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Novel Fixation Technique for the Surgical Repair of Lung Hernias
Novel Fixation Technique for the Surgical Repair of Lung Hernias Scott Wiens, MD, Ian Hunt, FRCS, James Mahood, MD, FRCSC, Azim Valji, MD, FRCSC, Kenneth Stewart, MD, FRCSC, and Eric L. R. Bédard, MD, MSc Division of Thoracic Surgery, Departments of Surgery and Orthopedic Surgery, University of Alberta, Edmonton, Alberta, Canada
We describe a novel technique for dealing with the rare complication of post-traumatic or post-thoracotomy lung herniation. The method uses techniques and fixation devices that have been developed for stabilization and fixation of the spine and surgical management of scoliosis. It
allows for a secure, reliable, and easily reproducible fixation of the chest-wall in patients with large intercostal lung hernias using standard spinal instruments. (Ann Thorac Surg 2009;88:1034 –5) © 2009 by The Society of Thoracic Surgeons
L
FEATURE ARTICLES
ung herniation is a recognized albeit rare complication after trauma or thoracotomy [1] and can occur even after minimally invasive cardiothoracic surgery [2]. Lung hernias may remain asymptomatic, and if small can be managed conservatively [3]; however, if they become large and or symptomatic, most would advocate surgical repair. Numerous approaches have been described including both thorascopic and open techniques [3, 4]. Most approaches involve closing the defect using sutures, prosthetic patches, or meshes, but occasionally material such as fascia lata or
Accepted for publication Dec 2, 2008. Address correspondence to Dr Bédard, Royal Alexandra Hospital, 10240 Kingsway Ave, Edmonton, Alberta, T5H 3V9, Canada; e-mail: [email protected].
Fig 2. Intraoperative image showing a secured fixation repair with the laminar hooks (black arrow) and titanium bars (white arrows) in situ.
more complex plastics procedures using muscle flaps have been attempted [3, 5]. We describe a novel technique that uses laminar hooks connected to titanium bars that are fixated to the posterior ribs using modified hooks. The technique and instruments used are well known to spinal surgeons in managing spinal injuries and for conditions such as scoliosis [6, 7]. This method has been successfully used in managing three patients (2 clinically large symptomatic posttraumatic lung hernias, which were both motor vehicle accidents with multiple rib fractures as part of their injuries, and 1 post-thoracotomy lung hernia, which was a lobectomy for lung cancer, for which the sixth rib was notched posteriorly) (Fig 1). All were posterolateral involving the fifth to ninth ribs, and the patients underwent computed tomography to confirm diagnosis.
Technique Fig 1. Coronal computed tomographic scan demonstrating traumatic lung herniation. © 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
The patients were placed in a standard lateral-decubitus position after double-lung ventilation and isolation of the 0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2008.12.032
Ann Thorac Surg 2009;88:1034 –5
HOW TO DO IT WIENS ET AL REPAIR OF LUNG HERNIAS
1035
appropriate lung. A thoracotomy incision centered over the palpable hernia was performed, and any redundant pleural tissue associated with the hernia was resected. Associated diaphragmatic defects were closed with interrupted nonabsorbable sutures (in 1 patient). A laminar hook passer was used subperiosteally to develop a plane for seating the laminar hooks on the superior aspect of the superior rib and inferior aspect of the inferior rib. Three laminar hooks were positioned on the superior rib and three corresponding hooks on the inferior rib. Three titanium rods were cut to appropriate length and placed in the laminar hooks. A contractive force was applied by the surgical assistant to reduce the defect; set screws were then placed to secure the rods to the laminar hooks (Fig 2). Cross bars were used to prevent migration of the laminar hooks. A single chest tube was placed prior to closure, and a standard wound closure of overlying muscle and subcutaneous tissue was performed over the fixation. All patients were encouraged to mobilize postoperatively and were discharged on the fourth or fifth postoperative day with no complications, and were prescribed oral analgesia. They were instructed to avoid lifting more than 5 kg for 6 weeks. All three patients were followed for 1 year postoperatively. All were able to return to pre-injury activity level by 3 months (including 1 patient returning to work as a laborer). The patients reported minimal discomfort at the 6-week follow-up visit. There were no wound complications and no recurrence of hernia. No patients required long-term analgesia (Fig 3).
Comment Previous methods reported in the literature include direct suturing, mesh repairs, and occasionally more complex muscle flaps [3, 5]. Most methods rely on approximating ribs where possible and closure of soft tissue surrounding the hernia sac. We believe that the laminar hook fixation uses the strength of the bony
anatomy of the chest wall to prevent recurrence. By using scoliosis fixation devices designed for use in children and adolescents, a low profile was maintained. The repair was not just restricted to low lesions, and as overlying muscle and subcutaneous tissue was closed over the repair, chronic pain did not seem to be a problem. Although all hernias were posterolateral, the repair is likely to be effective even for more anterior hernias. The use of pedicle hooks with crossbar attachments, a robust construct commonly used in spinal surgery and for complex scoliosis surgical correction, seems to be effective for the treatment of large symptomatic pulmonary hernias, and allows patients to return to full activity without restriction.
References 1. Minai OA, Hammond G, Curtis A. Hernia of the lung: a case report and review of literature. Conn Med 1997;61: 77– 81. 2. Athanassiadi K, Bagaev E, Simon A, Haverich A. Lung herniation: a rare complication in minimally invasive cardiothoracic surgery. Eur J Cardiothorac Surg 2008;33:774 – 6. 3. Weissberg D, Refaely Y. Hernia of the lung. Ann Thorac Surg 2002;74:1963– 6. 4. Khalil MW, Masala N, Waller DA, Cardillo G. Surgical repair of post-traumatic lung hernia using a video-assisted open technique. Interact CardioVasc Thorac Surg 2008;7: 506 –7. 5. Arslanian A, Oliaro A, Donati G, Filosso PL. Posttraumatic pulmonary hernia. J Thorac Cardiovasc Surg 2001;122: 619 –21. 6. Hildingsson C, Jonsson H. Posterior stabilization of the cervical spine with hooks and screws. A clinical evaluation of 26 patients with traumatic, degenerative or metastatic lesions, using a new implant system. Eur Spine J 2001;10: 50 – 4. 7. Wimmer C, Gluch H, Nogler M, Walochnik N. Treatment of idiopathic scoliosis with CD-instrumentation: lumbar pedicle screws versus laminar hooks in 66 patients. Acta Orthop Scand 2001;72:615–20.
FEATURE ARTICLES
Fig 3. Chest roentgenogram (A) anteroposterior view and (B) lateral view at the 9-month follow-up visit showing no displacement of the laminar hook and bar construct.
We describe a novel technique for dealing with the rare complication of post-traumatic or post-thoracotomy lung herniation. The method uses techniques and fixation devices that have been developed for stabilization and fixation of the spine and surgical management of scoliosis. It
allows for a secure, reliable, and easily reproducible fixation of the chest-wall in patients with large intercostal lung hernias using standard spinal instruments. (Ann Thorac Surg 2009;88:1034 –5) © 2009 by The Society of Thoracic Surgeons
L
FEATURE ARTICLES
ung herniation is a recognized albeit rare complication after trauma or thoracotomy [1] and can occur even after minimally invasive cardiothoracic surgery [2]. Lung hernias may remain asymptomatic, and if small can be managed conservatively [3]; however, if they become large and or symptomatic, most would advocate surgical repair. Numerous approaches have been described including both thorascopic and open techniques [3, 4]. Most approaches involve closing the defect using sutures, prosthetic patches, or meshes, but occasionally material such as fascia lata or
Accepted for publication Dec 2, 2008. Address correspondence to Dr Bédard, Royal Alexandra Hospital, 10240 Kingsway Ave, Edmonton, Alberta, T5H 3V9, Canada; e-mail: [email protected].
Fig 2. Intraoperative image showing a secured fixation repair with the laminar hooks (black arrow) and titanium bars (white arrows) in situ.
more complex plastics procedures using muscle flaps have been attempted [3, 5]. We describe a novel technique that uses laminar hooks connected to titanium bars that are fixated to the posterior ribs using modified hooks. The technique and instruments used are well known to spinal surgeons in managing spinal injuries and for conditions such as scoliosis [6, 7]. This method has been successfully used in managing three patients (2 clinically large symptomatic posttraumatic lung hernias, which were both motor vehicle accidents with multiple rib fractures as part of their injuries, and 1 post-thoracotomy lung hernia, which was a lobectomy for lung cancer, for which the sixth rib was notched posteriorly) (Fig 1). All were posterolateral involving the fifth to ninth ribs, and the patients underwent computed tomography to confirm diagnosis.
Technique Fig 1. Coronal computed tomographic scan demonstrating traumatic lung herniation. © 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
The patients were placed in a standard lateral-decubitus position after double-lung ventilation and isolation of the 0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2008.12.032
Ann Thorac Surg 2009;88:1034 –5
HOW TO DO IT WIENS ET AL REPAIR OF LUNG HERNIAS
1035
appropriate lung. A thoracotomy incision centered over the palpable hernia was performed, and any redundant pleural tissue associated with the hernia was resected. Associated diaphragmatic defects were closed with interrupted nonabsorbable sutures (in 1 patient). A laminar hook passer was used subperiosteally to develop a plane for seating the laminar hooks on the superior aspect of the superior rib and inferior aspect of the inferior rib. Three laminar hooks were positioned on the superior rib and three corresponding hooks on the inferior rib. Three titanium rods were cut to appropriate length and placed in the laminar hooks. A contractive force was applied by the surgical assistant to reduce the defect; set screws were then placed to secure the rods to the laminar hooks (Fig 2). Cross bars were used to prevent migration of the laminar hooks. A single chest tube was placed prior to closure, and a standard wound closure of overlying muscle and subcutaneous tissue was performed over the fixation. All patients were encouraged to mobilize postoperatively and were discharged on the fourth or fifth postoperative day with no complications, and were prescribed oral analgesia. They were instructed to avoid lifting more than 5 kg for 6 weeks. All three patients were followed for 1 year postoperatively. All were able to return to pre-injury activity level by 3 months (including 1 patient returning to work as a laborer). The patients reported minimal discomfort at the 6-week follow-up visit. There were no wound complications and no recurrence of hernia. No patients required long-term analgesia (Fig 3).
Comment Previous methods reported in the literature include direct suturing, mesh repairs, and occasionally more complex muscle flaps [3, 5]. Most methods rely on approximating ribs where possible and closure of soft tissue surrounding the hernia sac. We believe that the laminar hook fixation uses the strength of the bony
anatomy of the chest wall to prevent recurrence. By using scoliosis fixation devices designed for use in children and adolescents, a low profile was maintained. The repair was not just restricted to low lesions, and as overlying muscle and subcutaneous tissue was closed over the repair, chronic pain did not seem to be a problem. Although all hernias were posterolateral, the repair is likely to be effective even for more anterior hernias. The use of pedicle hooks with crossbar attachments, a robust construct commonly used in spinal surgery and for complex scoliosis surgical correction, seems to be effective for the treatment of large symptomatic pulmonary hernias, and allows patients to return to full activity without restriction.
References 1. Minai OA, Hammond G, Curtis A. Hernia of the lung: a case report and review of literature. Conn Med 1997;61: 77– 81. 2. Athanassiadi K, Bagaev E, Simon A, Haverich A. Lung herniation: a rare complication in minimally invasive cardiothoracic surgery. Eur J Cardiothorac Surg 2008;33:774 – 6. 3. Weissberg D, Refaely Y. Hernia of the lung. Ann Thorac Surg 2002;74:1963– 6. 4. Khalil MW, Masala N, Waller DA, Cardillo G. Surgical repair of post-traumatic lung hernia using a video-assisted open technique. Interact CardioVasc Thorac Surg 2008;7: 506 –7. 5. Arslanian A, Oliaro A, Donati G, Filosso PL. Posttraumatic pulmonary hernia. J Thorac Cardiovasc Surg 2001;122: 619 –21. 6. Hildingsson C, Jonsson H. Posterior stabilization of the cervical spine with hooks and screws. A clinical evaluation of 26 patients with traumatic, degenerative or metastatic lesions, using a new implant system. Eur Spine J 2001;10: 50 – 4. 7. Wimmer C, Gluch H, Nogler M, Walochnik N. Treatment of idiopathic scoliosis with CD-instrumentation: lumbar pedicle screws versus laminar hooks in 66 patients. Acta Orthop Scand 2001;72:615–20.
FEATURE ARTICLES
Fig 3. Chest roentgenogram (A) anteroposterior view and (B) lateral view at the 9-month follow-up visit showing no displacement of the laminar hook and bar construct.