Strangulation of Chronic Transdiaphragmatic Intercostal Hernia Peiyu Kao, MD, Hsin-Yuan Fang, PhD, Ting-Yu Lu, MD, Shih-Chao Hsu, MD, Chien-Kuang Chen, MD, and Pin-Ru Chen, MD Division of Thoracic Surgery, Department of Surgery and Division of General Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan
Transdiaphragmatic intercostal hernia (TIH) caused by violent coughing is a rare clinical diagnosis. Most patients diagnosed with TIH have a chronic condition consisting of a hernia that can be reduced completely by surgical intervention. Our patient presented with acute abdomen resulting from mechanical bowel obstruction secondary to an incarcerated hernia. Acute TIH presents a diagnostic challenge because of its rarity and lack of specific signs or symptoms in the differential diagnosis of acute abdomen. We recommend performing diagnostic computed tomography (CT) early if there is suspicion of TIH. Surgical intervention is always needed. Surgical intervention was complicated in this case, necessitating both transthoracic and abdominal exposure to resect the ischemic bowel segment. Nonetheless, the patient recovered uneventfully. (Ann Thorac Surg 2014;97:e155–7) Ó 2014 by The Society of Thoracic Surgeons
T
ransdiaphragmatic intercostal hernia (TIH) is a rare clinical diagnosis. Most TIHs are caused by trauma, and only 6 cases in the literature are reported to be secondary to violent coughing. Diaphragmatic hernia induced by a chronic coughing usually presents as a progressive chest mass with respiratory compromise from intestinal loops in the thoracic cavity. When a patient presents with an acute abdomen and a chest mass, TIH must be considered. Incarceration of a hernia is always an indication for surgical intervention. A 73-year-old man with coronary artery disease presented to the emergency room with left upper abdominal pain radiating to the left side of his back. He felt abdominal fullness but had no passage of flatus. The abdominal plain film revealed extensive intestinal gas in the abdomen, and the chest film showed blunting of the left costophrenic angle (Fig 1A). The clinical impression was intestinal obstruction. Hence, computed tomography (CT) was ordered. We reviewed the patient’s history and found that he had sustained a rib fracture after severe coughing 2 years before admission. Subsequently, the patient noticed diffuse
Accepted for publication Jan 29, 2014. Address correspondence to Dr Chen, Division of Thoracic Surgery, Department of Surgery, China Medical University Hospital, 2 Yu-De Rd, Taichung City, 404, Taiwan; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
abdominal ecchymosis that resolved spontaneously. He also noted a nontender mass intermittently in his left flank after the coughing episode. CT revealed small intestine inside the left chest cavity and a diaphragmatic defect in the left anterior diaphragm (Fig 1B). Emergency thoracotomy was recommended. We started a skin incision at the upper border of the chest mass. After dissecting the muscle between the seventh and eighth ribs, we noticed loops of irreducible and ischemic intestine. Therefore, we opened the abdominal cavity in the upper midline and enlarged the hernia defect (Fig 2B). We resected the 70 cm of ischemic ileum and repaired the diaphragm with interrupted 0 Prolene (Ethicon, Somerville, NJ) sutures. The patient recovered well and was discharged on the 20th postoperative day.
Comment Cough-induced intercostal transdiaphragmatic hernia is a rare medical condition, with only 6 similar cases presented in the literature [1–5]. In most cases, the hernia involved well-perfused viscera. Only 1 patient needed a partial colectomy. In our case, the patient presented with acute abdomen after a 2-year history of a bulge in the chest wall. The clinical impression was an intercostal hernia. Early surgical intervention before strangulation was not suggested because of a high anesthesia risk resulting from comorbid heart disease. In the emergency room, the patient was managed initially as if he had intestinal obstruction. CT showed bowel lumen in the left pleural cavity. As may be the case for a simple diaphragmatic hernia, TIH is a diagnosis frequently missed in its initial presentation [6]. CT with multiplanar reformation is preferred in the diagnosis of TIH; this modality can reveal the contents of the hernia sac. There is no specific sign that is diagnostic of TIH. In fact, TIH is too rare to be a prominent entity in the differential diagnosis when a patient presents with acute abdomen. A patient with strangulation is likely to seek help because of mechanical ileus and a fixed intercostal bulge [2]. If the hernia sac is reducible, the patient may recall a thoracoabdominal ecchymosis after a paroxysm of coughing [1, 2]. In addition, the patient may also recall an inconsistent chest mass and shortness of breath related to elevated intraabdominal pressure associated with coughing or heavy lifting. Rib fracture induced by violent coughing is well discussed in the literature [3, 4], in which the most widely discussed mechanism is stress fracture. When the force of the cough is greater than the elastic limit of the ribs, the cough can cause a fracture over the most vulnerable location—the costochondral junction. A second mechanism invokes an opposing force from the muscle attached to the same rib. This happens during violent coughing when the serratus anterior moves the ribs superiorly and laterally and the external oblique contracts to pull the ribs into alignment medially. Because the diaphragm arises from the anterior and inner aspect of the 6 lower ribs, rib discontinuity can 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.01.085
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CASE REPORT KAO ET AL TRANSDIAPHRAGMATIC INTERCOSTAL HERNIA
Ann Thorac Surg 2014;97:e155–7
Fig 1. (A) Plain chest roentgenogram demonstrates intestinal air bubble in the left lower intercostal space. This is a subtle finding (white arrow). (B) Computed tomography (CT) reveals diaphragmatic defect (gray arrow) and herniation of abdominal viscera into the pleural cavity as well as intercostal herniation (black arrow).
cause diaphragmatic weakness and even a defect over the diaphragm. In our opinion, a diaphragmatic defect resembles an acute muscle tear from the inner rib surface, initially bleeding and presenting as thoracoabdominal ecchymosis. When forced expiratory movements such as cough continue, the diaphragm is elevated while ribs are moving inward and downward [3]. Such opposing forces will eventually cause diaphragmatic rupture. The negative pressure with inhalation draws viscera into the thoracic cavity and eventually results in a diaphragmatic hernia. Both added pressure in the chest and poor coordination between respiratory muscles can cause poor healing of fractured ribs, resulting in TIH. We performed both thoracic and abdominal exploration because of unexpected bowel ischemia noted during the operation. We performed an abdominal midline incision to visualize the whole abdomen. We had considered extending the thoracic incision into the abdomen but elected not to do so because of concern that resultant pain could make it difficult to wean the patient from the ventilator.
Fig 2. (A) The operative image showed the step to enlarge the diaphragmatic defect to release incarcerated bowel loop. (B) Defect in the diaphragm is seen intraoperatively (view from thorax; white arrow).
Because the cases reported in the literature involved large diaphragmatic defects, artificial mesh was made available for this repair; however, in our patient, the chronic defect was only 2.5 3.0 cm. We performed intermittent whole-layer simple suture with 1-0 Prolene. The large intercostal defect was then reapproximated with multiple figure-of-8 sutures of 1-0 Vicryl (Ethicon, Somerville, NJ) and was covered with the serratus anterior muscle. We attempted to reconstruct the normal chest physiology. The patient stayed in the intensive care unit for 5 days and was free from ventilator support with adequate tidal volume. In conclusion, TIH must be considered when a patient presents with mechanical ileus and a chest bulge. A carefully elicited history of abdominal ecchymosis and a reducible chest mass may suggest TIH. Only CT can diagnose TIH preoperatively. Surgical intervention should be performed as soon as possible to maximize preservation of visceral and pulmonary organs. A dual approach of both thoracic and abdominal exploration may be beneficial, depending on whether there is incarceration.
Ann Thorac Surg 2014;97:e155–7
References 1. Rogers FB, Leavitt BJ, Jensen PE. Traumatic transdiaphragmatic intercostal hernia secondary to coughing: case report and review of the literature. J Trauma 1996;41:902–3. 2. Lasithiotakis K, Venianaki M, Tsavalas N, et al. Incarcerated spontaneous transdiaphragmatic intercostal hernia. Int J Surg Case Rep 201;2:212–4. 3. Hillenbrand A, Henne-Bruns D, Wurl P. Cough induced rib fracture, rupture of the diaphragm and abdominal herniation. World J Emerg Surg 2006;1:34.
CASE REPORT KAO ET AL TRANSDIAPHRAGMATIC INTERCOSTAL HERNIA
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4. Daniel R, Naidu B, Khalil-Marzouk J. Cough-induced rib fracture and diaphragmatic rupture resulting in simultaneous abdominal visceral herniation into the left hemithorax and subcutaneously. Eur J Cardiothorac Surg 2008;34:914–5. 5. Henriques AC, Malena CR, Freitas AC, Waisberg J, Pires AC. [Transdiaphragmatic intercostal hernia after spontaneous rib fractures secondary to coughing fit] [Article in Portugese]. Rev Col Bras Cir 2010;37:78–80. 6. Yanagawa Y, Kaneko N. A case of transdiaphragmatic intercostal hernia: the efficacy of using multidetector-row CT with multiplanar reformation. Emerg Med J 2011;28:10.
Transdiaphragmatic intercostal hernia (TIH) caused by violent coughing is a rare clinical diagnosis. Most patients diagnosed with TIH have a chronic condition consisting of a hernia that can be reduced completely by surgical intervention. Our patient presented with acute abdomen resulting from mechanical bowel obstruction secondary to an incarcerated hernia. Acute TIH presents a diagnostic challenge because of its rarity and lack of specific signs or symptoms in the differential diagnosis of acute abdomen. We recommend performing diagnostic computed tomography (CT) early if there is suspicion of TIH. Surgical intervention is always needed. Surgical intervention was complicated in this case, necessitating both transthoracic and abdominal exposure to resect the ischemic bowel segment. Nonetheless, the patient recovered uneventfully. (Ann Thorac Surg 2014;97:e155–7) Ó 2014 by The Society of Thoracic Surgeons
T
ransdiaphragmatic intercostal hernia (TIH) is a rare clinical diagnosis. Most TIHs are caused by trauma, and only 6 cases in the literature are reported to be secondary to violent coughing. Diaphragmatic hernia induced by a chronic coughing usually presents as a progressive chest mass with respiratory compromise from intestinal loops in the thoracic cavity. When a patient presents with an acute abdomen and a chest mass, TIH must be considered. Incarceration of a hernia is always an indication for surgical intervention. A 73-year-old man with coronary artery disease presented to the emergency room with left upper abdominal pain radiating to the left side of his back. He felt abdominal fullness but had no passage of flatus. The abdominal plain film revealed extensive intestinal gas in the abdomen, and the chest film showed blunting of the left costophrenic angle (Fig 1A). The clinical impression was intestinal obstruction. Hence, computed tomography (CT) was ordered. We reviewed the patient’s history and found that he had sustained a rib fracture after severe coughing 2 years before admission. Subsequently, the patient noticed diffuse
Accepted for publication Jan 29, 2014. Address correspondence to Dr Chen, Division of Thoracic Surgery, Department of Surgery, China Medical University Hospital, 2 Yu-De Rd, Taichung City, 404, Taiwan; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
abdominal ecchymosis that resolved spontaneously. He also noted a nontender mass intermittently in his left flank after the coughing episode. CT revealed small intestine inside the left chest cavity and a diaphragmatic defect in the left anterior diaphragm (Fig 1B). Emergency thoracotomy was recommended. We started a skin incision at the upper border of the chest mass. After dissecting the muscle between the seventh and eighth ribs, we noticed loops of irreducible and ischemic intestine. Therefore, we opened the abdominal cavity in the upper midline and enlarged the hernia defect (Fig 2B). We resected the 70 cm of ischemic ileum and repaired the diaphragm with interrupted 0 Prolene (Ethicon, Somerville, NJ) sutures. The patient recovered well and was discharged on the 20th postoperative day.
Comment Cough-induced intercostal transdiaphragmatic hernia is a rare medical condition, with only 6 similar cases presented in the literature [1–5]. In most cases, the hernia involved well-perfused viscera. Only 1 patient needed a partial colectomy. In our case, the patient presented with acute abdomen after a 2-year history of a bulge in the chest wall. The clinical impression was an intercostal hernia. Early surgical intervention before strangulation was not suggested because of a high anesthesia risk resulting from comorbid heart disease. In the emergency room, the patient was managed initially as if he had intestinal obstruction. CT showed bowel lumen in the left pleural cavity. As may be the case for a simple diaphragmatic hernia, TIH is a diagnosis frequently missed in its initial presentation [6]. CT with multiplanar reformation is preferred in the diagnosis of TIH; this modality can reveal the contents of the hernia sac. There is no specific sign that is diagnostic of TIH. In fact, TIH is too rare to be a prominent entity in the differential diagnosis when a patient presents with acute abdomen. A patient with strangulation is likely to seek help because of mechanical ileus and a fixed intercostal bulge [2]. If the hernia sac is reducible, the patient may recall a thoracoabdominal ecchymosis after a paroxysm of coughing [1, 2]. In addition, the patient may also recall an inconsistent chest mass and shortness of breath related to elevated intraabdominal pressure associated with coughing or heavy lifting. Rib fracture induced by violent coughing is well discussed in the literature [3, 4], in which the most widely discussed mechanism is stress fracture. When the force of the cough is greater than the elastic limit of the ribs, the cough can cause a fracture over the most vulnerable location—the costochondral junction. A second mechanism invokes an opposing force from the muscle attached to the same rib. This happens during violent coughing when the serratus anterior moves the ribs superiorly and laterally and the external oblique contracts to pull the ribs into alignment medially. Because the diaphragm arises from the anterior and inner aspect of the 6 lower ribs, rib discontinuity can 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.01.085
e156
CASE REPORT KAO ET AL TRANSDIAPHRAGMATIC INTERCOSTAL HERNIA
Ann Thorac Surg 2014;97:e155–7
Fig 1. (A) Plain chest roentgenogram demonstrates intestinal air bubble in the left lower intercostal space. This is a subtle finding (white arrow). (B) Computed tomography (CT) reveals diaphragmatic defect (gray arrow) and herniation of abdominal viscera into the pleural cavity as well as intercostal herniation (black arrow).
cause diaphragmatic weakness and even a defect over the diaphragm. In our opinion, a diaphragmatic defect resembles an acute muscle tear from the inner rib surface, initially bleeding and presenting as thoracoabdominal ecchymosis. When forced expiratory movements such as cough continue, the diaphragm is elevated while ribs are moving inward and downward [3]. Such opposing forces will eventually cause diaphragmatic rupture. The negative pressure with inhalation draws viscera into the thoracic cavity and eventually results in a diaphragmatic hernia. Both added pressure in the chest and poor coordination between respiratory muscles can cause poor healing of fractured ribs, resulting in TIH. We performed both thoracic and abdominal exploration because of unexpected bowel ischemia noted during the operation. We performed an abdominal midline incision to visualize the whole abdomen. We had considered extending the thoracic incision into the abdomen but elected not to do so because of concern that resultant pain could make it difficult to wean the patient from the ventilator.
Fig 2. (A) The operative image showed the step to enlarge the diaphragmatic defect to release incarcerated bowel loop. (B) Defect in the diaphragm is seen intraoperatively (view from thorax; white arrow).
Because the cases reported in the literature involved large diaphragmatic defects, artificial mesh was made available for this repair; however, in our patient, the chronic defect was only 2.5 3.0 cm. We performed intermittent whole-layer simple suture with 1-0 Prolene. The large intercostal defect was then reapproximated with multiple figure-of-8 sutures of 1-0 Vicryl (Ethicon, Somerville, NJ) and was covered with the serratus anterior muscle. We attempted to reconstruct the normal chest physiology. The patient stayed in the intensive care unit for 5 days and was free from ventilator support with adequate tidal volume. In conclusion, TIH must be considered when a patient presents with mechanical ileus and a chest bulge. A carefully elicited history of abdominal ecchymosis and a reducible chest mass may suggest TIH. Only CT can diagnose TIH preoperatively. Surgical intervention should be performed as soon as possible to maximize preservation of visceral and pulmonary organs. A dual approach of both thoracic and abdominal exploration may be beneficial, depending on whether there is incarceration.
Ann Thorac Surg 2014;97:e155–7
References 1. Rogers FB, Leavitt BJ, Jensen PE. Traumatic transdiaphragmatic intercostal hernia secondary to coughing: case report and review of the literature. J Trauma 1996;41:902–3. 2. Lasithiotakis K, Venianaki M, Tsavalas N, et al. Incarcerated spontaneous transdiaphragmatic intercostal hernia. Int J Surg Case Rep 201;2:212–4. 3. Hillenbrand A, Henne-Bruns D, Wurl P. Cough induced rib fracture, rupture of the diaphragm and abdominal herniation. World J Emerg Surg 2006;1:34.
CASE REPORT KAO ET AL TRANSDIAPHRAGMATIC INTERCOSTAL HERNIA
e157
4. Daniel R, Naidu B, Khalil-Marzouk J. Cough-induced rib fracture and diaphragmatic rupture resulting in simultaneous abdominal visceral herniation into the left hemithorax and subcutaneously. Eur J Cardiothorac Surg 2008;34:914–5. 5. Henriques AC, Malena CR, Freitas AC, Waisberg J, Pires AC. [Transdiaphragmatic intercostal hernia after spontaneous rib fractures secondary to coughing fit] [Article in Portugese]. Rev Col Bras Cir 2010;37:78–80. 6. Yanagawa Y, Kaneko N. A case of transdiaphragmatic intercostal hernia: the efficacy of using multidetector-row CT with multiplanar reformation. Emerg Med J 2011;28:10.
