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Ann Thorac Surg 1998;65:1155-1157
© 1998 The Society of Thoracic Surgeons

Case Reports

Video-Assisted Repair of a Traumatic Intercostal Pulmonary Hernia

Michael J. Reardon, MDa, Jan Fabré, MDa, Patrick R. Reardon, MDa, John C. Baldwin, MDa

a Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA

Accepted for publication November 15, 1997.

Address reprint requests to Dr Reardon, 6550 Fannin, Suite 1619, Houston, TX 77030
e-mail: (reardonm{at}bcm.tmc.edu)


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
A case of traumatic right lung herniation to an area of anterior costal sternal separation and right hemothorax is presented. Application of a thoracoscopic approach to a traumatic lung hernia of the chest wall in this case is discussed.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Traumatic lung hernia of the chest wall is unusual, but multiple previous descriptions exist [1–3]. Anterior herniation at the costal sternal junction has been associated with shoulder-strap injury in motor vehicle accidents and other forms of blunt trauma to the chest [4]. Both surgical and conservative management have been recommended for these hernias. The decision to operate is usually based on the size of the hernia and the possibility of incarceration of the lung. We present a case of right hemothorax and large lung hernia to the right fourth intercostal space. A thoracoscopic approach was chosen to evacuate the hemothorax, explore the chest for additional injuries, and reduce the lung herniation.

A 35-year-old previously healthy male motorcyclist was involved in a collision with a truck. Initial evaluation in the emergency room revealed a Glasgow coma scale of 14, a left-sided grade 3C open tibia fracture, and a left-sided grade 1 open femur fracture. A standard anteroposterior chest radiograph taken in the emergency room revealed no abnormalities. Orthopedic treatment was completed without difficulty. Three days after the patient’s admission, physical examination of the chest revealed a localized, nontender bulge measuring 5 x 6 cm overlying the third and fourth interspaces of the right parasternal area. On palpation the mass was compressible, had a spongy, crepitant feel, and was well demarcated. On auscultation clearly audible breath sounds could be heard over the mass. Chest computed tomography was performed, which showed a segment of the right lung parenchyma protruding beyond the confines of the musculoskeletal thorax into the subcutaneous space, and a large right-sided effusion thought to be a hemothorax (Fig 1). The patient was then transferred to our institution for thoracic surgical evaluation. In conjunction with this large right hemothorax, we thought that thoracoscopy for evacuation of the hemothorax, exploration for additional injuries, and repair of the hernia was indicated.



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  		Fig 1. Chest computed tomogram shows lung tissue protruding in the subcutaneous space and a large hemothorax.

 
Thoracoscopy performed 5 days after the original injury revealed an 850-mL hemothorax and several adhesions of the lung to the anterior chest wall. The hemothorax was mainly nonclotted and was evacuated without difficulty. After careful release of the adhesions, the herniation of the right upper lobe parenchyma through the anterior intercostal space was confirmed. No additional injuries were identified, and the diaphragm and apical pleura were intact. The herniated lung tissue was easily reduced with a bimanual push-pull technique. While the assistant applied gentle external pressure over the bulging area, traction was applied on the herniated lung tissue with a large, atraumatic grasper under videoscopic control. After reduction, the lung parenchyma was inspected and showed no signs of ischemia or perforation and the chest wall was without rib fractures. To prevent possible recurrence of the herniation, we directly closed the intercostal defect with approximating sutures to a small incision placed over the defect. A 32F chest tube was inserted through one of the working ports, and the lung was reexpanded. No postoperative bleeding or air leak was noted. On postoperative day 1, the chest tube was removed and the patient was transferred to the floor. The patient was discharged on the eighth postoperative day, because of the associated orthopedic problems. Six-month follow-up showed good healing without recurrence of the hernia.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Lung hernias are a rare entity, with approximately 300 cases reported in the literature. They were first described by Roland in 1499 [1] and classified by Morel-Lavalle in 1845 [2]. Approximately 20% of reported cases are described as congenital and 80% as acquired, of which the majority are traumatic in origin [3, 4]. Traumatic intercostal hernias are frequently associated with multiple rib fractures or tears in the intercostal muscles. They usually occur in the area adjacent to the sternum, medial to the costochondral junction, where the intercostal musculature is thinnest, the external intercostal muscle being entirely absent [4–6]. This area has also been associated with seat belt injury in three-point restraint seat belts [5]. Symptoms are infrequent and usually minimal. Clinical examination usually reveals a painless, well-demarcated, spongy bulge that may vary with respiration [3, 5, 7]. Diagnosis is usually made by chest radiography, although, oblique views may be necessary [3, 7]. Computed tomographic scan generally confirms the diagnosis [7]. Treatment may be conservative, but operation is warranted for larger or incarcerated hernias [3–5, 7].

Our patient also exhibited a right hemothorax on presentation at our institution. Thoracoscopy has been shown to be a very effective method for the early evacuation of thoracic collections [8]. It also allows exploration of the chest for additional injuries in cases of trauma.

In conclusion, we report a traumatic lung herniation of the chest wall reduced thoracoscopically. We believe that video-assisted repair of these hernias can be done safely and effectively in an early phase, when possible adhesions can be easily released. This is particularly worthwhile in the stable trauma patient, who may have associated diaphragmatic injuries or hemothorax.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Roland. De pulmonis sanarpot, liber III (cap) XXV. In: de Chavliae G. Cyrugia 1499:144.
  2. Morel-Lavalle A. Hernie du poumon. Bull Mem Soc Chir Paris 1845;1:75-195.
  3. Moncada R., Vade A., Gimenez C., et al. Congenital and acquired lung hernias. J Thorac Imag 1996;11:75-82.[Medline]
  4. Forty J., Wells F.C. Traumatic intercostal pulmonary hernia. Ann Thorac Surg 1990;49:670-671.[Abstract]
  5. May A.K., Chan B., Daniel T.M., Young J.S. Anterior lung herniation: another aspect of the seat belt syndrome. J Trauma 1995;38:587-589.[Medline]
  6. Hartung A., Grossman J.W. Hernia of the lung. Am J Roentgenol 1941;46:321-323.
  7. Scullion D.A., Negus R., Al-Kutoubi A. Case report: extrathoracic herniation of the lung with a review of the literature. Br J Radiol 1994;67:94-96.[Abstract/Free Full Text]
  8. Heniford B.T., Carrillo E.H., Spain D.A., Sosa J.L., Fulton R.L., Richardson J.D. The role of thoracoscopy in the management of retained thoracic collections after trauma. Ann Thorac Surg 1997;63:940-943.[Abstract/Free Full Text]



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This Article
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