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Ann Thorac Surg 1997;63:1455-1456
© 1997 The Society of Thoracic Surgeons

Case Report

Traumatic Lung Herniation

Gary S. Allen, MD, Ronald P. Fischer, MD, PhD

Department of Surgery, University of Texas Health Science Center, Houston, Texas

Accepted for publication November 20, 1996.


   Abstract
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Traumatic lung herniation is a poorly described entity. An important factor in the etiology of these lesions is the relative lack of muscular support afforded by the anterior thorax. We report a case of blunt thoracic trauma complicated by an incarcerated lung herniation.


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Herniation of the lung through a traumatically induced thoracic wall defect is a rare occurrence. Fewer than 300 traumatic lung herniations have been recorded in the five centuries since this injury was first reported [1]. During this century motor vehicle accidents have replaced penetrating thoracic trauma as the most common etiologic agent of traumatic lung herniation [2].

A 27-year-old restrained driver sustained blunt chest trauma in a motor vehicle accident. The primary evaluation revealed anterior thoracic ecchymosis and left lower lateral chest wall crepitus. A portable anteroposterior chest radiograph demonstrated bilateral hemopneumothoraces, fractures of the left third through fifth ribs, and bilateral sternoclavicular dislocations (Fig 1Go). Nevertheless, lung herniation was not suspected until it was demonstrated by chest computed tomography performed because of mediastinal widening and interruption of the right paratracheal stripe suggestive of aortic injury (Fig 2Go).



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  		Fig 1. . Anteroposterior chest roentgenogram showed a left lateral subcutaneous air collection.

 


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  		Fig 2. . Chest computed tomogram showed an incarcerated lung segment.

 
Intractable pain, bloody thoracostomy output, and diminished functional reserve capacity persisted despite narcotic analgesia and appropriate ventilator regimens. On hospital day 2 a left anterior thoracotomy was performed after double-lumen endotracheal intubation. The herniated segment of the lingula was incarcerated on the spicules of the left third through fifth rib fractures (Fig 3Go). The lacerated lung was repaired with running polyglycolic suture and the lung returned to the thoracic cavity. The edges of the thoracic wall defect were approximated with figure-of-8 pericostal sutures. The patient's recovery was uneventful, and he was discharged on the seventh postoperative day.



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  		Fig 3. . The incarcerated lung segment breaching the chest wall defect.

 

   Comment
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Lung herniations may be congenital, spontaneous, pathologic, or the result of thoracic wall trauma. Traumatic lung hernias have been reported secondary to operative procedures, falls, motor vehicle accidents, and penetrating chest trauma [3, 4]. Spontaneous herniations account for 29% and are usually a consequence of abnormally high intrathoracic pressure generated by coughing, heavy lifting, or chronic obstructive pulmonary disease [5]. The remaining lung herniations are the result of a pathologic process of the thoracic cage [5]. The anterior thorax is the site of predilection for both spontaneous and traumatic lung herniations presumably because the anterior thorax lacks the muscular support afforded the posterior thoracic wall by the trapezius, latissimus dorsi, and rhomboid muscles [6]. The majority of congenital lung herniations occur through the superior thoracic cage between the sternocleidomastoid and scalenus anticus [7]. Lateral lung herniation as suffered by our patient is rare.

Usually posttraumatic lung herniation is visualized on chest radiographs as a well-circumscribed loculation of subcutaneous air, although tangential views may be necessary in some patients to demonstrate the herniation. We suspect that in recent years lung herniation is most often demonstrated by computed tomography. In addition, computed tomography better defines the dimensions of the hernia and provides valuable information regarding the thoracic cage and pleural space [8].

Regardless of the cause, lung herniations are unlikely to resolve spontaneously. In the past small hernias were managed by thoracic strapping [4, 8]. However, because strapping impairs thoracic wall motion, reduces pulmonary compliance, and increases the incidence of atelectasis and infection, it has been abandoned in favor of primary surgical repair. Pericostal fixation of adjacent ribs with absorbable sutures usually suffices to bridge the defect. If additional cover is needed the ribs can be divided and released from their pericostal envelopes before being shifted into place. Larger defects may require fascia lata grafts and muscle flaps to close the defect, and on rare occasions prosthetic material may be needed to bridge the gap. Only rarely is it necessary to resect incarcerated lung before closing the thoracic wall defect, although repair of the incarcerated lung may be necessary as it was in our patient.

The true incidence of traumatic lung herniation is difficult to assess as it is likely that many remain occult because of a low index of suspicion, subtle physical findings, and lack of symptoms. Incarceration is unusual but when present most often results from entrapment of the lung on rib spicules at the site of rib fractures, as occurred in our patient. The more liberal use of computed tomography may expand the number of diagnoses. Early surgical repair offers the best results with a low morbidity, and the long-term prognosis is excellent.


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Address reprint requests to Dr Allen, Department of Surgery, University of Texas Health Science Center, 6431 Fannin, MSB4.268, Houston, TX 77030.


   References
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 References
 

  1. Goodman HI. Hernia of lung. J Thorac Surg 1933;2:368–79.
  2. May AK, Chan B, Daniel TM, Young JS. Anterior lung herniation: another aspect of the seat belt syndrome. J Trauma 1995;38:587–9.[Medline]
  3. Hei ER, Deal CW. Intercostal lung hernia subsequent to harvesting of the internal mammary artery. Ann Thorac Surg 1995;59:1579–80.[Abstract/Free Full Text]
  4. Forty J, Wells C. Traumatic intercostal pulmonary hernia. Ann Thorac Surg 1990;49:670–1.[Abstract]
  5. Hiscoe B, Digman J. Types and incidence of lung hernias. J Thorac Cardiovasc Surg 1955;30:335–42.
  6. Maurer E, Blades B. Hernia of the lung. J Thorac Surg 1946;15:77–98.
  7. Hartung A, Grossman JW. Hernia of the lung. Am J Roentgenol 1941;46:321–8.
  8. Scullion DA, Negus R, Al-Kutoubi A. Case report: extrathoracic herniation of the lung with a review of the literature. Br J Radiol 1994;67:94–6.[Abstract/Free Full Text]



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