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Transdiaphragmatic Intercostal Hernia
Transdiaphragmatic Intercostal Hernia F.. Hammond Cole, Jr., M.D., Mark P. Miller, M.D., and Clay V. Jones, M.D. ABSTRACT A 72-year-old man was seen with coughinduced rib fractures, a diaphragmatic tear, and an intercostal hernia containing abdominal contents. A review of the literature of this rare problem is presented, and techniques of repair are discussed. Intercostal transdiaphragmatic hernia is a rarely reported lesion that probably occurs more frequently than the literature indicates. In the present report, we describe the surgical repair of this entity and review the literature.
A 72-year-old man sought medical attention for symptoms of a right lower lobe pneumonia that failed to respond to outpatient management and required admission. Two months earlier he had experienced a severe coughing episode, followed by left-sided lower chest pain. An ecchymotic area developed from clavicle to iliac crest in the region of pain, and six weeks later he noticed a soft, variable mass that gradually enlarged. The patient had multiple additional illnesses, including organic heart disease, chronic obstructive lung disease, adult-onset diabetes with insulin dependence, and gout. He had previously undergone inguinal hernia repair and a venous stripping and ligation. Physical examination revealed an elderly, chronically ill man with chronic obstructive pulmonary disease. He had a soft, intercostal mass about 10 cm in diameter between the eighth and ninth ribs, which protruded at the anterior axillary line and was readily reducible. When the patient assumed the right lateral decubitus position, there was a striking depression in the intercostal space. Chest films showed a fracture of the eighth rib, a soft tissue mass at the lateral aspect of the left lung base, and parenchymal density in the right lower lobe. Rib films showed fractures of the eighth, ninth, and tenth ribs with wide displacement of the latter two fragments. There was marked air density in soft tissues of the left wall of the chest (Fig 1). Barium studies confirmed abdominal viscera in the subcutaneous tissue of the thorax (Fig 2). Following treatment for his pneumonia, operative repair was performed. Initially, a short incision was made over the hernia sac. A clearly defined sac composed of pleura and attenuated thoracic fascia was identified. There was a segmental fracture of the eighth rib with a large, intercostal
defect, while the inferior portion of the thorax contained small bowel. The intestine was not adherent to the lung. The chest wall defect was 15cm long and 5 cm wide. Just posterior to the sternal attachment of the diaphragm, a 5-cm tear was seen. The incision was extended to a full thoracotomy in the seventh intercostal space, and repair was achieved by reducing the bowel beneath the diaphragm and closing the diaphragmatic rent in two layers. The hernia sac was excised, and the chest wall was reconstructed by closing the rib defect with nonabsorbable pericostal sutures. The patient’s postoperative course was uneventful, and he was discharged on the eighth postoperative day.
Comment Intercostal transdiaphragmatic hernia is a rare but clinically recognizable entity. Croce and Mehta (11 described a patient who had a spontaneous lateral detachment of the right hemidiaphragm from the chest wall along with a ninth segmental rib fracture. The resultant hernia sac was partially bound by peritoneum and produced a pleuroperitoneal hernia. Although this patient’s defect was similar etiologically and anatomically to the one seen in our patient, there were important differences in the composition of the sac and in the size and contents of the hernia.
From the Department of Surgery, University of Tennessee Center for the Health Sciences, Methodist Hospitals of Memphis, Memphis, TN. Accepted for publication Aug 23, 1985. Address reprint requests to Dr.Cole, 1325 Eastmoreland 312, Memphis, TN 38104.
565 Ann Thorac Surg 41:565-5&, May 1986
Fig 1 . Roentgenogram for rib detail showing soft tissue gas density.
566 The Annals of Thoracic Surgery Vol 41 No 5 May 1986
Fig 2 . Barium study showing small bowel in left hemithorax and herizia sac.
There have been several isolated reports of penetrating trauma that produced similar hernias. Francis and Barnsley [2] described a patient with intercostal herniation of abdominal contents following a penetrating chest injury, and Maurer and Blades [3], in a review of the literature, presented four similar occurrences that followed combat trauma. The formation of a transdiaphragmatic intercostal hernia requires a chain of anatomical events. First, a defect in the diaphragm allows abdominal contents to enter the chest. Next, a weakness in the thoracic wall allows protrusion of the abdominal contents. Herniations through
the chest wall are associated with increases in intrathoracic pressure and have a predilection for areas of potential weakness in the chest wall. These areas occur anteriorly from the costochondral junction to the sternum because of the absence of external intercostal muscles and posteriorly from the costal angle to the vertebrae as a result of the absence of internal intercostal muscles (41. Therefore, the combination of a disruption of the diaphragm and a chest wall defect affords the formation of an intercostal transdiaphragmatic hernia. The diagnosis of these hernias can easily be made with the presence of a palpable defect in the thoracic wall through which a reducible soft tissue mass appears. The contents of a hernia can be ascertained by observing that the containing lung varies in size paradoxically with respiration and is increased by Valsalva‘s maneuver [2]. An increase in hernia size with inspiration and a decrease with expiration occur when there is a diaphragmatic injury with prolapse of abdominal viscera into the thorax and out through the chest wall [2]. Roentgenogram of the chest wall after barium administration should confirm the diagnosis. The authors thank Dr. Donald C. Watson for his encouragement and assistance in the preparation of this manuscript.
References 1. Croce EJ, Mehta VA: Intercostal pleuroperitoneal hernia. J Thorac Cardiovasc Surg 77%!!,1979 2. Francis DM, Barnsley WC: Intercostal herniation of abdominal contents following a penetrating chest injury. Aust NZ J Surg 49:357, 1979 3. Maurer E, Blades B Hernia of the lung. J Thorac Surg 1577, 19% 4. Saw EC, Yokoyama T, Lee BC, et a1 Intercostal pulmonary hernia. Arch Surg 111:548, 1976
A 72-year-old man sought medical attention for symptoms of a right lower lobe pneumonia that failed to respond to outpatient management and required admission. Two months earlier he had experienced a severe coughing episode, followed by left-sided lower chest pain. An ecchymotic area developed from clavicle to iliac crest in the region of pain, and six weeks later he noticed a soft, variable mass that gradually enlarged. The patient had multiple additional illnesses, including organic heart disease, chronic obstructive lung disease, adult-onset diabetes with insulin dependence, and gout. He had previously undergone inguinal hernia repair and a venous stripping and ligation. Physical examination revealed an elderly, chronically ill man with chronic obstructive pulmonary disease. He had a soft, intercostal mass about 10 cm in diameter between the eighth and ninth ribs, which protruded at the anterior axillary line and was readily reducible. When the patient assumed the right lateral decubitus position, there was a striking depression in the intercostal space. Chest films showed a fracture of the eighth rib, a soft tissue mass at the lateral aspect of the left lung base, and parenchymal density in the right lower lobe. Rib films showed fractures of the eighth, ninth, and tenth ribs with wide displacement of the latter two fragments. There was marked air density in soft tissues of the left wall of the chest (Fig 1). Barium studies confirmed abdominal viscera in the subcutaneous tissue of the thorax (Fig 2). Following treatment for his pneumonia, operative repair was performed. Initially, a short incision was made over the hernia sac. A clearly defined sac composed of pleura and attenuated thoracic fascia was identified. There was a segmental fracture of the eighth rib with a large, intercostal
defect, while the inferior portion of the thorax contained small bowel. The intestine was not adherent to the lung. The chest wall defect was 15cm long and 5 cm wide. Just posterior to the sternal attachment of the diaphragm, a 5-cm tear was seen. The incision was extended to a full thoracotomy in the seventh intercostal space, and repair was achieved by reducing the bowel beneath the diaphragm and closing the diaphragmatic rent in two layers. The hernia sac was excised, and the chest wall was reconstructed by closing the rib defect with nonabsorbable pericostal sutures. The patient’s postoperative course was uneventful, and he was discharged on the eighth postoperative day.
Comment Intercostal transdiaphragmatic hernia is a rare but clinically recognizable entity. Croce and Mehta (11 described a patient who had a spontaneous lateral detachment of the right hemidiaphragm from the chest wall along with a ninth segmental rib fracture. The resultant hernia sac was partially bound by peritoneum and produced a pleuroperitoneal hernia. Although this patient’s defect was similar etiologically and anatomically to the one seen in our patient, there were important differences in the composition of the sac and in the size and contents of the hernia.
From the Department of Surgery, University of Tennessee Center for the Health Sciences, Methodist Hospitals of Memphis, Memphis, TN. Accepted for publication Aug 23, 1985. Address reprint requests to Dr.Cole, 1325 Eastmoreland 312, Memphis, TN 38104.
565 Ann Thorac Surg 41:565-5&, May 1986
Fig 1 . Roentgenogram for rib detail showing soft tissue gas density.
566 The Annals of Thoracic Surgery Vol 41 No 5 May 1986
Fig 2 . Barium study showing small bowel in left hemithorax and herizia sac.
There have been several isolated reports of penetrating trauma that produced similar hernias. Francis and Barnsley [2] described a patient with intercostal herniation of abdominal contents following a penetrating chest injury, and Maurer and Blades [3], in a review of the literature, presented four similar occurrences that followed combat trauma. The formation of a transdiaphragmatic intercostal hernia requires a chain of anatomical events. First, a defect in the diaphragm allows abdominal contents to enter the chest. Next, a weakness in the thoracic wall allows protrusion of the abdominal contents. Herniations through
the chest wall are associated with increases in intrathoracic pressure and have a predilection for areas of potential weakness in the chest wall. These areas occur anteriorly from the costochondral junction to the sternum because of the absence of external intercostal muscles and posteriorly from the costal angle to the vertebrae as a result of the absence of internal intercostal muscles (41. Therefore, the combination of a disruption of the diaphragm and a chest wall defect affords the formation of an intercostal transdiaphragmatic hernia. The diagnosis of these hernias can easily be made with the presence of a palpable defect in the thoracic wall through which a reducible soft tissue mass appears. The contents of a hernia can be ascertained by observing that the containing lung varies in size paradoxically with respiration and is increased by Valsalva‘s maneuver [2]. An increase in hernia size with inspiration and a decrease with expiration occur when there is a diaphragmatic injury with prolapse of abdominal viscera into the thorax and out through the chest wall [2]. Roentgenogram of the chest wall after barium administration should confirm the diagnosis. The authors thank Dr. Donald C. Watson for his encouragement and assistance in the preparation of this manuscript.
References 1. Croce EJ, Mehta VA: Intercostal pleuroperitoneal hernia. J Thorac Cardiovasc Surg 77%!!,1979 2. Francis DM, Barnsley WC: Intercostal herniation of abdominal contents following a penetrating chest injury. Aust NZ J Surg 49:357, 1979 3. Maurer E, Blades B Hernia of the lung. J Thorac Surg 1577, 19% 4. Saw EC, Yokoyama T, Lee BC, et a1 Intercostal pulmonary hernia. Arch Surg 111:548, 1976