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Ann Thorac Surg 2001;72:606-607
© 2001 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, The Cleveland Clinic, Cleveland, Ohio, USA
b Departments of Surgery and Pulmonary Medicine, Lovelace Medical Center, Albuquerque, New Mexico, USA
c Division of Thoracic and Cardiovascular Surgery, University of New Mexico, Albuquerque, New Mexico, USA
Accepted for publication June 1, 2000.
Address reprint requests to Dr Temes, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109-1998
e-mail: temest{at}ccf.org
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Introduction |
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A 68-year-old man with end-stage chronic obstructive pulmonary disease was admitted with left-sided secondary spontaneous pneumothorax, and a chest tube was placed. He required insertion of a second chest tube to reexpand the lung. The patient’s air leak failed to resolve, and ultimately he was referred for correction by video-assisted thoracic surgery. Three 30-mm ports were placed along the line of a posterolateral thoracotomy incision. At each port, subcutaneous tissues were divided with electrocautery and the chest was entered bluntly. Parietal pleurectomy of the entire anterior, lateral, and posterior chest wall was performed. Multiple blebs and bulla were encountered, and suspicious areas were resected with an endoscopic 45-mm stapler. Chest tubes (36F) were left through the two most anterior incisions. The intercostal spaces were not closed. The fascia was closed in all three incisions with 2-0 Vicryl (Ethicon, Somerville, NJ) suture. The patient was discharged to his home doing well.
Eleven months later the patient complained of worsening dyspnea. The patient had stigmata of severe chronic obstructive pulmonary disease, and bulging of the chest wall at the site of one of the incisions was noted. High-resolution computed tomography of the chest was performed to evaluate for progression of chronic obstructive pulmonary disease. Herniation of the lingula through a chest wall defect at the site of a previous thoracoscopy port was identified (Fig 1). This herniation was small and was asymptomatic. Therefore, no surgical correction was performed.
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Patients at highest risk for lung hernia appear to be those with elevated intrathoracic pressures: patients with morbid obesity or end-stage chronic obstructive pulmonary disease. Other risk factors include tissue weakness or poor healing from malnutrition, steroids, diabetes, or other comorbidities. Patients undergoing chest wall resections without reconstructions and patients with gaps in the interspace between paracostal sutures after thoracotomy do not routinely develop hernias. This suggests that chest wall defects alone are not sufficient to produce lung herniation.
Patients often present with a history of cough, trauma, or previous surgery at the site of hernia. Symptoms may or may not be present. When present, they include pain, intermittent mass, cough, or dyspnea. Signs of hernia include bulging with cough or palpable defects of the thoracic cage. Incarceration, as seen in our patient, is unusual. Respiratory compromise and strangulation could also potentially occur.
Asymptomatic lung hernias may not require correction [2]. Surgical repair is recommended for symptomatic hernias. Operation consists of reduction of the lung, excision of the hernia sac, and closure of the chest wall defect using suture, autologous materials, or prosthetic materials [2].
Often thoracoscopic ports are created bluntly, the intercostal defect is large, and trocars are not used. The interspace at the site of a thoracoscopy port is often not sutured. In high-risk patients, minimizing port size, using small trocars, creating small intercostal defects and closing the intercostal space, and repairing fascial defects may lessen the future occurrence of this complication.
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