonary disease (COPD), oral steroid use, and diabetes mellitus. Primary repair was performed in 18 patients and mesh repair in 9 patients, with a median operative time of 116 minutes. Excluding the 4 acute hernias repaired during the same admission as the initial thoracotomy, postoperative complications occurred in 22% of patients who underwent prosthetic repair and 42% of patients who underwent primary repair (p=0.4). Median hospital stay did not differ between herniorrhaphy techniques.

CONCLUSIONS

Previous thoracotomy, obesity, COPD, steroid use, and diabetes mellitus are common in patients in whom chest wall hernias develop. Prosthetic herniorrhaphy is not associated with an increased risk of postoperative complications relative to primary repair.

Successful treatment of flail chest with chondrosternal disruption and traumatic parasternal lung hernia with titanium rib bridges

The surgical principles for the treatment of flail chest have yet to be fully established. Furthermore, the relationship between flail chest and lung hernias is unclear. We report here a rare case of chondrosternal traumatic disruption and lung hernia that was treated with a novel technique using titanium rib bridges and clips, which successfully reduced the hernia defect and provided stability to the chest wall. This procedure was beneficial in minimising the patient's ventilation time and time away from work.