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Ann Thorac Surg 1998;65:1150-1151
© 1998 The Society of Thoracic Surgeons

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Case Reports

Delayed Presentation of Traumatic Parasternal Lung Hernia

^a Atlantic Health Sciences Corporation, Saint John, New Brunswick, Canada

Accepted for publication November 8, 1997.

Address reprint requests to Dr Jacka, Department of Anesthesia, Atlantic Health Sciences Corporation, 400 University Ave, Saint John, NB, Canada E2L 4L2
e-mail: (mjjacka{at}nbnet.nb.ca)

	Abstract

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Traumatic lung herniation is an unusual clinical problem. This case report describes a morbidly obese individual who sustained significant chest trauma in a motor vehicle accident. Lung herniation was noted at the time of delayed respiratory failure necessitating ventilation. The significance of the lung hernia in this patient’s respiratory failure is uncertain. The lung hernia was repaired surgically to relieve pain, prevent incarceration, and optimize respiratory function. After a brief period of postoperative ventilation, the patient recovered markedly and has been well since.

	Introduction

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Lung herniation, first described by Roland in 1499 [1, 2], is an unusual clinical problem. This report describes the diagnosis and management of a traumatic lung hernia that resulted from a seat-belt injury.

A 55-year-old morbidly obese man (176 kg) was the seat-belted driver broad-sided in a high-speed two-vehicle collision that killed the other driver. At presentation, he had mild right-sided pleuritic chest pain and a small amount of fluctuant, crepitant tissue deformity (similar to subcutaneous emphysema) localized to the right parasternal region. Chest radiography showed a right-sided pulmonary contusion and widened mediastinum. Aortography showed no disruption. Two days later, he required intubation and ventilation because of pneumonia. A right-sided hemothorax of 1,500 mL was drained. His respiratory function gradually improved, and he was extubated after 22 days. However, 5 days later he again required emergency intubation and ventilation. Physical examination revealed the same fluctuant, well-demarcated deformity in the right parasternal region as at admission. A new right-sided pleural effusion was seen on chest radiograms, which was confirmed to be blood. Dynamic contrast-enhanced computed tomographic scan (Fig 1) showed that a large portion of the right lung had herniated through a parasternal defect in the chest wall. This episode of respiratory failure was thought to be caused by mechanical fatigue, aggravated by paradoxical chest wall movement, and compounded by his morbid obesity. Because of the size of the lung hernia, its potential for incarceration, and the potential for recurrent respiratory failure, we considered definitive repair. Fluoroscopy demonstrated normally functioning hemidiaphragms. Pulmonary function tests showed severe limitation, but significant improvement was seen after lung rehabilitation (Table 1).

View larger version (126K): [in this window] [in a new window]   Fig 1. Computed tomographic scan of the patient’s chest showing large right parasternal lung hernia, costochondral disruptions, and bilateral pleural effusions.

	Comment

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This report describes the management of a patient who suffered a rare form of traumatic lung hernia. The patient sustained soft tissue injuries of the chest and multiple costochondral separations, contralateral to the side of the impact, typical for the restraint mechanism [3]. Other reports [3, 4] have described similar morbidly obese drivers using three-point restraint systems. It is suggested that the three-point (shoulder harness and lap belt) restraint system immobilized the left hemithorax compared with the right. The relatively unrestrained right hemithorax could move forward, applying a shear force at the right parasternal area. Costochondral separation would ensue, and the increased ipsilateral intrathoracic pressure would predispose to lung herniation. These injuries represent a variant of the "seat belt syndrome" [5]. Further use of air bags may reduce the incidence of this syndrome [5], although lateral impacts (in which the vehicle’s occupants are not protected by air bags) may still result in significant injury.

The defect in this patient’s chest wall was primarily repaired by an intrathoracic polytetrafluoroethylene patch, in addition to concurrent placement of wire sutures, after reduction of the incarcerated lung. This represents a combination of the two methods of repair for this type of lesion: primary closure of the defect and placement of prosthetic material to maintain reduction of the incarcerated lung [6, 7].

The usual management of a lung hernia is conservative. Operation is reserved for large or incarcerated hernias, those that are intractably painful, or those that are cosmetically unacceptable [2, 8]. Operative repair was undertaken in this case because of respiratory failure, incarceration of lung tissue, and pain localized to the defect.

In summary, this patient presented with a flail chest and pulmonary contusion contralateral to the side of impact. These injuries, coupled with his morbid obesity, delayed the recognition and management of his parasternal lung hernia. The usual functional significance of traumatic lung hernias is difficult to quantify, because they often occur in association with other severe traumatic pathology. Clinical significance may occur by incarceration, respiratory failure, intractable pain, or disfigurement. When an operation is required, primary closure is usually optimal, unless a large defect necessitates use of prosthetic material.

	References

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1. Morel-Lavelle A. Hernies du poumon. Bull Soc Chir Paris 1847;1:75-195.
2. Moncada R., Vade A., Gimenez C., et al. Congenital and acquired lung hernias. J Thorac Imag 1996;11:75-82.[Medline]
3. Arajarvi E., Santavirta S. Chest injuries sustained in severe traffic accidents by seatbelt wearers. J Trauma 1989;29:37-41.[Medline]
4. May A.K., Chan B., Daniel T.M., Young J.S. Anterior lung herniation: another aspect of the seatbelt syndrome. J Trauma 1995;38:587-589.[Medline]
5. Garrett J.N., Braunstein P.W. The seatbelt syndrome. J Trauma 1962;2:220-238.[Medline]
6. Cernilia J., Lin J., Ott R., et al. A technique for repair of traumatic parasternal lung herniation. J Trauma 1995;38:935-936.[Medline]
7. Cohen M.J., Starling J.R. Repair of subxiphoid incisional hernias with Marlex mesh after median sternotomy. Arch Surg 1985;120:1270-1271.[Abstract/Free Full Text]
8. Scullion D.A., Negus R., Al-Kutoubi A. Extrathoracic herniation of the lung with a review of the literature. Br J Radiol 1994;67:94-96.[Abstract/Free Full Text]

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