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.

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

“…12 There are only a few reports, including the present, of liver segments being contained in an intercostal hernia, with or without other coexisting abdominal viscera (Table 1). 4,5,10,[12][13][14][15][16][17] The diagnosis of intercostal hernia has been historically challenging, with the interval between the initial traumatic incident and the repair of the hernia varying from immediately after the trauma to more than three decades later. 9 Clinically, a patient with transdiaphragmatic intercostal hernia would typically present with a reducible, palpable soft tissue lump in the lower chest wall with a positive cough impulse.…”

“…Although rare in the existing literature, these types of hernias have been suggested to actually be more frequent than the literature indicates, as their course is often asymptomatic. 9,12 More common on the left thoracic side, 9 these types of hernias are almost always located inferiorly to the seventh rib, and may contain omentum, colon, spleen, stomach, and/or small bowel. 12 There are only a few reports, including the present, of liver segments being contained in an intercostal hernia, with or without other coexisting abdominal viscera (Table 1).…”

“…9,12 More common on the left thoracic side, 9 these types of hernias are almost always located inferiorly to the seventh rib, and may contain omentum, colon, spleen, stomach, and/or small bowel. 12 There are only a few reports, including the present, of liver segments being contained in an intercostal hernia, with or without other coexisting abdominal viscera (Table 1). 4,5,10,[12][13][14][15][16][17] The diagnosis of intercostal hernia has been historically challenging, with the interval between the initial traumatic incident and the repair of the hernia varying from immediately after the trauma to more than three decades later.…”

Laparoscopic IPOM repair of an acquired abdominal intercostal hernia

“…A combined open and laparoscopic method was also demonstrated in the literature 19. The techniques to repair the defect in AAIH include primary closure and reinforcement absorbable or non-absorbable mesh 19…”

“…Losanoff et al use cable loops to approximate the ribs,2 but most of the late studies do not support its usage due to the risk of chronic pain and intercostal nerve damage 9 24. Erdas et al reveal that recurrence may occur in one-third of cases (28.6%),9 up to 12 months due to various reasons 19…”