Transdiaphragmatic Chest Wall Herniation

Abstract

Background The combination of traumatic simultaneous diaphragmatic rupture and chest wall herniation remains rare, with 42 cases of traumatic transdiaphragmatic intercostal hernia (TDIH) reported in the literature since 1946. An accurate count of cases is difficult to obtain, as TDIH nomenclature has been variable. 1 - 5 Risk factors for traumatic TDIH are not well established. As these injuries are uncommon, best management techniques have yet to be established. Reported repair techniques include primary closure, closure with mesh, and implantation of prosthetic or autologous material. We present our single-center series of 7 patients, the largest reported to our knowledge, and discuss the challenges of repairing these difficult injuries. Methods After obtaining institutional review board approval, data were abstracted from the electronic medical record on all adults who underwent evaluation and treatment for traumatic TDIH between July 2014 and January 2019. Results Of the 7 cases of traumatic TDIH, 6 patients developed TDIH secondary to cough; the seventh patient presented with chronic chest wall pain after an episode of heavy lifting. All patients were obese or overweight. Pain and a “popping sensation” were the most common presenting symptoms. All patients underwent operative intervention with primary repair of the diaphragm and suture approximation of the ribs. 3 patients had onlay mesh repair of the chest wall and/or abdominal wall. 1 patient had plating of his rib fracture. 3 patients had a recurrence of the intercostal portion of the hernia No patients have undergone reoperation thus far. Discussion While previously thought to more commonly occur on the left side due to the protective effects of the diaphragm, 2 the majority in this series had right-sided injuries. Herniation through the ninth-10th interspace remains the most common location. 4 Computed tomography imaging should be used for diagnosis and operative planning. It is best to manage these hernias acutely to re-establish normal anatomy. Mesh may be required in delayed reconstructions of if the chest wall cannot be re-approximated. Rib plating should be considered in cases of instability or flail. High rates of complications are not unexpected given the complicated and rare nature of the injury. Given the high rate of intercostal hernia recurrence, it is likely that mesh repair or should be more often used in the treatment of this injury.

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

“…There remains debate regarding the optimal management of the IH component, especially considering the demonstrated chronic presentation in the obese patient. Other authors have reported failure rates of up to 66% for surgical repair using sutures with or without single layer mesh, in keeping with our experience 20,21 . We encountered some failures with suture repair and extrathoracic mesh repair, before moving to the double layer mesh repair (DLMR).…”

“…Other authors have reported failure rates of up to 66% for surgical repair using sutures with or without single layer mesh, in keeping with our experience. 20,21 We encountered some failures with suture repair and extrathoracic mesh repair, before moving to the double layer mesh repair (DLMR). While we have not sought patient-reported quality of life outcome data in this study, the surgical results of DLMR appear satisfactory.…”