Interact CardioVasc Thorac Surg 2008;7:506-507. doi:10.1510/icvts.2007.168658
© 2008 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Surgical repair of post-traumatic lung hernia using a video-assisted open technique
Mohammed W. Khalil*,
Nicola Masala,
David A. Waller and
Giuseppe Cardillo
Department of Thoracic Surgery, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
Received 20 September 2007;
received in revised form 29 December 2007;
accepted 1 January 2008
*Corresponding author. Fax: +44 116 2502662.
E-mail address: wesam{at}doctor.com (M.W. Khalil).
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Abstract
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Post-traumatic lung herniation through a defect in the chest wall is an uncommon injury, with only about 300 reported in the literature. Various methods of treatment and repair have been described, including both purely thoracoscopic to full open techniques. We repaired a case by using a combination of minithoracotomy and video-assistance through the minithoracotomy wound. The patient did well and there was minimal postoperative pain.
Key Words: Lung; Hernia; Trauma
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1. Introduction
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Lung hernia is an uncommon entity defined as the protrusion of pulmonary tissue and pleural membranes through defects of the thoracic wall. Chest trauma is the most common cause. It was first described by Roland in 1499, and only about 300 cases have been reported in the literature since then [1, 2]. We report here a case which followed a fall from a height, and how we employed a video-assisted minithoracotomy approach to its management.
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2. Case summary
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A 61-year-old male presented to our unit following a fall from a height. He sustained left-sided blunt chest injury, with tenderness and swelling over the upper ribs just lateral to the sternum. The swelling was spongy, crepitant, and well demarcated. The patient himself was not in respiratory distress and was cardiovascularly stable. Chest X-ray revealed a small haemothorax but no pneumothorax, and no rib fractures. However, a CT-scan of the chest revealed fractures of the second and third costal cartilages, with herniation of part of the left upper lobe through the defect (Fig. 1).
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Fig. 1. CT-scan of the patient showing part of the left upper lobe herniating through the defect in the chest wall.
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The patient was then taken to the theatre and a muscle-sparing minithoracotomy was made directly over the swelling. The pectoralis major was retracted medially and the herniated part of the upper lobe was seen protruding through the defect in the chest wall (Fig. 2). The muscle was then divided in the same line of its fibres, and the herniated part was examined and found to be viable. It was then reduced back to the chest cavity. The second and third cartilages were found to be comminuted and therefore excised. Through the defect, a video-thoracoscope was inserted and the haemothorax was evacuated. The cavity was then inspected for other injuries to the lung and diaphragmatic injury was ruled out. A chest drain was then inserted under the video-assisted vision. The scope was then removed and the defect was closed using a 2 mm GORE-TEX patch, stitched in place with interrupted prolene sutures. The patient did very well and was discharged seven days postoperatively.
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Fig. 2. Intraoperative view of the herniated part of the left upper lobe beneath the pectoralis major (retracted).
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3. Discussion
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Lung herniation usually results from trauma to the chest wall. It could also follow inadequate healing following thoracotomy and has even been reported to spontaneously occur after a bout of cough [2]. In a few cases the hernia is congenital, with delayed presentation.
Lung tissue can herniate through a defect between the ribs (intercostal hernias), or through the superior thoracic aperture (supraclavicular hernias). In intercostals hernias, the anterior thorax is the site of predilection because it lacks the muscular support of the posterior thorax provided by the trapezius, rhomboids, and latissimus dorsi muscles [3]. And, as in our case, they are frequently associated with multiple rib or chondral fractures, and occur in the area between the sternum and the costochondral junction, where the intercostals muscle layer is thinnest, the external intercostals muscle being absent there.
Clinically, post-traumatic lung herniation could present with subtle physical findings or no symptoms. Presence of a localized swelling that feels spongy and crepitant-like surgical emphysema, especially if well demarcated, should raise suspicion. Cough impulse might also be present, raising the index of suspicion. Chest radiographs might reveal nothing, though tangential views may demonstrate the herniation. Computerized tomographic scan of the chest is the radiological investigation of choice in the diagnosis of lung herniation. This will show the defect in the chest wall as well as the herniated part of the lung protruding through the defect (Fig. 1).
In supraclavicular hernias, conservative treatment is usually sufficient. However, immediate surgical repair is mandatory in intercostals hernias, as there is more risk of incarceration. Before the herniated lung tissue is reduced, careful inspection must be carried out to ensure that it is not necrotic. Lung tissue can be considered viable if it still retains its pinkish hue, with visible carbon-marked subpleural lymphatics. Further confirmation of viability is sought after reduction and insertion of the videoscope, where comparison is made between the reduced part and the surrounding lung tissue. Incarceration of the herniated lung tissue is uncommon, but if it occurs, excision of the involved part of the lung is carried out by stapling devices. Smaller chest wall defects can usually be closed by primary sutures and fixation of adjacent ribs by pericostal stitches. However, larger defects, especially if associated with comminution of the involved skeletal elements (as in our case), muscle flaps or prosthetic grafts, such as Gore-Tex or polypropylene mesh, are necessary for appropriate closure [3, 4]. During the surgical repair, videothoracoscopy through the defect can be used to evacuate any haematoma, assess the cavity and diaphragm for occult injuries, insert the chest drain, and to ensure adequate lung expansion (especially of the reduced part) prior to the repair of the defect. This obviates the need for a separate incision to insert the camera port, as has been reported in a previous case in the literature [5], and will reduce the postoperative pain that could result from manipulation of the camera in the port.
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References
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- Michael JJ, Fabio Luison. Delayed presentation of traumatic parasternal lung hernia. Ann Thorac Surg 1998;65:1150–1151.[Abstract/Free Full Text]
- Gary SA, Ronald PF. Traumatic lung herniation. Ann Thorac Surg 1997;63:1455–1456.[Abstract/Free Full Text]
- Loic LL, Pierre-Mathieu B, Francois P, Louis B, Rene J. Traumatic extrathoracic lung herniation. Ann Thorac Surg 2002;74:927–929.[Abstract/Free Full Text]
- Szentkereszty Z, Boros M, Sapy P, Kiss SS. Surgical treatment of intercostals hernia with implantation of polypropylene mesh. Hernia 2006 8;10:345–346.
- Micheal JR, Jan Fabre, Patrick RR, John CB. Video-assisted repair of a traumatic intercostals pulmonary hernia. Ann Thorac Surg 1998;65:1155–1157.[Abstract/Free Full Text]
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Abstract
1. Introduction