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Traumatic transdiaphragmatic intercostal hernia, defined as an acquired herniation of abdominal contents through disrupted intercostal muscles, is a rarely reported entity. We present the first reported case of a traumatic transdiaphragmatic intercostal hernia complicated by strangulation of the herniated visceral contents.
Following blunt trauma,...
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Context 1
... 7 months follow-up, the patient presented with a large reducible TTIH ( Figure 3). On CT, the defect mea- sured 120 x 90 mm and the sac contained the hepatic flexure of the colon and a small part of the liver margin ( Figure 4). The repair of the defect was planned in 2 months in order to allow full recovery from injury and optimization of body weight. ...Citations
... Primary thoracoabdominal hernias are a rare phenomenon involving the triad of intercostal hernia or chest wall defect, abdominal wall hernia, and diaphragmatic hernia, which may occur in isolation or in combination. Historically, diaphragmatic hernias are more commonly identified in cases of blunt or penetrating trauma [1][2][3], but have also been recognized as an isolated pathology after thoracic or retroperitoneal surgery [4,5]. These hernias can also occur spontaneously as a consequence of forceful coughing, potentially resulting in some combination of rib fracture, disruption of the oblique and intercostal muscular attachments to the chest wall, and detachment of the diaphragm [6][7][8]. ...
Background
Primary thoracoabdominal hernias involve the triad of an intercostal hernia, abdominal wall hernia, and diaphragmatic hernia. We report a case series of this rare entity and describe the evolution and outcomes.Methods
We completed a retrospective analysis of thoracoabdominal hernia repairs performed January 2010–April 2019 at Prisma Health–Upstate and Carolinas Medical Center. This includes all patients with spontaneous defects, excluding incisional hernias or those resulting from external trauma.ResultsOf 16 patients with thoracoabdominal hernias, 15 patients developed hernias after forceful coughing and one patient developed a hernia after strenuous physical activity. Seven patients required at least one additional intervention; two for recurrence; two for recurrence of original intercostal repairs done elsewhere; two for wound complications; and one had a missed abdominal wall component.Conclusions
Primary thoracoabdominal hernias require a high index of suspicion. Durable repair involves complex reconstruction of the thoracoabdominal wall including the diaphragm, intercostal space, rib fracture fixation, and mesh reinforcement of the abdominal wall with permanent fixation constructs.
... 2 Erdas et al and others have reported that 15% of the acquired abdominal intercostal hernia can be complicated by incarceration or strangulation of the abdominal viscera. 3,4,11 Therefore surgical repair is the treatment of choice. Several surgical techniques can be used to repair the intercostal defect; however, tension free mesh repair is the technique of choice. ...
A 2-month-old entire female domestic short-hair cat (Felis domestica) with no history of trauma was presented for assessment of a swelling on the left thoracic wall. Palpation revealed a large, painless, reducible swelling between the tenth and eleventh ribs on the left side. Radiograph demonstrated dorsal displacement of the abdominal viscera through the tenth intercostal space. An abdominal ultrasound examination confirmed the displacement of stomach and spleen through tenth intercostal space. Surgical correction of the herniated contents was undertaken via intercostal celiotomy. An acellular dermal matrix scaffold, prepared from deceased donor caprine-skin upon treatment with 0.25% trypsin in 4 mol/L NaCl for 8 hours followed by 2% sodium dodecyl sulfate for 48 hours, was used to repair a 3 cm wide intercostal defect present between the tenth and eleventh ribs. Recovery was uncomplicated and the cat was asymptomatic till followup period of 26-month after surgery. Congenital intercostal hernia in a cat is being reported, which, to our knowledge, is the first report of its kind.
... Individual reports have linked sudden increase in thoracoabdominal pressure gradient such as violent coughing spell, heavy lifting, and parturition as a predisposing risk factor for herniation, with coughing being the most common of them all. [1][2][3][4][7][8][9] Commonly, the symptoms of spontaneous intercostal herniation are thoracoabdominal pain, nausea, and vomiting, which are similar to intrathoracic herniation, where dyspnea may also be present and all of these symptoms were present in our patient. 1,2,9,10 Ecchymosis or bulge or both over the hernia is usually seen in patients with concomitant intercostal muscle rupture as was seen in our patient. ...
... A review of 20 cases of spontaneous diaphragmatic rupture of diaphragm (variable intraabdominal hernial contents) by Losanoff et al were also repaired by thoracotomy as compared to our case, which was managed conservatively. 1 A case reported by Bendinelli et al, commented on the failure of conservative measures for a lacerated liver herniation, which led to liver necrosis, ultimately needing surgery. 7 Surgical interventions in our case were deferred because there was no evidence of laceration and instead, a close follow-up was implemented. A key derivation from this review is to maintain a high suspicion of liver herniation in patients with poor abdominal muscle strength with sudden worsening of cough. ...
Nontraumatic and spontaneous intercostal and intrathoracic herniations are defined as protrusions of intra-abdominal contents through acquired or congenital defects of the abdominal and thoracic walls without any proceeding trauma and are sparsely reported in the literature with less than 35 detailed case reports reported in the literature worldwide. Most of these cases result from abdominal trauma and are considered surgical emergencies. The content of these herniations, as reported in the literature, have classically been lungs and intra-abdominal organs. We report a case of nontraumatic intercostal and intrathoracic liver herniation, which was managed conservatively given minimal liver injury and rapidly improving symptoms.
... CT scan is the most used diagnostic tool, since it allows to confirm intercostal hernia, rule out visceral lesions and plan surgery [4]. Ultrasonography can be useful to carry out a first assessment, since it is faster and less expensive but not as effective as CT scan in identifying associated intra-abdominal lesions [5][6][7][8][9]. As reported by Erdas et al. 15% of AAIHs can be complicated by incarceration or strangulation [1]. ...
... (5) Through that weakness of the lateral abdominal wall, a part of the liver is herniating. (15,16) These hernias are quite rare so they are considered a rare phenomenon. Also, liver herniation is very rarely seen through a weakness or defect of the diaphragm, which is usually congenital or as a consequence of chest trauma. ...
... Also, liver herniation is very rarely seen through a weakness or defect of the diaphragm, which is usually congenital or as a consequence of chest trauma. (13,16) Most often, this liver herniation is not accompanied by marked symptomatology. In the literature, we encountered only one case with the incarceration of the herniated lobe of the liver. ...
... In the literature, we encountered only one case with the incarceration of the herniated lobe of the liver. (16) Lumbar hernias are rare postero-lateral abdominal wall hernias. Lumbar hernias are rare defects of the posterior abdominal wall. ...
... Abdominal intercostal hernias (AIH) are a rare entity with varying numbers (i.e., between 10 to 29) cases reported in the surgical literature. [1][2][3][4][5][6][7] Intercostal hernias are appropriately categorized into acquired versus spontaneous with the presence (i.e., a trans-diaphragmatic intercostal hernia) or absence of diaphragmatic involvement 1 This case series will report on two AIH cases that did not involve the patients' diaphragms. ...
... 8 Diagnosis is usually delayed due to a low index of provider suspicion and failure to consider this entity in the differential diagnosis. 1,2 In most cases, the AIH is formally diagnosed on a computed tomography (CT) scan of the chest and abdomen. Other diagnostic modalities include a thorough physical exam, laparoscopy, and ultrasound. ...
... 9 Contents can include anything from within the peritoneal cavity with colon, liver, omentum, fat, and stomach all reported. 1,2 The hernia contents are rarely incarcerated and even strangulated, in one documented case causing liver necrosis. 2 A variety of repairs have been described in the surgical literature including open trans-abdominal, thoracotomy, and laparoscopic repair. 1 Usually these are repaired in a tension free fashion and covered with mesh. 1 Although some experts have advocated for re-approximation of the involved ribs, this is rarely performed due to defect size and concerns of iatrogenic rib fractures and external deformity. ...
Abdominal intercostal hernia (AIH) is a rare clinical entity in which intra-abdominal visceral contents protrude through a defect between adjacent ribs. Most AIH are repaired via (an open or a laparoscopic) transabdominal approach or a thoracotomy. In this paper, the authors present two cases of AIH. Both cases of AIH developed in male patients after severe coughing episodes and demonstrated on computed tomography (CT) to include multiple abdominal viscera. In both cases, a robot-assisted laparoscopic hernia repair was performed utilizing Sepramesh and V-Lock suturing. To our knowledge, these are the first case reports of a robotic approach to repair of AIH. Both cases demonstrate the safety of this approach and expand on novel robotic approaches to ventral hernia repairs. Studies of longer term outcomes from this surgical approach are limited in the literature due to small number of cases and even fewer associated case reports.
... Although rare in the existing literature, these types of hernias have been suggested to actually be more frequent than the literature indicates, as their course is often asymptomatic. 9,12 More common on the left thoracic side, 9 these types of hernias are almost always located inferiorly to the seventh rib, and may contain omentum, colon, spleen, stomach, and/or small bowel. 12 There are only a few reports, including the present, of liver segments being contained in an intercostal hernia, with or without other coexisting abdominal viscera (Table 1). ...
... 9,12 More common on the left thoracic side, 9 these types of hernias are almost always located inferiorly to the seventh rib, and may contain omentum, colon, spleen, stomach, and/or small bowel. 12 There are only a few reports, including the present, of liver segments being contained in an intercostal hernia, with or without other coexisting abdominal viscera (Table 1). 4,5,10,[12][13][14][15][16][17] The diagnosis of intercostal hernia has been historically challenging, with the interval between the initial traumatic incident and the repair of the hernia varying from immediately after the trauma to more than three decades later. ...
... 12 There are only a few reports, including the present, of liver segments being contained in an intercostal hernia, with or without other coexisting abdominal viscera (Table 1). 4,5,10,[12][13][14][15][16][17] The diagnosis of intercostal hernia has been historically challenging, with the interval between the initial traumatic incident and the repair of the hernia varying from immediately after the trauma to more than three decades later. 9 Clinically, a patient with transdiaphragmatic intercostal hernia would typically present with a reducible, palpable soft tissue lump in the lower chest wall with a positive cough impulse. ...
Intercostal hernias are rare, and usually occur following injuries of the thoracic wall. The scope of this report is to present a case of a 53-year-old obese patient that developed a transdiaphragmatic intercostal hernia. The patient presented with a palpable, sizeable, reducible mass in the right lateral thoracic wall, with evident bowel sounds in the area, 6 months after a motor-vehicle accident. On computed tomography (CT), the hernia sac contained part of the liver and part of the ascending colon. A surgical repair of the defect was performed, using a prosthetic patch. The patient's postoperative course was uneventful and she remains recurrence free at 12 months after surgery. Intercostal hernias should be suspected following high-impact injuries of the thoracic wall, and CT scans will facilitate the diagnosis of intercostal hernia. We consider the surgical repair of the defect, with placement of a prosthetic mesh, as the treatment of choice to ensure a favorable outcome.
... A combined open (direct) and laparoscopic (indirect) method was also successfully performed [27]. Techniques to repair the defect include primary closure, absorbable and nonabsorbable meshes and patches, and prosthetic mesh reinforced by cable banding [29]. ...
... Regardless of approach, the most recent comprehensive literature review on AAIH by Erdas et al. reports that recurrences occurred in 28.6% [9] of cases and were seen in up to 12 months [29]. This number could be underestimated, since several cases had short follow-up times of less than 3 months [24,25,30] or were not followed up at all [33,34]. ...
Acquired abdominal intercostal hernia (AAIH) is a rare disease phenomenon where intra-abdominal contents reach the intercostal space directly from the peritoneal cavity through an acquired defect in the abdominal wall musculature and fascia. We discuss a case of a 51-year-old obese female who arrived to the emergency room with a painful swelling between her left 10th rib and 11th rib. She gave a history of a stab wound to the area 15 years earlier. A CT scan revealed a fat containing intercostal hernia with no diaphragmatic defect. An open operative approach with a hernia patch was used to repair this hernia. These hernias are difficult to diagnose, so a high clinical suspicion and thorough history and physical exam are important. This review discusses pathogenesis, clinical presentation, complications, and appropriate treatment strategies of AAIH.
... Currently, most authors make a clear distinction between lung and abdominal intercostal hernia, but confusing terminology is still used, with the term ''abdominal intercostal hernia'' (AIH) being applied regardless of whether viscera reached the intercostal space directly from the peritoneal cavity or from a transdiaphragmatic defect [4][5][6][7][8][9][10][11]. Furthermore, descriptive terms referring to etiology (incisional intercostal hernia [5,12,13]) or hernia content (intercostal herniations of… [11,14], hernia of intra-abdominal fat in the thorax [15], colon containing intercostal hernia [16]) are occasionally used. In agreement with Bobbio et al. [17], we believe that the term ''abdominal intercostal hernia'' should be reserved for cases with no diaphragmatic injury, while the other cases should be labeled ''transdiaphragmatic intercostal hernia''. ...
... At the first clinical evaluation, 5 patients received a wrong or imprecise diagnosis, including generic ileus (1 case), and hematoma (4 case). Furthermore, a typical case of AAIH (according to the CT findings and the description of the operation) was defined as ''transdiaphragmatic intercostal hernia'' in one study [14]. The imaging techniques most useful in making a correct diagnosis were CT scan (16 cases) and US (5 cases (6 cases). ...
... Analysis of these reports showed that AAIH mainly developed under the 9th rib with no significant differences as to side, and the number of males was about double that of females. Aside from incisional hernias, commonly secondary to surgery for retroperitoneal diseases [5,12,13,19], most cases of AAIH are secondary to major [7,8,10,14,17,22], (personal case) or minor [9,11,16,21] trauma, although 20 % would appear to be spontaneous [4,6,20]. Major trauma commonly consists in severe blunt strikes, while minor trauma is always the result of a sudden increase in thoracic pressure due to severe coughing in patients suffering from COPD. ...
The protrusion of abdominal viscera through an intercostal space under an intact diaphragm is a very rare condition. The aim of this study is to elucidate the etiology, clinical features, and therapeutic options on what several authors call "abdominal intercostal hernia" (AIH).
A typical case of AIH of the 9th left intercostal space in a 48-year-old man is presented. A literature search was conducted on the Medline and Scopus databases. Only acquired AIHs (AAIHs) were considered, while lung, transdiaphragmatic, and congenital intercostal hernias were excluded.
Eighteen studies met selection criteria and a total of 20 patients were useful for analysis. Etiology was related mainly to traumatism (65 %) or to previous surgery (20 %). The intercostal defects were mostly located under the 9th rib without significant differences as to side. The main symptom was chest swelling (85 %), often associated with discomfort or pain (76 %). Acute complications such as incarceration and strangulation occurred in three patients. CT was the most employed diagnostic tool (80 %). Early diagnosis was made in 25 % of cases. Seventeen patients underwent hernia repair with either open (73 %) or laparoscopic approach (28 %), and various techniques with and without prosthesis were described. Recurrence occurred in 28.6 % of patients, during a mean follow-up of 8.6 months.
AAIH should be always suspected when chest swelling occurs after a minor or major trauma, and CT must be promptly performed to rule out diaphragmatic or abdominal viscera injury. This condition requires surgery to prevent serious complications, the first-choice technique should be mesh tension-free repair.
... (2,(5)(6)(7) Failing to recognize transdiaphragmatic intercostal hernia can be potentially fatal, because of possible complications, such as strangulation. (8) We report the cases of three patients who developed cough-induced herniation of intestinal loops through the diaphragm and intercostal space, associated with rib fracture, describing the radiographic, ultrasonographic, CT, and magnetic resonance findings obtained in the cases. ...
Transdiaphragmatic intercostal hernia is uncommon and mostly related to blunt or
penetrating trauma. We report three similar cases of cough-induced
transdiaphragmatic intercostal hernia, highlighting the anatomic findings
obtained with different imaging modalities (radiography, ultrasonography, CT,
and magnetic resonance) in each of the cases.
