Acquired abdominal intercostal hernia: case report and systematic review of the literature

Robotic extended total extraperitoneal transversus abdominus release for traumatic flank and abdominal intercostal hernias

PURPOSE

Traumatic abdominal intercostal/flank hernias present a perplexing challenge for surgeons seeking to repair them. There has been a paucity of studies describing robotic repairs of such hernias. We aim to evaluate the effectiveness of the Robotic-assisted Extended Total Extraperitoneal/Transversus Abdominus Release (rETEP/TAR) method in repairing traumatic abdominal intercostal and flank hernias.

METHODS

Patients with traumatic abdominal intercostal hernias at a high-volume hernia center between 2019 and 2022 were identified and retrospective data including patient demographics, perioperative parameters, postoperative complications and up to a three-year follow-up were collected for those undergoing rETEP/TAR. Robotic ETEP access was gained through the retro-rectus space ipsilateral to the hernia, using a transversus abdominis release performed laterally to the level of the posterior axillary line. Dissection was completed from the pelvis to the central tendon as necessary.

RESULTS

A total of 8 patients were analyzed. All patients suffered traumatic or Valsalvainduced hernias. The average age was 54 +/-15yrs. The mean defect size was 11x17cm. Heavyweight uncoated polypropylene mesh was placed in the retromuscular space and secured with transfascial suture. Mean mesh size was 34x30cm and mean operative time was 216 +/- 69 minutes. The median length of stay was 1 day. All patients reported improvement in pain without any evidence of recurrence at postoperative follow-up.

CONCLUSION

This study demonstrates that the Robotic-assisted ETEP/TAR technique is an effective way of repairing abdominal intercostal and flank hernias.

Rare intercostal herniation of abdominal organs in COPD patient managed non-operatively

Nontraumatic intercostal and intrathoracic herniation of intra-abdominal organs is rare and has been sparsely reported in the literature. They are defined as protrusion of intra-abdominal contents through defects in the chest wall. The cases reported in the literature mostly involved herniation of intra-abdominal contents and the lungs through the defect. In this case report, we describe a case of intra-abdominal contents herniation through an intercostal defect with subsequent improvement in patient's respiratory status related to the hernia.

Transdiaphragmatic intercostal herniation in the setting of trauma

Transdiaphragmatic intercostal herniation is a rare injury that can be associated with blunt trauma. Since its first documentation within the literature in 1946, there have been less than 50 cases reported. We present a case involving a 56-year old female who presented to our Trauma Center with transdiaphragmatic intercostal herniation caused by blunt trauma from a high-velocity T-bone vehicular collision. Upon presentation, she exhibited bilateral breath sounds; however, with labored breathing, chest pain, and hypoxia. The initial chest radiograph interpretation indicated the presence of "left lower lobe infiltrates", and subsequent computed tomography imaging identified "a small lateral hernia along the left mid abdomen". After initial resuscitation, her condition deteriorated, exhibiting respiratory distress and becoming increasingly hypercarbic, requiring intubation. Review of the imaging showed disruption of the left hemidiaphragm with intrathoracic herniation of colon and stomach through the thoracic wall between the ninth and tenth ribs. Consequently, a thoracotomy was performed in the operating room, revealing a large defect between the two ribs with disruption of the intercostal muscles and inferior displacement of rib space. Lung and omentum had herniated through the disrupted rib space and the diaphragmatic rupture was attenuated anteriorly, measuring 11x6cm. After reduction of the herniated organs, a biologic porcine mesh was placed and an intermediate complex closure of the thoracic wall hernia was performed. The patient was later extubated, recovered from her injuries with no complications and was discharged. With the low incidence of transdiaphragmatic intercostal herniation, there is no standardized surgical management. Recent literature suggests that these injuries should be managed with mesh, rather than sutures only, due to high rates of recurrence. Furthermore, diaphragmatic injuries may suffer a delay in diagnosis. Therefore, a high index of suspicion should be maintained in patients with respiratory distress following a blunt trauma, with close review of computed tomography.

Traumatic abdominal intercostal hernia: A rare experience

Traumatic abdominal intercostal hernias (AIHs) are an extremely rare surgical encounter, with amorphous literature. A case report of recurrent AIHs, evident only at surgery, and its management is presented. The inadequacy of experience and data translates to frequent missed diagnosis and suboptimal surgical management with high recurrence rates.

THE FIRST EXPERIENCE OF THORACOSCOPIC HERNIOPLASTY FOR INTERCOSTAL PULMONARY HERNIA (CLINICAL OBSERVATION AND LITERATURE REVIEW)

A pulmonary hernia is a protrusion of the lung through a defect in the surrounding tissues, a rather rare pathology and each clinical case is of scientific interest. The first description of this rare pathology was performed by Roland in 1499. About 300 observations have been described in the world literature, most of the publications are isolated cases of observation of this pathology. We have presented the first experience of thoracoscopic hernioplasty in the Russian Federation for intercostal pulmonary hernia, and also summarized the literature data on this topic.

Abdominal intercostal hernia and costal arch repair

A 70-year-old asthmatic man presented with a history of chronic intermittent left-sided chest pains and a bulge-like deformity of his chest which became more prominent with expiration. He sustained a traumatic fall 2 years prior whereby he fractured his right humerus at the surgical neck, requiring total arthroplasty. Examination and CT imaging of the thorax revealed a left costal arch fracture with hemidiaphragm rupture and associated transperitoneal fat herniation. He underwent left thoracolaparotomy with costal arch and diaphragmatic hernia repair. He was discharged 48 hours postoperatively and is satisfied with good outcomes under initial follow-up. This case report highlights the surgical management of a condition that usually presents late after significant trauma and may progress to visceral strangulation if untreated.

Robotic Repair of an Acquired Abdominal Intercostal Hernia

Introduction:

Intercostal hernias are a rare clinical entity. They are divided into trans-diaphragmatic intercostal or abdominal intercostal hernias based upon the presence or absence of diaphragmatic injury. There are various means of repair for these hernias, including open, laparoscopic, and robotic approaches. We present the second known robotic repair of an abdominal intercostal hernia and review of the relevant literature.

Case Description:

A 54-year-old morbidly obese male was found to have an abdominal intercostal hernia on the right between the 9^th and 10^th ribs. His symptoms were significant for a large, tender right chest wall mass. Through a three-port approach, polypropylene mesh and circumferential sutures were used to create a double-wall of reinforcement to secure the area of weakness.

Discussion:

This rare case of an intercostal hernia utilized robotic-assisted laparoscopic repair and led to a favorable outcome, whereby the patient reported significant improvement in pain, comfort, and quality of life. Thus, minimally invasive robotic surgery for this complex structural pathology can be safer and have less complications than other current treatments.

Radiographic identification of thoracoabdominal hernias

PURPOSE

Hernias 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.

RESULTS

Six 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.

Abdominal Intercostal Hernia in a Cat (Felis Domestica)

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 follow-up 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.

Traumatic thoracoabdominal hernia repair using a novel chest-wall reconstruction technique: a case report

Thoracoabdominal hernia following blunt trauma is extremely rare. Abdominal viscera are more likely to herniate into the thorax if there is traumatic diaphragmatic rupture. We report the case of a patient presenting with a traumatic thoracoabdominal hernia containing part of the right lobe of the liver and the hepatic flexure of the colon. The hernia migrated cranially, to protrude through a seventh intercostal defect despite the diaphragm remaining fully intact. The need for early multispecialty (thoracic and hepatobiliary) surgical repair is highlighted, with improvements in surgical outcome for a complex trauma case by using a novel chest-wall reconstruction technique.

Mesh trimming and suture reconstruction for wound dehiscence after huge abdominal intercostal hernia repair: A case report

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Large abdominal intercostal hernia in the thoracoabdominal region must be treated.

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Repair of abdominal intercostal hernia using mesh and surgical approach is controversial.

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With exposed mesh, partial mesh removal may be an option if conditions are met.

Introduction

Abdominal intercostal hernia repair for huge incisional hernia after thoracoabdominal surgery involves a complex anatomical structure. Hence, it is difficult to apply the laparoscopic approach to large hernias in the lateral upper abdomen. Further the optimal approach to mesh exposure without infection after incisional hernia repair is still controversial. Herein, we describe our experience of repairing a huge abdominal intercostal hernia by mesh trimming and suture reconstruction for wound dehiscence.

Presentation of case

A 73-year-old man presented with an incisional hernia in the left flank from just below the eight intercostal space to the transverse umbilical region 6 months after thoracoabdominal aortic aneurysm surgery. Computed tomography revealed an incisional hernia orifice of 17 × 13 cm located on the left flank around the ninth rib. We chose the open approach as treatment because the hernia orifice was large, and we created a mesh placement space in the extraperitoneal cavity and placed expanded polytetrafluoroethylene mesh there with 1–0 nonabsorbable monofilament suture. At postoperative day 26, we observed mesh exposure due to wound dehiscence. Mesh trimming and suture reconstruction for wound dehiscence was performed because there were no signs of wound infection. The postoperative course was uneventful including infection and dehiscence. The patient has been well without recurrence for 14 months since last operation.

Conclusions

Optimal treatment for repair of a large abdominal intercostal hernia with thoracoabdominal location is necessary. Moreover, partial mesh removal may be one of the treatment options for mesh exposure if conditions are met.

Laparoscopic IPOM repair of an acquired abdominal intercostal hernia

Acquired abdominal intercostal hernia (AAIH) is an infrequent occurrence whereby intra-abdominal contents herniate into intercostal space directly from the peritoneal cavity through an acquired defect in the abdominal wall musculature and fascia. These hernias are difficult to diagnose and should always be suspected when a chest wall swelling occur after major or minor trauma. Surgical repair is warranted in symptomatic patients. The majority of AAIHs are repaired through an open approach using tension-free mesh, with significant recurrence risk. Recently, laparoscopic and robot-assisted repairs have been proposed. We discuss a 49-year-old man presented through outpatient setting with a 5-year history of ongoing left subcostal discomfort and a reducible lump. His history included a workplace accident 5 years ago. Contrast-enhanced abdominal CT confirmed AAIH with omentum herniation into the sac. A successful laparoscopic repair with intraperitoneal onlay mesh technique using composite mesh was performed.

Robotic repair of a large abdominal intercostal hernia: a case report and review of literature

Abdominal intercostal hernia is an uncommon phenomenon, reported in few case reports and small case series. If left untreated, it can lead to strangulation and visceral ischemia. Prompt diagnosis and appropriate surgical intervention are thus critical to prevent resulting morbidity. We present a 50-year-old woman with a large abdominal intercostal hernia after an open nephrectomy. She underwent a successful robotic repair of the hernia with mesh placement. Through the presentation, we would like to raise awareness of intercostal hernia as a complication of open nephrectomy and significance of early diagnosis in avoiding potential morbidity. We also performed a review of literature especially focusing on acquired abdominal intercostal hernia secondary to prior surgery. Although intercostal hernias can be difficult to repair secondary to the size and location, adequate visualization and surgical planning are critical to successful repair.

Rare case of a strangulated intercostal flank hernia following open nephrectomy: A case report and review of literature

INTRODUCTION

Flank incisions may be associated with incisional flank hernias, which may progress to incarceration and strangulation. Compromised integrity of the abdominal and intercostal musculature due to previous surgery may be associated with herniation of abdominal contents into the intercostal space. There have been six previously reported cases of herniation into the intercostal space after a flank incision for a surgical procedure. This case highlights the clinical picture associated with an emergent strangulated hernia and highlights the critical steps in its management.

PRESENTATION OF CASE

We present a case of a 79-year-old adult man with multiple comorbidities presenting with a strangulated flank hernia secondary to an intercostal incision for a right-sided open nephrectomy. The strangulated hernia required emergent intervention including right-sided hemi-colectomy with ileostomy and mucous fistula.

DISCUSSION

Abdominal incisional hernias are rare and therefore easily overlooked, but may result in significant morbidity or even death in the patient.. The diagnosis can be made with a thorough clinical examination and ultrasound or computed topographical investigation. Once a hernia has become incarcerated, emergent surgical management is necessary to avoid strangulation and small bowel obstruction.

CONCLUSION

Urgent diagnosis and treatment of this extremely rare hernia is paramount especially in the setting of strangulation.

Laparoscopic repair of a rare acquired abdominal intercostal hernia

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Intercostal hernias are rare, usually acquired hernias.

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They most commonly are associated with stab wounds and present late.

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They require surgical treatment for correction.

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Open repair is well established but laparoscopic surgery has tremendous advantages in fixing these hernias.

INTRODUCTION

An acquired abdominal intercostal hernia (AIH) is a very rare and sporadically reported entity. Most cases of AIH are secondary to major trauma and the treatment of choice is surgical repair.

PRESENTATION OF CASE

We present the case of a 58-year-old man who presented with a painless intercostal swelling, which started after previous penetrating trauma to the same area. Radiological assessment was done with CT scan and the hernia was repaired with a laparoscopic approach using mesh.

DISCUSSION

AIH is a rare entity and trauma has an integral role in the pathophysiology. Surgical repair is the treatment of choice, however, due to the paucity of cases, there is no established method of choice for such repair. We present the first reported case in the Caribbean, which was repaired with the laparoscopic approach.

CONCLUSION

Although AIH is a rare condition, the pathophysiology seems relatively straightforward and the use of CT scan is recommended to confirm the diagnosis. The laparoscopic approach, with all its established benefits, appears to be a safe and feasible option in its management.

Acquired abdominal intercostal hernia: a case report and literature review

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.