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Case Report
*Corresponding Author: Aubin Sandio, MD, MPH Wayne State University School of Medicine.
Citation: David Douglas Banga Nkomo, Aubin Sandio, Sandra Yakan, Linda Mokam Ngantchou, Casimir Fankem. et all (2023). Severe Post Traumatic Intercostal Surgical Hernia Repaired: A Case Report. J. Clinical Cardiology and Cardiovascular Interventions, 6(3); DOI:10.31579/2641-0419/301
Copyright: © 2023 Aubin Sandio, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 27 January 2023 | Accepted: 14 March 2023 | Published: 31 March 2023
Keywords: intercostal hernia; chest trauma; surgical repair; thoracotomy
Intercostal hernia is defined as a protrusion of the lung parenchyma and or pleura through a defect in the intercostal muscles between adjacent ribs. It is a rare condition, usually asymptomatic, in most cases acquired following a chest trauma or following a chest surgery, and whom diagnostic is clinical. Intercostal hernia may be managed by a surgical repair or not. The decision to operate May considered the size of the hernia, the symptoms, and the patient’s comorbid conditions. We report a case of intercostal hernia occurring after penetrating chest trauma, and successfully treated surgically by thoracotomy in our center.
Intercostal hernia is defined as a protrusion of the lung parenchyma and or pleura through a defect in the intercostal muscles between adjacent ribs [1]. It can be congenital or acquired. When intercostal hernia is acquired, it can be iatrogenic, especially after thoracic surgery or it can be secondary to chest trauma [2]. Often asymptomatic, intercostal hernia is clinically revealed by a bulging mass, protruding through the chest wall. [3]. in some case, surgical repair is the appropriate treatment. We report a case of this rare clinical condition occurring after thoracic trauma, and successfully treated surgically in our center
A 74-year-old man consult in our clinic, for an impulsive swelling, on coughing, located at the external lateral border of the right pectoralis major muscle, associated with a lapping sensation that had been evolving for about 3 months. Four months earlier, that man was stabled with a knife, at that part of the chest, as well as in the lateral side of the right and left forearms. He sustained a longitudinal linear and deep wound of about 7 cm long, on the lateral border of right pectoralis major. He also sustained multiple minor wounds on both forearms. All that wounds was sutured and later on, evolved to scar formation. One month later, the patient noticed a gradual and progressively enlarged swelling at the right pectoral region, especially on coughing.
This painless swelling was formerly associated with a sensation of lapping in the right hemi thorax as well as an effort dyspnea stage 2 of Sadoul. At his examination, the swelling was a bulging mass, protruding through the chest wall during coughing, or at the Valsalva maneuver (Figure 1)
Figure 1: Clinical view of the chest of the patient
A chest X-ray followed by a thoracic CT scan was performed. They reveal a right hydro pneumothorax, and the second one revealed almost a rib fracture with a bone defect at the level of the tumefaction (Figure 2). The diagnosis of intercostal hernia will be retained as well as the indication of a surgical repair.
 |
| Figure 2: Computed tomography showing one of the intercostal muscular defect and rib fracture (Arrow in blue). |
He was operated on by thoracotomy, during which, in addition to the bone defect causing a costal pseudarthrosis, a muscular defect on two intercostal spaces of about 3 cm in diameter each, on either side of the bone defect, was also noticed (Figure 3).
a- Operative view of the intercostal muscular defect
b- Operative view of the rib fracture
c- Postoperative after muscular defect repaired with prosthetic mesh
Figure 3: Operative view of the intercostal hernia
In addition, a pleural effusion of about 700 cc of sero sanguineous fluid will be aspirated through the muscular-bone defect. The lung looks normal in appearance. Intercostal hernia was treated by placing a dacron prosthesis. A plasty of the pectoralis major muscle was also be performed. The surgical approach was closed with a chest tube as well as with redons positioned in the sub-muscular and subcutaneous spaces. The postoperative course was simple.
Intercostal hernia is one of the four types of thoracic hernia according the anatomical classification made by Morel-Lavallee in 1845, including cervical lung hernia, diaphragmatic hernia and mediastinal hernia [4,5,6]. Even intercostal hernia is the most frequent of those four types, it remains a very rare clinical entity as there is less than one thousand cases reported on the literature, since the first case of thoracic hernia reported by Rolland and al, in 1499 [1,7]. There is an etiological classification made by Minai and al. According that classification, the etiology of intercostal hernia can be congenital or acquired. Nevertheless, the most common etiology is the traumatic one [8,9].
Unlike our patient who presented with shortness of breath, patients with intercostal hernia as well as patients with thoracic hernia are commonly asymptomatic. However, several patients may report pain, persistent cough, shortness of breath and often hemoptysis [10]. The diagnostic of intercostal hernia is clinical, based on the identification of a bulging mass of the chest, accentuated by Valsalva maneuver [2]. Imaging modalities may be useful to diagnose associated injuries or the status of the underlying lung.
Considered therapeutic management there is no consensus about. Conservative management and surgical management can be both considered. The decision, even usually made case by case, may always considered the size of the hernia which will allow the possibility of spontaneous healing, the symptoms (pain, dyspnea), the risk of parenchyma incarceration, and the patient’s comorbid conditions [11,12]
In the literature review, for patient who have undergone surgical repair different procedures have been found in the literature ranging from chest wall reconstruction with or without prosthetic material to rib fixation and lung resection. Due to this wide range of procedures, Kuckelman and al describe a new classification (Traumatic Rib Cage Hernias (TRCH) grading system), based on the severity of the chest wall defect [13]. According to that classification our patient which present with intercostal muscle tear, of average 2 cm width, associated to one simple non-displaced adjacent rib fractures and none organ herniation must be classified on grade 1, and must benefited of rib plating spanning defect, prosthetic mesh reinforced repair of soft tissue defect. The surgical approach of the area of chest wall defect is always a direct approach as for our patient. A thoracotomy or minimally invasive approach can be considered when a lung resection is required [11]. Rib fractures can be repair with screwed plates or sutured with steels wires. The chest wall soft tissue defect can be repaired by primary closure, by implantation of a prosthetic mesh or by muscle flaps [14,15].
The outcome of surgical repaired intercostal hernia is usually good, as there is no reported mortality and morbidity.
Intercostal hernia is a clinical rare condition, usually asymptomatic, in most cases acquired and secondary to traumatism or following chest surgery, whom diagnostic is clinical, and which have a good outcome. The challenge in the management of that condition is, firstly, in the taking decision to operate or not the patient, and in the choice of surgical approach as well as in the choice of the procedure to perform. Thus, the decision to operate shall considered the size of the hernia, the symptoms, and the patient’s comorbid conditions. The procedure to perform will depend of the status of underlying lung, the associated injuries and the availability of prosthetic material.
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