Posttraumatic Transdiaphragmatic Intercostal Hernia: Report of a Case and Review of the Literature

Abstract

Intercostal hernias are rare, and usually occur following injuries of the thoracic wall. The scope of this report is to present a case of a 53-year-old obese patient that developed a transdiaphragmatic intercostal hernia. The patient presented with a palpable, sizeable, reducible mass in the right lateral thoracic wall, with evident bowel sounds in the area, 6 months after a motor-vehicle accident. On computed tomography (CT), the hernia sac contained part of the liver and part of the ascending colon. A surgical repair of the defect was performed, using a prosthetic patch. The patient's postoperative course was uneventful and she remains recurrence free at 12 months after surgery. Intercostal hernias should be suspected following high-impact injuries of the thoracic wall, and CT scans will facilitate the diagnosis of intercostal hernia. We consider the surgical repair of the defect, with placement of a prosthetic mesh, as the treatment of choice to ensure a favorable outcome.

Post-traumatic intercostal and diaphragm hernias following a sneezing episode

“…Obtaining preoperative cross-sectional imaging is paramount. Imaging can help define other possible diagnoses, such as a haematoma or lipoma 2. Even though the CT did not show the diaphragm hernia, this case clearly demonstrates that a diaphragm hernia may also present with intercostal hernia.…”

“…However, more surgeons are opting to repair these hernias as lung herniations will not resolve spontaneously independent of aetiology 1. The indications for operative management include, but are not limited to, increasing size, pain, difficulty reducing the hernia and cosmetic reasons 2 3. In agreement with others, we would strongly advocate for operative repair for any patient with abdominal viscera associated with the hernia, given the risk of incarceration and strangulation 2.…”

“…Not all patients with intercostal hernias are symptomatic, and therefore there are likely more intercostal hernias than those that have been reported. Others have reported late presentations of intercostal hernias that were initially occult but enlarged over time 2. So, maintaining a high index of suspicion for patients presenting with pain in an area they previously had chest trauma is important.…”

“…So, maintaining a high index of suspicion for patients presenting with pain in an area they previously had chest trauma is important. When symptomatic, there is usually a reducible tender bulge that enlarges with increased intrathoracic pressure 2 3. Obtaining preoperative cross-sectional imaging is paramount.…”

“…This can matter significantly for operative planning, and to understand what visceral or pleural contents are within the hernia sac. Others have reported cases with the intestine and liver within intercostal hernias, which clearly require a coexisting diaphragm hernia 2 4…”