Soft right chest wall swelling simulating lipoma following motor vehicle accident: transdiaphragmatic intercostal hernia. A case report and review of literature

INTRODUCTION: Intercostal herniation of abdominal contents through a diaphragmatic defect is rare. We report a case of transdiaphragmatic intercostal hernia secondary to blunt trauma, initially misdiagnosed as lipoma, later confirmed by CT scan. METHODS: We present a case of a 77-year-old who was involved in a motor vehicle accident and sustained a hand fracture. Later that year his wife noticed an egg-shaped soft swelling on his right chest wall. He was seen in the minor operative clinic, and a lipoma excision was attempted when it was found to be an intercostal hernia. Colon was seen in the hernial pouch. RESULTS: Anatomically, the chest wall is weak from the costochondral junction to the sternum because of lack of external intercostal muscle support, and from the costal angle posteriorly to the vertebrae because of lack of internal intercostal musculature. The integrity of the thoracic cage is disrupted by tears of the intercostal musculature between fractured ribs. This defect leads to separation of the ribs and development of a potential weakened space for hernia. This chest wall muscular weakness can occur anywhere and can be more pronounced if it occurs at anatomically weakened areas. In the presence of associated diaphragmatic rupture, there is herniation of abdominal viscera. The treatment includes immediate surgical repair either by abdominal or thoracoabdominal approach. CONCLUSIONS: A thorough physical examination may suggest the diagnosis, but confirmation by chest radiograph, CT scan, and sometimes by gastrointestinal contrast studies is often helpful for preoperative planning. A high index of suspicion for diaphragmatic injury or intercostal herniation during the initial evaluation, coupled with chest and abdominal diagnostic testing once the patient is stable, can avert undue delay in diagnosis and catastrophe from incarceration of a hernia.     

Transdiaphragmatic intercostal hernia following blunt trauma

We report a rare case of traumatic transdiaphragmatic intercostal hernia (TDIH) in an 85-year-old women who was transported to our hospital by ambulance after blunt trauma caused by the involvement in a motor vehicle accident. Chest and abdominal computed tomography (CT) revealed a left diaphragmatic rupture with a chest wall hernia involving loops of small intestine. An emergency operation was performed and led to a diagnosis of TDIH. Surgery via a thoracoabdominal incision in the left side was performed to reduce the hernia contents, and the diaphragmatic and intercostal defects were reconstructed by direct suture. CT scans were very helpful in detecting TDIH in this case.     

Occult diaphragmatic injury from stab wounds to the lower chest and abdomen

Ninety-five patients with stab wounds to the lower chest and abdomen underwent routine abdominal exploration. Eighteen of these patients had diaphragmatic injury and in five patients it was the only injury found. Isolated diaphragmatic injury in asymptomatic patients cannot be reliably delineated by either serial physical examination or peritoneal lavage. Delayed recognition of incarcerated diaphragmatic hernia after stab wounds to the lower left chest and upper abdomen has an associated mortality rate of 36%. The anatomic area of concern can be defined as stab wounds that penetrate the left side of the chest below the fourth intercostal space anteriorly, the sixth intercostal space laterally, and the tip of the scapula posteriorly. Exploratory laparotomy is necessary in these patients until a reliable nonoperative method is established that can exclude injuries to the diaphragm.     

Endoscopic repair of an abdominal intercostal hernia

Abdominal viscera herniation through the chest wall is a rare condition. A case is presented of an abdominal intercostal hernia of the seventh right intercostal space; its pathogenesis and clinical features are described, and also the combined endoscopic and percutaneous surgical approach employed for its repair.     

Transdiaphragmatic intercostal hernia following a penetrating thoracoabdominal injury: report of a case

Intercostal hernias with abdominal viscera have rarely been reported following penetrating accidental or surgical trauma. We report herein a case of a traumatic rupture of the left hemidiaphragm, presenting as an intercostal hernia 2 years after a penetrating thoracoabdominal injury. The diaphragmatic rupture had been initially very small and could not be detected in the serial chest films and abdominal computed tomographic scans. The injury was also missed during an exploratory lateral thoracotomy. The patient was admitted with the chief complaint of a painful and gradually enlarging left-sided chest wall bulge of 8 months' duration. Surgery via an anterolateral thoracotomy along the axis of the intercostal hernia was performed, and the omentum and splenic flexura of the colon were reduced. Received: July 24, 2000 / Accepted: January 9, 2001     

Traumatic diaphragmatic hernia presenting as a tension fecopneumothorax

A traumatic diaphragmatic hernia is a well-known complication following blunt abdominal or penetrating thoracic trauma. Although the majority of cases are diagnosed immediately, some patients may present later with a diaphragmatic hernia. It occurs in approximately 3% of abdominal traumas. Diagnosis requires a high index of suspicion since diaphragmatic injury can only reliably be ruled out by direct visualization, i.e., laparoscopy. Hence, delayed presentation with complications secondary to the injury is not uncommon. We discuss a case of a young man who presented in respiratory distress 5 years after a stab wound to the left chest. The patient was hypoxic, with a chest X-ray (CXR) demonstrating a pneumothorax with effusion. A chest tube was placed with a rush of air and feculent drainage. CT scan revealed an incarcerated transverse colon in a diaphragmatic hernia. The laparotomy demonstrated necrotic colon in the chest with gross fecal contamination in the chest. The diaphragmatic defect was closed and a Hartmann’s procedure performed. The patient developed empyema in the postoperative period. Our patient is the twelfth reported case of a tension fecopneumothorax resulting from traumatic diaphragmatic herniation. This paper reviews all cases, including the diagnostic workup, operative approach, and expected postoperative course of this unusual condition.     

Transdiaphragmatic intercostal hernia

A 72-year-old man was seen with cough-induced rib fractures, a diaphragmatic tear, and an intercostal hernia containing abdominal contents. A review of the literature of this rare problem is presented, and techniques of repair are discussed.     

Laparoscopic repair of a chronic diaphragmatic hernia

Diaphragmatic injuries that remain undetected after an acute traumatic event may lead to the formation of a diaphragmatic hernia. Symptoms of a chronic diaphragmatic hernia are related to the incarceration of abdominal contents in the defect or to impingement of the lung, heart, or thoracic esophagus by abdominal viscera. A 49-year-old woman with a symptomatic chronic diaphragmatic hernia from an unrecognized iatrogenic injury to the left hemidiaphragm sought treatment. The diaphragmatic injury occurred 2 years earlier when a low, left-sided chest tube was placed for a persistent pleural effusion 2 weeks after a lower lobectomy for an aspergilloma. The patient's diaphragmatic hernia was diagnosed after an upper gastrointestinal series and an esophagogastroduodenoscopy. Approximately 75% of her stomach was incarcerated in the diaphragmatic defect. The diaphragmatic hernia was repaired laparoscopically using a 9 cm x 10-cm polytetrafluoroethylene patch sewn with nonabsorbable, interrupted, horizontal mattress sutures. Improvement of video technology, laparoscopic instruments, and surgical skills has allowed surgeons to expand the boundaries of advanced therapeutic laparoscopy. These factors facilitated the authors' standard tension-free prosthetic repair of a chronic diaphragmatic hernia using minimally invasive techniques.     

Diaphragmatic herniation after oesophagectomy: a report of two cases

Diaphragmatic herniation is the protrusion of abdominal structures into the chest through a defect in the diaphragm. It is a rare complication following oesophagectomy. Preoperative diagnosis is important in order to establish both the nature and extent of the diaphragmatic defect. The treatment of choice is surgery. In a series of 574 intrathoracic oesophagogastroplasties performed at our Institution from 1990 to 2004, the prevalence of diaphragmatic herniation was 0.35%. We report two cases of major diaphragmatic herniation after oesophagectomy for cancer performed using a laparotomic-thoracotomic (case 1) and a laparoscopicthoracotomic approach (case 2). The case 1 patient was asymptomatic: hernia repair involved hiatoplasty and mesh positioning. The case 2 patient presented with vomiting and abdominal pain: she underwent emergency laparoscopic surgery and direct closure of the diaphragmatic tear. At 12 months' follow-up, both patients were symptom-free. A barium swallow confirmed that the previously herniated abdominal viscera had returned to the abdomen. Diaphragmatic herniation following oesophagectomy is a rare complication which may be asymptomatic or present as bowel obstruction. Several aetiopathogenetic factors may be responsible for diaphragmatic hernias: enlargement of the diaphragmatic hiatus, a combination of negative pressure in the chest and positive pressure in the abdomen, and small number of adhesions in the case of patients operated on with minimally invasive surgery. Surgical repair is the treatment of choice and is mandatory as emergency treatment in the case of symptomatic hernias.     

Incisional Intercostal Hernia With Prolapse of the Colon After Right Partial Nephrectomy

A 75-year-old woman with a history of myocardial infarction, gallstones, and right renal cancer was referred to our department because of right flank pain. She had a surgical scar on the right abdomen between the 10th and 11th ribs; computed tomography demonstrated intercostal herniation of the colon. Recognizing the possibility of adhesions of the hernia and colon, we used a median skin incision and patched a polyester mesh coated with absorbent collagen. The patient had an uneventful postoperative course, with no pain for 6 months postoperatively. Transdiaphragmatic intercostal hernias with abdominal contents commonly develop after trauma or thoracic surgery. Incisional intercostal hernias seldom develop after nephrectomy; the present case is only the fourth report. We conjecture that a costochondral incision can induce subluxation of the costotransverse joint, intercostal nerve injury, and atrophy of the intercostal and abdominal oblique muscles. Surgeons must therefore recognize the potential, albeit rare, for intercostal hernia after nephrectomy.     

Diaphragmatic rupture during labor

Diaphragmatic rupture during labor is uncommon and generally occurs in patients with a history of congenital diaphragmatic hernia or traumatic abdominal or chest injury. We present a case of a 41-year-old woman who presented with abdominal pain, vomiting and hypoventilation four days after a full-term home delivery. Chest radiography suggested the presence of a ruptured diaphragm, and laparotomy revealed a congenital left Bochdalek defect with herniation of the stomach, transverse colon and spleen into the left pleural cavity. Diaphragmatic hernia rupture during labor is a serious but rare complication that requires emergency surgery to prevent visceral perforation and cardio-respiratory failure.     

Laparoscopic repair of abdominal intercostal hernia: a case report and review of the literature

Abdominal intercostal herniation occurs rarely, with only 27 previous cases reported in the literature. An 84-year-old man presented with a painful large thoraco-abdominal mass. He had no history of trauma or surgery to the chest or abdomen. A thoraco-abdominal computerized tomography scan revealed a protrusion of intra-abdominal omental fat into a sac between the left eighth and ninth ribs. We present a novel technique for the repair of this uncommon condition. There were no peri-operative complications and the patient was asymptomatic on review 9 months later. We suggest that a laparoscopic approach may be used for treatment of an uncomplicated abdominal intercostal hernia.     

Strangulated intercostal liver herniation subsequent to blunt trauma. First report with review of the world literature

ABSTRACT: Traumatic transdiaphragmatic intercostal hernia, defined as an acquired herniation of abdominal contents through disrupted intercostal muscles, is a rarely reported entity. We present the first reported case of a traumatic transdiaphragmatic intercostal hernia complicated by strangulation of the herniated visceral contents.Following blunt trauma, a 61-year old man developed a traumatic transdiaphragmatic intercostal hernia complicated by strangulation of liver segment VI. Due to pre-existing respiratory problems and the presence of multiple other injuries (grade III kidney laceration and lung contusion) the hernia was managed non-operatively for the first 2?weeks.The strangulated liver segment eventually underwent ischemic necrosis. Six weeks later the resulting subcutaneous abscess required surgical drainage. Nine months post injury the large symptomatic intercostal hernia was treated with laparoscopic mesh repair. Twelve months after the initial trauma, a small recurrence of the hernia required laparoscopic re-fixation of the mesh.This paper outlines important steps in managing a rare post traumatic entity. Early liver reduction and hernia repair would have been ideal. The adopted conservative approach caused liver necrosis and required staged procedures to achieve a good outcome.     

Congenital Intercostal Lung Herniation Combined with an Unusual Morgagni's Hernia

A 70-year-old male visited urgent care due to coughing for 1 month and left chest pain. He had no history of trauma. The initial chest computed tomography (CT) showed the 7th left intercostal lung herniation. A follow-up CT showed an intercostal lung herniation combined with a bowl herniation, which had developed due to a Morgagni's hernia. An emergency operation was performed due to the incarceration of the bowl and lung. The primary repair of the diaphragm was performed and the direct approximation of the 7th intercostal space was determined. We concluded that the defect of the diaphragm and the intercostal muscle was a congenital lesion, and the recurrent coughing was the aggravating factor of herniation.     

Rupture of the diaphragm and pericardium with cardiac herniation after blunt chest trauma

A 61-year-old man was transferred to our institution because of blunt chest trauma after accidentally falling. A chest roentgenogram (CXR) and computed tomography (CT) revealed bilateral hemopneumothorax and fractures of multiple left ribs, the pelvis, and the left femur. On the second day in hospital, the patient suddenly complained of dyspnea. Emergency CXR and CT revealed elevation of the left diaphragm, suggestive of a traumatic diaphragmatic hernia; emergency surgery was performed. We confirmed rupture of the diaphragm and pericardium with cardiac herniation: the pleural pericardium and diaphragm were torn individually, and the heart and abdominal organs had herniated into the pleural cavity. They were repaired, and there were no cardiopulmonary complications during or after the operation. Pericardiodiaphragmatic rupture with cardiac herniation after multiple blunt traumas is rare. We describe the successful treatment of a diaphragmatic and pericardial rupture with cardiac herniation, with special reference to pericardial injuries.     

Strangulated traumatic hernia of the diaphragm. A report of two cases

The herniation of abdominal viscera in the thorax can immediately follow diaphragmatic rupture or be delayed even years after the injury. The herniated viscera can strangulate; this consequence may lead to a dangerous misdiagnosis which could be lethal for the patient. Radiological procedures, serial chest X-ray studies, CT and MRI scans are mandatory to confirm diagnosis. The insertion of a naso-gastric tube is a very helpful method in ruling out hypertensive pneumothorax in the presence of an air-fluid level in the thorax. We report 2 cases of strangulated traumatic hernia of the diaphragm occurring just a few hours (case 1) and 18 months (case 2) after the trauma. During thoracotomy, a rupture of the left diaphragmatic cupola was demonstrated with herniation of the stomach in case 1, the stomach, spleen and transverse colon in case 2. No postoperative mortality or morbidity were detected.     

Colobronchial Fistula Complicating a Traumatic Right Diaphragmatic Hernia: A Case Report

Abstract The delayed presentation of traumatic diaphragmatic hernia is associated with high morbidity and mortality. Acute colobronchial fistula complicating delayed presentation of traumatic diaphragmatic hernia is previously unreported. A 52-year-old woman presented with a 4-day history of dyspnoea, feculent sputum and chest and abdominal pain 3 months after a road traffic accident. The diagnosis of Chilaiditi's syndrome, diaphragmatic hernia and colobronchial fistula was confirmed with computed tomography (CT) and treated by chest drain, primary hernia repair and right hemicolectomy. Spontaneous decompression through the bronchus had prevented tension fecopneumathorax. The diagnosis of diaphragmatic hernia is difficult but delay is associated with increased mortality. Symptoms include dyspnoea, chest and abdominal pain, with decreased respiratory sounds and visceral sounds in the thorax. Abdominal visceral structures or gas on CXR, CT or contrast studies will confirm the diagnosis. The initial operative approach is laparotomy but thoracotomy must be considered as abdominal viscera may be adherent to thoracic structures.     

儿童先天性膈疝的超声表现及诊断价值

目的分析儿童先天性膈疝的超声表现及超声对其诊断价值。 方法选择2012年1月至2019年1月,屯昌县人民医院收治的先天性膈疝患儿30例,采用超声和X线片对患儿左、右膈疝和疝内容物进行诊断,并通过手术证实其对儿童先天性膈疝诊断的准确性。 结果手术结果表明,30例先天性膈疝的患儿中,左侧疝26例,右侧疝4例;疝内容物为空腔器官者9例,空腔与实质器官合并者21例。先天性膈疝患儿超声表现为上腹部膈肌回声中断,可见肺下界上移;经胸部背、侧腰部扫视隔离肺可见胸腔内与其他肺组织不相连的囊实混合回声区;经腹部扫视,空腔器官疝入则腹腔显示较空虚,实质性器官疝入,在正常位置不能显示器官结构。先天性膈疝患儿X线片表现为膈上可见半圆形肿块影,心脏及气管向健侧移位,腹部较空虚密实。超声诊断对先天性膈疝患儿膈疝位置和疝内容物的判断准确率（100.00%和90.00%）显著高于X线片（93.33%和56.67%,P<0.05）。 结论超声诊断能通过回声和图像结构对儿童先天性膈疝的位置和疝内容物进行判断,其诊断准确率显著高于X线片,值得在临床推广应用。     

创伤性膈疝的诊断和急救

目的总结创伤性膈疝的诊疗经验。方法对我院1976年6月～2004年10月所收治的创伤性膈疝30例进行回顾性分析。结果创伤性膈疝的病因以交通事故最多见，胸部平片检查确诊率34．6％，全组治愈28例(93．33％)。2例因多脏器功能衰竭死亡(6．66％)。随访16例，无复发。结论创伤性膈疝延误诊断与膈疝形成过程、病情危重等因素有关，动态观察伤员病情变化，及时复查胸部平片是防止延误诊断的主要措施。创伤性膈疝确诊后应急诊手术。     

Traumatic diaphragmatic hernia presenting as a tension fecopneumothorax

Abstract. Diaphragmatic injury with accompanying hernia is a well-documented complication associated with both penetrating and blunt trauma. It occurs in approximately 3% of abdominal injuries with a 2:1 ratio of penetrating to blunt trauma. Diagnosis requires a high index of suspicion since diaphragmatic injury can only reliably be ruled out by direct visualization, i.e., laparoscopy. Hence, delayed presentation with complications secondary to the injury is not uncommon. We discuss a case of a young man who presented in respiratory distress six years after a stab wound to the left chest. The patient was hypoxic, with a chest X-ray (CXR) demonstrating a pneumothorax with effusion. A chest tube was placed with a rush of air and foul-smelling purulent drainage. Work-up revealed incarcerated transverse colon in a diaphragmatic hernia. Celiotomy demonstrated necrotic colon in the chest with gross fecal contamination in both the chest and abdomen. The diaphragmatic defect was closed and a Hartmann's procedure performed. The patient did well postoperatively except for the development of an empyema, which resolved with conservative management. Our patient is the eleventh reported case of a tension fecopneumothorax resulting from traumatic diaphragmatic herniation. This paper reviews all cases including the diagnostic work-up, operative approach, and expected postoperative course of this unusual condition. Electronic Publication