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Axial contrast-enhanced computed tomography image. The image shows a bulge in the left posterolateral abdominal wall with fascial layers intact
Source publication
Background
A pseudohernia is an abdominal wall bulge that may be mistaken for a hernia but that lacks the disruption of the abdominal wall that characterizes a hernia. Thus, the natural history and treatment of this condition differ from those of a hernia. This is the first report of a pseudohernia due to cough-associated rib fracture.
Case presen...
Citations
... Apart from HZ infection, a pseudohernia may also occur with variety of syndromes involving neuropathy or denervation including Diabetes Mellitus and following a trauma to nerves as after surgical operations, rib fractures etc 18 . Complete recovery in PHAP occurs in 6-12 months in 55-75% of cases 6 . ...
... Apart from HZ infection, a pseudohernia may also occur with variety of syndromes involving neuropathy or denervation including Diabetes Mellitus and following a trauma to nerves as after surgical operations, rib fractures etc 18 . Complete recovery in PHAP occurs in 6-12 months in 55-75% of cases 6 . ...
... Abdominal pseudohernia is a rare clinical entity that consists of an abnormal bulging of the abdominal wall that can resemble a true hernia but has no associated underlying fascial or muscle defect [1]. Abdominal pseudohernia is believed to result from denervation of the abdominal muscles in cases of herpes zoster infection [2], diabetes mellitus [3], lower thoracic or upper lumbar disc herniation [4][5][6][7][8][9][10], surgical injuries [11], and rib fractures [1]. ...
... Abdominal pseudohernia is a rare clinical entity that consists of an abnormal bulging of the abdominal wall that can resemble a true hernia but has no associated underlying fascial or muscle defect [1]. Abdominal pseudohernia is believed to result from denervation of the abdominal muscles in cases of herpes zoster infection [2], diabetes mellitus [3], lower thoracic or upper lumbar disc herniation [4][5][6][7][8][9][10], surgical injuries [11], and rib fractures [1]. ...
... After both conditions have been eliminated, pseudohernia may be considered. Abdominal pseudohernia is most often caused by herpes zoster infection and can also result from denervation of abdominal muscles in cases of diabetes, lower thoracic or upper lumbar disc herniation, surgical injury, and rib fracture [1][2][3][4][5][6][7][8][9][10][11]. Therefore, differential diagnosis of the above diseases should be considered in patients with pseudohernia. ...
Background
An abdominal pseudohernia is a rare clinical entity that consists of an abnormal bulging of the abdominal wall that can resemble a true hernia but does not have an associated underlying fascial or muscle defect. Abdominal pseudohernia is believed to result from denervation of the abdominal muscles in cases of herpes zoster infection, diabetes mellitus, lower thoracic or upper lumbar disc herniation, surgical injuries, and rib fracture. To date, nine cases of abdominal pseudohernia caused by disc herniation at the lower thoracic or upper lumbar levels have been reported.
Case presentation
A 35-year-old man with no underlying disease or traumatic event presented with chief complaints of left flank pain and a protruding left lower abdominal mass that had formed one day earlier. There was no true abdominal hernia on abdominal computed tomography (CT), although CT and magnetic resonance imaging (MRI) showed a herniated soft (non-calcified) disc into the left neural foramen at the T11-12 level. A nonsteroidal anti-inflammatory drug was prescribed for the flank pain, and the patient was followed on a regular basis for six months. Follow-up MRI taken at the last visit showed complete resorption of the herniated disc. Abdominal pseudohernia and flank pain were also completely resolved.
Conclusion
We report a rare case of monoradiculopathy-induced abdominal pseudohernia caused by foraminal soft disc herniation at the T11-12 level. In patients who have an abdominal pseudohernia without herpes zoster infection, diabetes mellitus, or traumatic events, lower thoracic disc herniations should be included in differential diagnosis.
... An abdominal wall pseudohernia is an abnormal bulging of the abdominal wall, which can resemble a true hernia, but without an underlying fascial or muscle defect. 1 It is a rare phenomenon, 2,3 and can arise from a wide range of causes, all of which are related to an underlying segmental neuropathy with subsequent denervation of the abdominal wall musculature. It can be a diagnostic challenge both clinically and radiologically. ...
... An abdominal pseudohernia is an abnormal bulging of the abdominal wall, which can resemble a true hernia, but without an associated underlying fascial or muscle defect. 1 As such, the abdominal wall itself often appears entirely normal on imaging, unless there is evidence of chronic muscle denervation. ...
... Rib fracture). 1 The differential diagnosis for an abdominal wall pseudohernia is large, depending on whether it presents as a focal bulge, abdominal muscular weakness, neurosensory abnormalities, or a combination of these. A focal bulge may act as a 'red herring' and make a clinician consider an underlying mass or true hernia, rather than investigating a neurological cause. ...
An abdominal wall pseudohernia is a rare clinical entity which consists of an abnormal bulging of the abdominal wall that can resemble a true hernia, but without an associated underlying fascial or muscle defect. It is caused by segmental neuropathy and subsequent denervation of abdominal wall musculature. We present two cases of an abdominal wall pseudohernia. One secondary to a thoracic extraforaminal disc herniation in a 57-year-old male, which, as far as the authors are aware, has not been described previously. The other in a 67 year old male due to right foraminal and paracentral disc protrusion at T9/10.
... This distinction is important because pseudohernias, which are abdominal wall bulges in the absence of musculofascial defects, can present with nearly identical clinical presentation. While frequently caused by truncal radiculoneuropathy from diabetes or herpes zoster infection, pseudohernias can also occur after retroperitoneal flank incisions and cough-associated rib fractures which can lead to diagnostic uncertainty [15][16][17][18]. Surgery is not felt to be useful for this condition and the therapy is largely symptom management. ...
PurposeHernias spanning both chest and abdominal walls are uncommon and associated with chest wall trauma, coughing and obesity. This study describes the radiographic appearance of these hernias to guide proper identification and operative planning. Proposed standardized reporting patterns are also presented.Methods
The cross sectional imaging of patients presenting with thoracoabdominal hernias was reviewed. Radiographic reports were supplemented by surgeon imaging review and operative findings during repair. Defect dimensions, hernia content, level of herniation, presence of osseous or cartilaginous disruption of the chest wall and degree of rib displacement were collected. Disruption of myofascial planes was also noted.ResultsSix patients were identified. All hernias occurred below the 9th rib and were associated with complete intercostal muscle disruption. The transversus abdominis was disrupted in all hernias and the internal oblique was disrupted in five of the hernias. The majority (83%) had caudal rib displacement (median 6.8 cm compared to contralateral side). Median hernia width was 10.35 cm (1.6–19.1 cm) and median length was 10.2 cm (1.8–14.3 cm). Five patients had associated bone/cartilage injuries: two with 11th rib fractures, two with combined bone and cartilaginous fractures and one with a surgical rib resection.Conclusion
The typical injury pattern of thoracoabdominal hernias includes disruption of the intercostal muscles, transversus abdominis, and commonly the internal oblique with an intact external oblique. Inferior rib displacement by hernia contents and unopposed pull of the abdominal musculature is common. Osseous or cartilaginous disruption always occurs unless the defect is bounded on at least one side by a floating rib.
... Of note, there are generally no findings specific to AWP on computed tomography (CT) or other types of imaging [5]. Moreover, although the protrusion with an AWP resembles a hernia, there is no actual muscular disruption, with all muscle and fascial layers remaining intact [6]. As the use of renal cell carcinoma ablation continues to expand, the incidence of associated neurologic complications, such as AWP, is likely to increase. ...
... AWP development is a well-recognized complication of abdominal surgery, herpes zoster infection, diabetes mellitus, and iatrogenic trauma [6][7][8][9][10][11][12][13]. Knowledge of the anatomical course of the intercostal nerves can lower the risk for AWP during laparoscopic surgery [14]. ...
Introduction:
Percutaneous cryoablation (PCA) is increasingly recognized as a feasible minimally invasive, nephron-sparing treatment for renal cell carcinomas, with comparable efficacy to nephrectomy. The development of abdominal wall pseudohernia (AWP) is a rare complication of PCA for renal masses, which can negatively impact patients' quality of life.
Aim:
To retrospectively evaluate the risk factors and prognosis for AWP after PCA and, based on these results, to discuss strategies to lower the risk of AWP associated with image-guided PCA for renal masses.
Material and methods:
We retrospectively studied 117 PCAs performed for renal masses in 92 patients, between 2016 and 2019, at our hospital. We compared the following clinical characteristics (age, sex, body mass index, tumour diameter, RENAL nephrometry score, procedural details, transcatheter arterial embolization, dissection techniques, number of cryoneedles used, location of needles, and location of ice ball) between those who developed AWP and those who did not.
Results:
Of the 117 PCAs (92 patients) included in our study group, AWP complications were observed in 6 (5.1%) procedures. Puncture through the erector spinae muscle (p < 0.01) and non-use of hydro- or pneumo-dissection (p = 0.01) were identified as risk factors for AWP.
Conclusions:
Although PCA is relatively safe to perform and the occurrence of an associated AWP is a rare and infrequent complication, the risk for AWP could be further decreased by avoiding punctures through the erector spinae muscle and using hydro- or pneumo-dissection.
... An abdominal pseudohernia is a protrusion of the abdominal wall that resembles a hernia but differs from a true hernia in that it has no actual muscular disruption and all muscle and fascial layers remain intact. [1] Pseudohernia is a rare phenomenon, which has been reported in association with various syndromes involving peripheral neuropathy, including zoster infection, [2] diabetes mellitus, [3,4] and following operative trauma. [5][6][7] Until now, pseudohernia has often been neglected, and cases are rarely reported. ...
Rationale:
An abdominal pseudohernia is a protrusion of the abdominal wall that there is no actual muscular disruption. This report presents a case in which abdominal muscle activities were accurately and quantitatively measured using ultrasonography (US) and surface electromyography in a patient with abdominal pseudohernia.
Patient concerns:
A 62-year-old man presented with a marked protrusion on the left abdomen with increasing abdominal pressure.
Diagnoses:
First, the thickness of the abdominal muscle was measured with US while the patient constantly blew the positive expiratory pressure device. When the force was applied to the abdomen, the mean thickness of the muscle layer on the lesion site was found to be thinner. Second, the activities of the abdominal muscles were measured using surface electromyography by attaching electrodes to 8 channels at the same time. When the same pressure was applied on both sides of the abdomen, more recruitment occurred to compensate for muscle weakness at the lesion site. Through the previous 2 tests, the decrease in muscle activity in the lesion area could be quantitatively evaluated. Third, the denervation of the muscle was confirmed using US-guided needle electromyography.
Interventions:
The patient in this case was wearing an abdominal binder. In addition, he had been training his abdominal muscles through McGill exercise and breathing exercises such as with a positive expiratory pressure device.
Outcomes:
The patient was able to understand his symptoms. A follow-up test will be performed to see if there is any improvement.
Lessons:
By using these outstanding assessment methods, proper diagnosis and rehabilitation treatment strategies can be developed.
... This was attributed to more than anticipated ICN damage during cryoablation. This sensation has known associations with herpes Zoster (23), diabetic neuropathy (24), and rib fractures (25). We, on physical examination, did not see an abdominal wall bulge or feel a defect, however, we did not get a CT scan to evaluate this further and confirm the findings. ...
PURPOSE Post-thoracotomy pain syndrome is a common condition affecting up to 50% of post-thoracotomy patients. However, percutaneous computed tomography (CT)-guided intercostal nerve cryoablation may provide symptomatic benefit in chronic and/or refractory cases. METHODS A retrospective review of our institution's comprehensive case log from October 2017 to September 2018 for patients who underwent cryoablation was analyzed. Thirteen patients with post-thoracotomy pain syndrome, refractory to medical management, were treated with CT-guided intercostal nerve cryoablation. Most patients had treatment of the intercostal nerve at the level of their thoracotomy scar, two levels above and below. The safety and technical success of this technique and the clinical outcomes of the study population were then retrospectively reviewed. RESULTS Of the patients, 69% experienced significant improvement in their pain symptoms with a median pain improvement score of 3 points (range, -1 to 8 points) over a median follow-up of 11 months (range, 2-18.6 months). Complications included pneumothorax in 8% and pseudohernia in 23% of patients. CONCLUSION CT-guided intercostal nerve cryoablation may be an effective technique in the treatment of post-thoracotomy pain syndrome and requires further study.
... Another point of caution is that the intercostal nerves at this level contribute to lateral abdominal wall muscular tone and function. Care must be taken if this rib segment is to be manipulated in any way because injuring the intercostal nerve can result in a flank pseudo-hernia that can be disfiguring, painful, and exceedingly challenging to treat (2). Furthermore, it can create lower thoracic instability that may compromise repair of the adjacent plated ribs which may result in hardware failure. ...
Although surgical fixation of rib fractures is increasingly being performed around the world, very little has been published on how to access the chest wall itself. Having performed over one hundred rib fixations in our institution in the past five years, our surgical technique has evolved as more has come to be understood about these types of injuries through examination of the literature, our own experience, and discussions with colleagues experienced in treating these patients. Retrospective chart review of our trauma registry revealed prevalent fracture patterns and we sought to describe the three simple approaches to the chest wall that we most commonly use based on these data and validated through cadaveric dissections. What follows is a description of our experience with surgical fixation and analysis of the anatomy based on functional approaches to common injury patterns. Analysis of CT scans of patients with flail chest injuries revealed the most commonly encountered in our patients requiring surgical fixation. We identified three basic incisions used to access the areas of interest in a majority of cases. Careful cadaveric dissections allowed us to provide a detailed description of what portions of the chest wall would be accessible through each with and without sparing of the chest musculature. This paper describes viable options for approaching the chest wall for most rib fracture patterns in need of surgical fixation. This is not comprehensive review, but merely presents some of the effective alternatives to a standard thoracotomy as an approach to the chest wall with the hope and expectation that future publications will expand and improve upon the techniques described here.
... 4,5,12,13 Nerve injury after laparoscopic surgery is extremely rare, with only scarce reports in the literature. 2,5,6,10,14,16 Herein, we report an unusual case of subcostal nerve injury occurring after laparoscopic posterior flank wall lipoma resection, and we review the anatomy of the subcostal nerve and its relation to adjacent structures. ...
... Other scarce case reports in the literature have delineated the occurrence of subcostal nerve injury after laparoscopic cholecystectomy, laparoscopic appendectomy, splanchnic nerve radiofrequency ablation, and rib fractures. 2,6,10,14,16 To the best of our knowledge, this is the first case of iatrogenic subcostal nerve injury following laparoscopic posterior abdominal wall lipoma resection. The challenge, of course, is that the use of an anteriorly placed laparoscope places the subcostal nerve behind the lipoma, where the surgeon is blind to it. ...
Endoscopic surgery has revolutionized the field of minimally invasive surgery. Nerve injury after laparoscopic surgery is presumably rare, with only scarce reports in the literature; however, the use of these techniques for new purposes presents the opportunity for novel complications. The authors report a case of subcostal nerve injury after an anterior laparoscopic approach to a posterior abdominal wall lipoma.
A 62-year-old woman presented with a left abdominal flank bulge (pseudohernia) that developed after laparoscopic posterior flank wall lipoma resection. Imaging demonstrated frank ballooning of the oblique muscles; denervation atrophy and thinning of the external oblique, internal oblique, and transverse abdominis muscles; and thinning of the rectus abdominis muscle. The patient underwent subcostal nerve repair and removal of a foreign plastic material from the laparoscopic procedure. At 8 months, she has regained substantial improvement in abdominal wall strength.
Although endoscopic procedures have resulted in significant reduction in morbidity, “minimally invasive” approaches should not be confused with “low risk” when approaching novel pathology. The subcostal nerve is at risk of injury in posterior abdominal wall surgery, whether laparoscopic or not. With the pseudohernia and abdominal bulge after this surgery, the cosmetic appeal of laparoscopic incisions was definitively undone. Selecting an approach based on the anatomy of adjacent structures may lead to a better functional result.
