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Ann Thorac Surg 1995;59:1579-1580
© 1995 The Society of Thoracic Surgeons

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Case Report

Intercostal Lung Hernia Subsequent to Harvesting of the Left Internal Mammary Artery

Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, Australia

Accepted for publication November 2, 1994.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
We report a case of an intercostal lung hernia developing subsequent to harvesting of the left internal mammary artery. Intercostal lung hernia is extremely rare, with most cases reported after blunt thoracic trauma. In the absence of symptoms, this was treated conservatively.

	Introduction

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Intercostal lung hernia is an uncommon condition usually occurring secondary to penetrating chest wall trauma or in a previous thoracotomy scar. Iatrogenic cases have been reported at sites of previous chest tube insertion, usually in the presence of underlying sepsis [1]. We report an intercostal lung hernia secondary to harvesting of the left internal mammary artery.

A 59-year-old man presented in November 1991 for elective coronary artery bypass grafting. He had a 2-year history of grade II angina pectoris. Risk factors included a 30-year history of cigarette smoking, with a 10-year history of chronic airways limitation. Coronary angiography revealed triple-vessel disease with normal left ventricular function.

Coronary revascularization using long saphenous vein and the left internal mammary artery was undertaken. Via a median sternotomy the left internal mammary artery was dissected from its bed with a 1-cm muscular pedicle using unipolar diathermy. The artery's subclavian origin was left intact. This was followed by routine cardiopulmonary bypass and coronary artery grafting. The patient made an uneventful postoperative recovery, apart from some minor left basal atelectasis, and was discharged from hospital on the seventh postoperative day.

He enjoyed excellent symptomatic relief, although his chronic cough persisted. In January 1994, some 27 months later, he complained of an intermittent bulge in the left second intercostal space anteriorly. This occurred after an episode of severe coughing. Normal respiration examination of the chest was unremarkable, with the lump becoming visible only upon coughing (Fig 1) or the Valsalva maneuver. It was not tender and had the classic crepitant feel of lung tissue. An intercostal lung hernia was confirmed by computed tomographic scanning with Valsalva maneuver (Fig 2).

View larger version (130K): [in this window] [in a new window]   Fig 1. . The hernia is clearly visible as the patient coughs.

View larger version (138K): [in this window] [in a new window]   Fig 2. . Computed tomographic scan of the chest during Valsalva maneuver. Lung is seen protruding from the thoracic cavity.

	Comment

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Dissection of the internal mammary artery from the chest wall may lead to sufficient weakness of the intercostal muscle layer to cause a ``consecutive'' hernia, especially during sudden increase in intrathoracic pressure. Apart from direct injury, the intercostal muscle weakness results from local tissue ischemia and subsequent atrophy, or denervation injury as described by Goodman and associates [7].

Intercostal lung hernias do not pose a serious threat unless they undergo incarceration and strangulation with resultant hemoptysis and pain at the site of herniation [8]. The uncomplicated hernia may present as a soft crepitant bulge that enlarges on deep inspiration or coughing, or becomes evident, as in this case, upon Valsalva maneuver. Controversy exists concerning the role of surgical repair. There are advocates for operative repair as a matter of routine [8], but the observation that spontaneous regression can occur has led to support for conservative management. In the absence of symptoms we have elected a course of conservative management in our patient. He remains well at 6 months' follow-up.

	Footnotes

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Address reprint requests to Dr Deal, Department of Cardiothoracic Surgery, Royal North Shore Hospital, Pacific Highway, St. Leonards 2065, Sydney, Australia.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Bhalla M, Leitman BS, Forcade C, Stern E, Naidich DP, McCauley DI. Lung hernia: radiographic features. Am J Roentgenol 1990;154:51–3.
2. Morel-Lavallee A. Hernies du poumon. Bull Soc Chir Paris 1845–1847;1:75–195.
3. Hiscoe DB, Digman GJ. Types and incidence of lung hernias. J Thorac Cardiovasc Surg 1955;30:335–42.
4. Maurer E, Blades B. Hernia of the lung. J Thorac Surg 1946;15:77–98.
5. Montgomery JG, Lutz H. Hernias of the lung. Ann Surg 1925;82:220–31.
6. Hartung A, Grossman JW. Hernia of the lung. Am J Roentgenol 1941;46:321–3.
7. Goodman P, Balachandran S, Guinto FC Jr. Post-operative atrophy of postero-lateral chest wall musculature: CT demonstration. J Comput Assist Tomogr 1993;17:63–6.
8. Forty J, Wells FC. Traumatic intercostal pulmonary hernia. Ann Thorac Surg 1990;49:620–1.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by La Hei, E. R. Articles by Deal, C. W. Search for Related Content PubMed Articles by La Hei, E. R. Articles by Deal, C. W.