Ann Thorac Surg 2004;77:699-701
© 2004 The Society of Thoracic Surgeons
Case report
Recurrent intercostal herniation of the liver
Julian E. Losanoff, MDa,
Bruce W. Richman, MAa,
James W. Jones, MD, PhDa*
a Department of Surgery, University of Missouri-Columbia, Columbia, Missouri, USA
Accepted for publication April 29, 2003.
* Address reprint requests to Dr Jones, Department of Surgery (M580 HSC), University of Missouri-Columbia, One Hospital Drive, Columbia, MO 65212, USA
e-mail: jonesjw{at}health.missouri.edu
 |
Abstract
|
|---|
Abdominal intercostal hernia occurs rarely, with only 26 previous cases reported in the professional literature. A 51-year-old man presented with a painful right chest protrusion. One year earlier he had experienced a severe coughing spell and spontaneous rib fracture and chest protrusion. He was treated with endogenous tissue reinforcement and had no clinical improvement. Magnetic resonance imaging revealed the liver protruding through the chest wall. The hernia was reduced and the chest wall was repaired with prosthetic mesh and cables. Attention to the chest wall anatomy and reliable tissue closure including pericostal or transcostal nonabsorbable sutures and a prosthetic bridge over the defect are the best way to eliminate the patient's risk for recurrence.
|
Introduction
|
|---|
Abdominal intercostal hernia has been rarely reported. The condition occurs as acquired herniation of abdominal contents through disrupted diaphragmatic and intercostal muscles. A Medline database search and review of existing bibliographies identified 26 previously reported cases [1–5].
A 51-year-old man presented with a painful mass protruding from his right hemithorax. One-year before admission he had a severe coughing episode with a spontaneous rib fracture. A painful right chest protrusion appeared after 6 months. Open surgery 2 months later affected no improvement. History was significant for noninsulin dependent diabetes mellitus, coronary artery disease, and smoking.
Physical examination revealed a hard 4x18 cm reducible mass between the sixth and eighth right ribs, protruding between the anterior and posterior axillary lines with a Valsalva maneuver. The mass fluctuated with respiration and was markedly painful. When the patient assumed the left lateral decubitus position, there was a striking depression in the intercostal space, with the ribs widely separated and no free rib movement. A thoracotomy scar overlay the defect. No bowel sounds were audible in the thorax. A chest roentgenogram revealed a missing seventh rib and a soft tissue mass at the lateral aspect of the right lung base. A magnetic resonance imaging (MRI) scan revealed the liver protruding through a defect in the chest wall; the dome of the diaphragm was intact but extremely lax, overlying the defect's posterolateral aspect (Fig 1).
All other organs were normal. The laboratory values were within normal limits.
View larger version (148K):
[in this window]
[in a new window]
|
Fig 1. Frontal plane magnetic resonance imaging illustrating right intercostal liver protrusion (note the intact diaphragm contour on top of the lesion).
|
|
The diagnosis of intercostal liver hernia of the liver was made and an elective repair planned. A right lateral thoracotomy was centered over the hernia axis and incorporated the scar. With the seventh rib missing, the space between the sixth and eighth ribs was 6-cm wide and covered by attenuated scar tissue through which the hernia contents were palpable. No prosthetic or visible suture material remained from the previous surgery. The scar tissue was considered too weak for a reliable endogenous repair. The chest cavity was entered through the scar. There were no pleural adhesions. The ribs surrounding the defect and their costochondral junctions were found to be stable. No disruptions or scars of the anterior diaphragmatic muscle fibers were found and there was no communication with the peritoneal cavity. The lung was intact. The sixth intercostal neurovascular bundle was identified and preserved. A chest drain was inserted under direct visual control. The sixth and eighth ribs were stripped of their periosteum. Three single 1-mm stainless steel Songer cable loops (Songer Spinal Cable System; Pioneer Surgical Technology, Inc., Marquette, MI) were passed subperiosteally and equidistantly around them and left loose. Marlex mesh (C.R. Bard, Inc., Murray Hill, NJ) was sutured to the rib periosteum as far as possible superiorly and inferiorly, and to the scarred intercostal muscle anteriorly and posteriorly (Fig 2).
The two ribs were then approximated on top of the mesh and the cables tightened and crimped, creating a bilayered repair with mesh covered by the approximated sixth and eighth ribs. The subcutaneous tissue and skin were closed in layers.
View larger version (31K):
[in this window]
[in a new window]
|
Fig 2. Schematic cross-sectional drawing illustrating the subperiosteally passed cable (white arrowheads) and prosthetic mesh (black arrowheads) sutured to the posterior periosteum of the ribs (black arrows).
|
|
The postoperative course was uneventful, with hospital discharge on the fourth postoperative day. A dual energy X-ray absorptiometry (DEXA) scan using a Lunar DPX-IQ densitometer (http://www.bonedensitometry.com/lunar-dpx-iq.htm) revealed a decreased bone mineral density and the patient was treated accordingly. At 1-month follow-up he had no complaints and the repair was sound.
|
Comment
|
|---|
Most patients with abdominal intercostal hernias have had penetrating or blunt thoracoabdominal injuries involving massive rib fractures [1, 3]. Those in whom hernias occurred after apparently minor events, such as coughing or heavy lifting [4], had multiple predisposing conditions such as chronic obstructive pulmonary disease, asthma treated with steroids, or diabetes mellitus, as did our patient. His impaired bone mineral density suggests that osteoporosis can lead to rib fractures and thus precipitate the hernia.
The clinical features of intercostal abdominal hernias typically include voluminous bulges causing marked discomfort and pain [1–5]. A same-admission diagnosis is made in a minority of patients because hematoma and edema obscure the protruding abdominal contents. The remaining hernias are diagnosed between 4 weeks and 37 years after the acute event. All reported hernias have been located distal to the eighth rib level, usually in the left hemithorax [1–4]. The diagnoses are easily made by physical examination after hematomas and edema resolve and the bulge becomes visible. The surgical findings include diaphragmatic tears or diaphragm detachments from the costal margins, typically associated with 4 to 30 cm intercostal defects, and a hernia sac containing abdominal organs (liver in 23%) [4, 5]. Both the diaphragm and chest wall can be repaired using endogenous tissues, but prosthetic reinforcement is necessary in very large or recurrent defects [1].
Recurrence of the patient's hernia indicated an early repair failure. We found no evidence of reliable tissue closure, such as pericostal or transcostal nonabsorbable sutures, or a prosthetic bridge over the defect, suggesting that incomplete closure of the chest wall precipitated the recurrence. The literature's follow-up data, however meager, indicates an overall recurrence rate of 11.5%, represented by three hernias presenting at 1, 2, and 5 months postoperatively, with no mortality [1, 3]. Theoretical explanations for these recurrent cases include ripping of the sutures [1], a missed diaphragmatic tear, or diaphragm disruption caused by the displaced, jagged rib fractures [3].
Our method of repair aimed to improve the closure. We considered that the hernia was recurrent and large, and that there were no reliable anchoring structures except the bony defect borders. We also considered possible bone and soft tissue weakness resulting from the patient's multiple and long-standing comorbid illnesses. The permanent mesh screen formed a tension-free first barrier at the endothoracic level [1] and used rib periosteum as the most reliable anchoring structure at the defect's upper and lower levels. Our decision to use supplemental rib closure was based on the precarious anterior and posterior mesh anchoring for which only scar tissue was available.
The alternatives to approximate the ribs included synthetic sutures, wire, or cable. The latter method was chosen based on its biomechanical durability once submitted to repetitive muscle tension. The Songer Spinal Cable System was developed as an alternative to monofilament wire for osseous fixation. The system integrates either stainless steel or titanium cable, which is tightened and secured using a tensioner/crimper instrument. Its advantages over wire include ease of use, flexibility, strength, and consistency. Biomechanical testing has revealed that the maximum yield strength of a single stainless steel cable loop was more than two times greater than a double stainless steel wire loop; cables required 6 to 22 times more cycles to failure than wire [6]. The cable crimp connections resist more than 4 times the tension at which wire loops untwist [6, 7]. Banding of bony structures by round-stranded crimped cables has been demonstrated to better transmit forces when tissues are subjected to muscular tension. The tension forces are transmitted through the cable in a controlled manner, with a beneficial level of elasticity and resistance to cable fatigue [6]. We also passed the cables over rib cortical bone to eliminate the risk of material migration through the bone [6].
Abdominal intercostal hernias are rarely encountered and difficult to diagnose from the outset [1–5]. The condition's contemporary management demands a high index of suspicion and close attention to the damaged anatomy. Use of permanent prosthetic mesh to reinforce the defect and cable banding around the ribs to counteract the dehiscence tension forces are reliable methods of repairing those hernias for which massive loss of chest wall integrity precludes endogenous repair.
|
References
|
|---|
- Le Neel J.C., Mousseau P.A., Leborgne J., Horeau J.M., Labour P.E., Mousseau M. La hernie intercostale abdominale. Rapport de quatre observations. Ann Chir 1978;32:138-141.[Medline]
- Sommer T. Lumbar intercostal hernia–a rare condition. Ugeskr Laeger 1999;161:6640-6641.[Medline]
- Sharma O.P., Duffy B. Transdiaphragmatic intercostal hernia: review of the world literature and presentation of a case. J Trauma 2001;50:1140-1143.[Medline]
- Losanoff J.E., Richman B.W., Jones J.W. Transdiaphragmatic intercostal hernia: review of the world literature. J Trauma 2001;51:1218-1219.
- Best I.M. Complication of the retroperitoneal approach: intercostal abdominal hernia. Am Surg 2001;67:635-636.[Medline]
- Songer M.N., Spencer D.L., Meyer P.R., Jr, Jayaraman G. The use of sublaminar cables to replace Lugue wires. Spine 1991;16(8 Suppl):S418-421.[Medline]
- Labitzke R. Manual of cable osteosynthesis. . New York: Springer, 2000.
This article has been cited by other articles:
|
|
|
|
 
A. Connery and E. Mutvalli
Cough-induced abdominal intercostal hernia.
J R Soc Med Sh Rep,
January 1, 2010;
1(3):
23 - 23.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
