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Ann Thorac Surg 1998;65:1772-1774
© 1998 The Society of Thoracic Surgeons

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Case Reports

Lung Herniation Secondary to Minimally Invasive Direct Coronary Artery Bypass Grafting

^a Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska, USA

Accepted for publication December 19, 1997.

Address reprint requests to Dr Sugimoto, Department of Surgery, Creighton University School of Medicine, 601 N 30th St, Suite 3740, Omaha, NE 68131

	Abstract

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Lung herniation after thoracotomy is rare. We report a 66-year-old man who presented with this complication after undergoing attempted minimally invasive direct coronary artery bypass grafting. The defect was repaired with a composite of Marlex mesh and methyl methacrylate.

	Introduction

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As we move away from the median sternotomy for cardiac operations and begin to use a variety of parasternal approaches, new and different complications including lung herniation may be seen. We describe a case of lung herniation that developed secondary to attempted minimally invasive direct coronary artery bypass grafting.

A 66-year-old man with a history of chronic obstructive pulmonary disease was referred to us with an increasing bulge in the anterior chest wall parasternally (Fig 1). He previously underwent attempted minimally invasive direct coronary artery bypass grafting, which required the excision of the costal cartilage and the head of the fourth rib. Because of an intramyocardial left anterior descending artery, the bypass was completed conventionally. Four weeks later, he noticed the bulge. On physical examination, there was an anterior chest wall defect measuring 4 x 4 cm, at the site of the previous operation, associated with paradoxical breathing. His forced expiratory volume in 1 second was 0.97 L, 32% of predicted, and his ratio of forced expiratory volume in 1 second to forced vital capacity was 35%, which failed to improve with bronchodilators. Ultimately, 3 months after our initial evaluation, the patient elected to undergo an operation to correct the defect. The time interval between the costal cartilage-rib excision and the lung hernia repair was 10 months. Under general anesthesia with a double-lumen endotracheal tube, the exploration was performed through the old scar, which revealed a 5 x 7-cm defect. Multiple lung adhesions were lysed. A composite of Marlex (Davol, Cranston, RI) mesh and methyl methacrylate was then sutured to the edges of the skeletal defect using interrupted 2/0 monofilament nylon (Fig 2). A chest tube was placed before wound closure. Postoperative recovery was unremarkable. His chest tube was removed on day 3. He was discharged on postoperative day 4 with no residual pneumothorax on chest roentgenograms. Eight months later, his forced expiratory volume in 1 second was 1.95 L, 61% of predicted, and the ratio of forced expiratory volume in 1 second to forced vital capacity was 42%. The patient was asymptomatic with no recurrent lung hernia.

View larger version (112K): [in this window] [in a new window]   Fig 1. The lung hernia during forced expiration (A) and during inspiration (B).

View larger version (179K): [in this window] [in a new window]   Fig 2. Reconstruction of the lung hernia using a composite of Marlex mesh and methyl methacrylate.

	Comment

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The diagnosis of lung hernia is straightforward. The patient may present with a bulge, which may increase in size with expiration and decrease with inspiration, or may present with chest pain or discomfort. Selective chest radiographs, especially the oblique views, should confirm the diagnosis. Symptomatic lung hernias should not require a computed tomographic scan for diagnosis unless an underlying cause is suspected [3].

Treatment of symptomatic lung hernia is surgical and is determined by factors such as size, pain, recurrent chest infections, incarceration, or paradoxical respiration with resultant poor ventilation. However, controversy exists regarding the role of surgery because spontaneous regression may occur [6]. During the operation, identification of the hernial sac and defect is essential so that the lung can be freed from adhesions and reduced into the thoracic cavity [3]. The type of reconstruction depends on the status of pleural cavity and the requirement for skeletal support and soft-tissue coverage. McCormack [7] believes that any defect greater than 5 cm should be reconstructed, although smaller defects may also require repair in a compromised patient with paradoxical respiration [7]. On the other hand, Picciocchi and associates [8] state that defects greater than 5 cm do not require reconstruction when located posteriorly and superiorly because of the shielding function of the scapula. A variety of materials have been used for lung hernia repair including periosteal flaps; Marlex, Vicryl (Ethicon, Somerville, NJ), or Prolene (Ethicon) mesh; expanded polytetrafluoroethylene patch; or a composite of Marlex mesh and methyl methacrylate [7]. Soft-tissue coverage with skin grafts, muscle flaps, or omentum is only necessary if there is a loss of soft tissue.

If the removal of costal cartilage becomes necessary for better exposure in minimally invasive direct coronary artery bypass grafting, lung herniation may be a real problem for patients with chronic obstructive pulmonary disease. It is prudent, therefore, that these patients should be identified and primary reconstruction should be undertaken to prevent future lung herniation. If a lung hernia develops and becomes symptomatic or leads to deterioration of the respiratory status, appropriate surgical intervention is usually curative.

	References

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1. Sebba L., Baigelman W. Post-surgical lung hernia. Am J Med Sci 1982;284:40-43.[Medline]
2. Fisch A.E., Brodey P.A., Salman B.J., Mall J.C. Post-thoracotomy lung herniation. Br J Radiol 1978;51:688-690.[Abstract/Free Full Text]
3. Sonett J.R., O’Shea M.A., Caushaj P.F., Kulkarni M.G., Sandstrom S.H. Hernia of the lung: case report and literature review. Ir J Med Sci 1994;163:410-412.[Medline]
4. Munnell E.R. Herniation of the lung. Ann Thorac Surg 1968;5:204-212.[Medline]
5. Calafiore A.M., Angelini G.D., Bergsland J., Salerno T.A. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;62:1645-1648.
6. La Hei E.R., Deal C.W. Intercostal lung hernia subsequent to harvesting of the left internal mammary artery. Ann Thorac Surg 1995;59:1579-1580.[Abstract/Free Full Text]
7. McCormack P.M. Use of prosthetic materials in chest-wall reconstruction: assets and liabilities. Surg Clin N Am 1989;69:965-976.
8. Picciocchi A., Granone P., Cardillo G., Margaritora S., Benzoni C., D’Ugo D. Prosthetic reconstruction of the chest wall. Int Surg 1993;78:221-224.[Medline]

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This Article Abstract Full Text (PDF) 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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ramzi K. Deeik Jeffrey T. Sugimoto Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Deeik, R. K. Articles by Sugimoto, J. T. Search for Related Content PubMed PubMed Citation Articles by Deeik, R. K. Articles by Sugimoto, J. T.