Abdominal intercostal hernia (AIH) is uncommonly reported in the literature with only 20 cases reported to date.1–3 We report a case of a delayed incarcerated AIH secondary to blunt trauma from a motor vehicle accident in which the colon and diaphragm herniated through an associated chest defect that was repaired successfully through a transabdominal approach using primary repair of the defect in combination with onlay porcine patch reinforcement

Cowan, MD, Scott W.

Jenoff, MD, Jay S.

Nguyen, B.A., Phi D

Pucci, MD, Michael J.

English

Jefferson Digital Commons

Thomas Jefferson UniversityJefferson Digital CommonsDepartment of Surgery Gibbon Society HistoricalProfiles Department of Surgery11-1-2013Abdominal intercostal hernia: a rare complicationafter blunt trauma.Phi D Nguyen, B.A.Thomas Jefferson UniversityMichael J. Pucci, MDThomas Jefferson University, michael.pucci@jefferson.eduJay S. Jenoff, MDThomas Jefferson University, Jay.Jenoff@jefferson.eduScott W. Cowan, MDThomas Jefferson University, Scott.Cowan@jefferson.eduLet us know how access to this document benefits youFollow this and additional works at: https://jdc.jefferson.edu/gibbonsocietyprofilesPart of the History of Science, Technology, and Medicine Commons, and the Surgery CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inDepartment of Surgery Gibbon Society Historical Profiles by an authorized administrator of the Jefferson Digital Commons. For more information,please contact: JeffersonDigitalCommons@jefferson.edu.Recommended CitationNguyen, B.A., Phi D; Pucci, MD, Michael J.; Jenoff, MD, Jay S.; and Cowan, MD, Scott W.,"Abdominal intercostal hernia: a rare complication after blunt trauma." (2013). Department of SurgeryGibbon Society Historical Profiles. Paper 19.https://jdc.jefferson.edu/gibbonsocietyprofiles/19Brief ReportsBrief Reports should be submitted online to www.editorialmanager.com/amsurg. (See details online under ‘‘Instructions for Authors’’.) They should be nomore than 4 double-spaced pages with no Abstract or sub-headings, with amaximum of four (4) references. If figures are included, they should be limitedto two (2). The cost of printing color figures is the responsibility of the author.In general, authors of case reports should use the Brief Report format.Abdominal Intercostal Hernia: A RareComplication after Blunt TraumaAbdominal intercostal hernia (AIH) is uncommonlyreported in the literature with only 20 cases reported todate.1–3 We report a case of a delayed incarcerated AIHsecondary to blunt trauma from a motor vehicle accidentin which the colon and diaphragm herniated through anassociated chest defect that was repaired successfullythrough a transabdominal approach using primary repairof the defect in combination with onlay porcine patchreinforcement.A 62-year-old man was seen in the thoracic surgeryclinic for evaluation of a chronic left-sided chest walldefect with associated chest wall hernia. The patientwas involved in a motor vehicle accident 5 years prior,when he sustained multiple left-sided rib fractures anda splenic injury. He underwent emergent splenectomythrough a midline laparotomy and left thoracotomy torepair a lung injury. Over the last 2 years, a large bulgedeveloped in his left chest, which increased in sizewhen coughing and was associated with severe burningpain. Physical examination revealed a lateral chestwall defect involving ribs 7 to 9 with an associatedincarcerated hernia, which increased in size with Val-salva and coughing. On imaging, there was evidence offracture and separation of portions of the sevenththrough ninth left ribs with elevation of the patient’sleft hemidiaphragm (Fig. 1). Chest computed tomog-raphy scan revealed herniation of both the diaphragmand colon into the chest wall defect (Fig. 2).The AIH was approached transabdominally througha left subcostal incision. After adhesiolysis, a portionof the left colon and associated omentum were reducedout of the defect. The defect measured 3 · 3 cm andwas lined by herniated, attenuated diaphragm. Figure-of-eight 2-0 Prolene sutures were used to approximatethe edges of diaphragm. Next, a porcine tissue graft(Strattice; LifeCell Corporation, Branchburg, NJ) wassewn circumferentially as an onlay patch using inter-rupted Prolene sutures to cover and exclude the defect.Postoperatively, the patient developed a sterile intra-abdominal collection, which was drained percutane-ously and otherwise recovered well. The patient’ssymptoms resolved after the procedure.Herniation of either thoracic or abdominal contentsthrough intercostal spaces is a rare occurrence. Thesehernias, named intercostal hernias, typically resultfrom a traumatic injury or failure of healing a thoracicincision. A risk factor for the development of any typeof intercostal herniation is trauma to the chest wall,especially as a result of rib fracture. Although notnecessary for the development of the hernia, more than50 per cent of intercostal abdominal hernias have in-volved rib fractures.2 Although pleural or lung herni-ation is more common, there have been approximatelyFIG. 1. Coronal view computed tomography scan of the chestdemonstrating left-sided chest wall deformity and elevation of lefthemidiaphragm.Address correspondence and reprint requests to Scott W. Cowan,M.D., Department of Surgery, Thomas Jefferson University, 607College Building, 1025 Walnut Street, Philadelphia, PA 19107.E-mail: scott.cowan@jefferson.edu.E32420 cases reported of abdominal contents herniatingthrough intercostal spaces.1–3 The hypothesized causeof these hernias is multifactorial. A weakness in thethoracic wall and the natural pressure gradient betweenthe intra-abdominal and intrathoracic spaces contrib-ute to this unique situation.Terminology of these hernias is variable in the lit-erature. In general, abdominal intercostal hernia de-scribes the circumstance when abdominal contentsherniate through the intercostal spaces. However, this isa nonspecific term and does not delineate whethera diaphragmatic defect is present. More accurateterminology has been used in the circumstance wherethere is an abdominal intercostal hernia with an asso-ciated diaphragmatic defect, named transdiaphrag-matic intercostal hernia.2, 4 The majority of reportedcases of intercostal hernias are considered transdia-phragmatic, whereas far fewer cases exist without anassociated defect in the diaphragm such as in ourpatient.1–4Although trauma was the primary contributing factorresponsible for development of the AIH, progressionlikely occurred as a result of an obesity-related increasein intra-abdominal pressure. Also, the patient’s historyof splenectomy may have played a role because therewas no organ adjacent to the defect to help preventcolonic herniation.Acute and chronic traumatic transdiaphragmatichernias should be repaired once diagnosed. Operativetreatment has been described through both abdominaland thoracic approaches, dictated primarily by timingbetween injury and diagnosis. In our patient witha posttraumatic intercostal hernia with an intact di-aphragm, the transabdominal approach was chosenas a result of his prior thoracotomy and concern forpleural adhesions. The patient’s prior splenectomyallowed excellent visualization and safe reduction ofthe hernia contents. The use of a porcine onlay patchprimarily functioned as a buttress to the primary repair.In conclusion, the cause of AIH is usually multi-factorial and indications for intervention should bedictated by acuity, symptoms, and overall operativerisk. Operative repair should follow standard herni-orrhaphy principles, including complete reduction ofsac contents, primary closure if possible, and the use oftension-distributing patch materials.Phi D. Nguyen, B.A.Michael J. Pucci, M.D.Jay S. Jenoff, M.D.Scott W. Cowan, M.D.Department of SurgeryThomas Jefferson UniversityPhiladelphia, PennsylvaniaREFERENCES1. Thomasson J, Maxwell R. Intercostal hernias. Am Surg 2010;76:E125–7.2. Unlu E, Temizoz O, Cagli B. Acquired spontaneous intercostalabdominal hernia: case report and a comprehensive review of theworld literature. Australas Radiol 2007;51:163–7.3. Kurer MA, Bradford IM. Laparoscopic repair of abdominalintercostal hernia: a case report and review of the literature. SurgLaparosc Endosc Percutan Tech 2006;16:270–1.4. Chaar CI, Attanasio P, Detterbeck F. Disruption of the costalmargin with transdiaphragmatic abdominal herniation induced bycoughing. Am Surg 2008;74:350–3.FIG. 2. Axial view computed tomography scan of the chestdisplaying colon and diaphragm herniation.No. 11 BRIEF REPORTS E325

Abdominal intercostal hernia: a rare complication after blunt trauma.

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Abdominal intercostal hernia: a rare complication after blunt trauma.

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