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.

Outcomes of Primary Tumor Excision do not Differ from Non-Resection Methods in Pediatric Mesenchymal Hamartoma of the Liver: A Rapid Systematic Review

BACKGROUND

To conduct a rapid systematic review comparing the outcomes of primary tumor resection versus non-resection on patients with hepatic mesenchymal hamartoma.

METHODS

We searched the Ovid MEDLINE, EMBASE, Scopus, PubMed, Web of Science, and Google Scholar databases from January 1, 2000 to March 31, 2022. Studies that described cases of hepatic mesenchymal hamartoma, including management and outcomes, were included.

RESULTS

62 articles met inclusion criteria with 95 cases in total. Patients were assigned to the primary tumor resection (n = 85) or non-resection (n = 10) cohort based on the described management. Similar rates of morbidity (17% vs 20%) and mortality (6 vs 10%) were identified between cohorts. There were no differences in sex, liver lobe involvement, or tumor size among study groups.

CONCLUSIONS

Complete tumor resection should remain the gold standard for hepatic mesenchymal hamartomas when an adequate liver remnant exists. Reports of non-resected tumors demonstrating spontaneous regression or stability with watchful waiting have poor long term follow-up and have inadequate evidence of a true mesenchymal hamartoma diagnosis.

LEVEL OF EVIDENCE

Level I.