Spontaneous Chest Wall Herniation in Centrally Obese Patients: A Single-Center Experience of a Rare Problem

Costal margin injuries and trans-diaphragmatic intercostal hernia: Presentation, management and outcomes according to the Sheffield classification

BACKGROUND

Costal margin rupture (CMR) injuries are under-diagnosed and inconsistently managed, while carrying significant symptomatic burden. We hypothesized that the Sheffield Classification system of CMR injuries would relate to injury patterns and management options.

METHODS

Data were collected prospectively between 2006 and 2023 at a major trauma center in the United Kingdom. Computed tomography scans were interrogated and injuries were categorized according to the Sheffield Classification. Clinical, radiologic, management and outcome variables were assessed.

RESULTS

Fifty-four patients were included in the study. Intercostal hernia (IH) was present in 30 patients and associated with delayed presentation ( p = 0.004), expulsive mechanism of injury (i.e. such as occurs with coughing, sneezing, or retching), higher body mass index ( p < 0.001), and surgical management ( p = 0.02). There was a bimodal distribution of the level of the costal margin rupture, with IH Present and expulsive mechanism injuries occurring predominantly at the ninth costal cartilage, and IH Absent cases and other mechanisms at the seventh costal cartilage ( p < 0.001). There were correlations between the costal cartilage being thin at the site of the CMR and the presence of IH and expulsive etiology ( p < 0.001). Management was conservative in 23 and surgical in 31 cases. Extrathoracic mesh IH repairs were performed in 3, Double Layer Mesh Repairs in 8, Suture IH repairs in 5, CMR plating in 8, CMR sutures in 2, and associated Surgical Stabilization of Rib Fractures in 11 patients. There was one postoperative death. There were seven repeat surgical procedures in five patients.

CONCLUSION

The Sheffield Classification is associated statistically with presentation, related chest wall injury patterns, and type of definitive management. Further collaborative data collection is required to determine the optimal management strategies.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Surgical Repair of Spontaneous Lung Herniation Induced by Vigorous Coughing: A Case Report and Literature Review

Lung herniation is a rare clinical entity defined by extrathoracic protrusion of the lung or lung tissue due to a weakness in the thoracic wall. We present here a case of a 72-year-old male who presented with a spontaneous lung herniation, which occurred as a result of a ventral luxation of the third rib from the sternocostal joint due to vigorous coughing. The defect was repaired through anterolateral thoracotomy, reposition of the lung and approximating the ribs using heavy sutures. The postoperative course of the patient was uncomplicated. A brief review of the literature is also provided.

Case Report: Spontaneous lung intercostal hernia series and literature review

Spontaneous lung intercostal hernia (SLIH) is a rare condition potentially carrying severe morbidity. About 120 cases have been described so far, with an apparently increasing number of reports in recent years. The main presenting findings are chest pain and bulging, with ecchymosis in the affected area, hemoptysis, respiratory distress, and signs of infection or incarceration being described as well. The gold standard treatment has not been established, and conservative management has been advocated as first-line treatment for asymptomatic patients. Here, we report a case series of five patients, and surgical repair was deemed necessary for four of them either at first evaluation or after failure of conservative management. One patient remains under surveillance and conservative management. We believe that SLIH surgical repair should be considered as first-line treatment for fit patients, due to the uncertainty of its mid- and long-term impact and described pejorative trend/defect enlargement. A proposed algorithm for SLIH management is also presented.