International Journal of Abdominal Wall and Hernia Surgery

CASE REPORT
Year
: 2021  |  Volume : 4  |  Issue : 1  |  Page : 35--38

Abdominal intercostal hernia repair


Junsheng Li, Xiangyu Shao, Tao Cheng 
 Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing, China

Correspondence Address:
Dr. Junsheng Li
Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing 210009
China

Abstract

Abdominal intercostal hernia (AIH) is a rare disease, may occur secondary to trauma or previous surgery, recently. There is no consensus on the best treatment of AIH. The aim of the present study is to report the repair of AIH in a male patient. The AIH in a 56-year-old male was repaired with the laparoscopic procedure; the patient characteristics and repair details were described. The computed tomography scan revealed an intercostal hernia containing omentum between the 9th rib and 10th rib. The laparoscopic repair with synthetic mesh was successfully performed, and the patients were absent of symptoms at 8-month follow-up. There is no consensus on the best treatment of AIH, tension-free prosthetic repair is recommended, and the laparoscopic approach has several advantages for AIH repair.



How to cite this article:
Li J, Shao X, Cheng T. Abdominal intercostal hernia repair.Int J Abdom Wall Hernia Surg 2021;4:35-38


How to cite this URL:
Li J, Shao X, Cheng T. Abdominal intercostal hernia repair. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Jul 29 ];4:35-38
Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/1/35/309982


Full Text



 Introduction



Intercostal hernia is an uncommon hernia, caused by disruption or weakness of thoracoabdominal wall musculature and protrusion of abdominal viscera through a defect between two consecutive ribs.[1],[2],[3] Intercostal hernia can occur after surgery, blunt or penetrating injury of the thoracic wall, or previous surgery.[4] Occasionally, intercostal hernia may develop spontaneously or as a consequence of coughing-spell rib fracture, in such cases, chronic obstructive pulmonary disease often exists.[5],[6],[7] Clinically, there are two types of intercostal hernias, when the abdominal viscera gain entry to the intercostal space through an associated diaphragmatic defect, the term “Transdiaphragmatic intercostal hernia” was used, and the term “abdominal intercostal hernia (AIH)” was reserved for cases without diaphragmatic injury.[1],[4] The two types of intercostal hernia may overlap each other, but each has distinct clinical features and poses different surgical challenges. Given its rare occurrence and specific location, the appropriate treatment remains to be established. In the present study, we report a case of AIH, which was successfully repaired with the laparoscopic technique, the technique details, especially the mesh fixation strategy in this special hernia was addressed.

 Case Report



A 56-year-old male was admitted to our hospital with a complaint of swelling on the left lower chest wall, which increased in size for the past 2 weeks; he had mild pain, but no obstructive symptoms. The swelling increased with coughing and decreased in the right decubitus position [Figure 1]. The patient's body mass index was 24.5, his past history included a car accident 3 years ago, and he had right fracture of the head of the femur; he had no other significant medical history and risk factors for surgery. Physical examination showed a protruding parietal mass on the lateral aspect of the left thoracic wall, upon the reduction of the mass, the intercostal defect could be palpated and measured about 3 cm in width between the 9th and 10th intercostal space. Blood tests were unremarkable. Computed tomography (CT) scan showed a herniation of omentum extending between the 9th and 10th ribs, no rib fractures or diaphragmatic injury was identified, therefore, the diagnosis of left AIH was made [Figure 2], and an elective laparoscopic AIH repair was planned.{Figure 1}{Figure 2}

 Abdominal Intercostal Hernia Repair Technique



Laparoscopic repair was performed in general anesthesia, and the patient was placed in the standard supine position with the left side up. Pneumoperitoneum was induced through an umbilical trocar, the 10-mm optical trocar was placed in the umbilicus for endoscope, and two additional 5-mm ports were placed in the upper and lower quadrants of the abdomen along the midline. Endoscopic exploration revealed the parietal defect in the intercostal space containing omentum, and no diaphragmatic defect was present. The herniated omentum was reduced with blunt and sharp dissection; an intercostal defect of 9 cm in length was identified along the intercostal space [Figure 3]. The defect edges were closed by incorporating the adjacent fascia with 1-0 Stratafix suture in a running fashion [Figure 4], of note, the ribs were not approximated. A composite mesh (Parietex® composite mesh; Covidien, USA) was introduced and unfurled to cover the defect with at least 5 cm overlap in all directions. The caudal and ventral sides of the mesh were fixed with absorbable tacks (Absorbable Tack®, Covidien) on the abdominal wall, care was taken that the tack fixation was only applied on the abdominal wall, but not on the thoracic wall.{Figure 3}{Figure 4}

The cranial edge of the mesh was fixed on the thoracic wall with atraumatic methods by superficial sutures [Figure 5] and cyanoacrylate glue (Compont Medical Devices Co., Ltd. Beijing); similarly, the dorsal side of the mesh was also fixed on the posterior side with sutures and cyanoacrylate glue [Figure 6].{Figure 5}{Figure 6}

The operative time was 105 min, the postoperative course was uneventful, acute postoperative pain was mild (VAS 1–2). The patient was discharged on postoperative day 4. At 8-month follow-up, he recovered well with no chronic pain and recurrence [Figure 7].{Figure 7}

 Discussion



There are two types of intercostal hernias: the transdiaphragmatic intercostal hernia with a diaphragmatic defect and the AIH without a diaphragmatic defect. Several authors did not distinguish the two types of intercostal hernias between them and use the same term regardless of whether the abdominal contents herniated into the intercostal space through the diaphragmatic defect or not,[1],[4] however, the two types of hernias result in different clinical features and require different surgical strategies. Although AIH was rarely reported in the literature, the true incidence may be more frequent than literature reported, as it may be asymptomatic or localized thoracic discomfort and pain;[1] furthermore, the symptoms may be confused with a hematoma.[8],[9] Computed tomography can be useful, since it can not only recognize the intercostal hernia, measure the defect size, visualize the hernia contents, but more importantly to identify the concomitant diaphragmatic injury, and CT can also be helpful in planning the appropriate surgical strategy.

Although AIH can occur spontaneously, the majority of AIH developed after various types of traumas, which either completely disrupted the intercostal muscles, or progressively and repetitively weakened the fascia or muscles of the intercostal space.[1],[2] Several predisposing factors have been proposed to the occurrence of AIH after minor traumas, such as COPD, asthma, diabetes mellitus, steroids use, malnutrition, excessive weight loss, and increased intra-abdominal pressure.[2],[4] Erdas et al. found that that there was a delay presentation of AIH from the trauma to hospital admission, with a mean time of 24.4 months (range same day-20 years).[1] The present case had a car accident 3 years ago, and he had no symptoms within the 3 years. The delay onset of AIH may be due to the progressive strain on the intercostal musculatures, including the dynamic of physical activity, respiration, coughing, or straining. Anatomically, the chest wall is weak from the costochondral junction to the sternum because of a lack of external intercostal muscle support, and from the costal angle posteriorly to the vertebrae because of a lack of internal intercostal musculature, which makes these zones more vulnerable to develop AIH than others;[1],[2],[5] therefore, most of the AIH were located under the 9th rib, where ribs are not directly supported by sternum as those above.[1]

Surgery is always indicated, since abdominal viscera incarceration or strangulation can occur in 15% of the AIH.[1] AIH can be difficult to repair because of the special location. Although both open and endoscopic approaches have been reported for AIH repair,[1],[2],[3],[4],[5],[6],[7],[8],[9] due to the limited number of cases, it is difficult to determine the efficacy of various surgical techniques. Defect closure can be achieved by primary closure, absorbable and nonabsorbable meshes.[1],[2],[3],[10] Erdas et al. reported a recurrence of 28.6% regardless of repair procedures in a review study,[1] however, as they pointed out that the recurrence rate is likely higher than it appears, since the mean follow-up was very short (8.6 months). Therefore, tension-free mesh repair should be used, and rib approximation should be avoided, because such an approach may cause chronic pain and discomfort as well as intercostal nerve damage,[1] therefore, in the present case, rib approximation was not made; at 8-month follow-up, the patient reported no pain at all.

Traditionally, AIH repair was performed with open approach through a large skin incision.[1],[9],[10] With the increasing use of the minimal invasive technique in ventral and incisional hernia repair, AIH treated by laparoscopic technique has been reported in uncomplicated cases.[1],[10] By avoiding the large abdominal incision or the rib spreading during thoracotomy, the laparoscopic approach has the advantages of reduced postoperative pain, lower wound incision, and shorter hospital stay; in addition, the laparoscopic approach could also provide a better view to detect the diaphragmatic damage, which is another type of intercostal hernia, and can be repaired simultaneously.

A major challenge in laparoscopic AIH repair is mesh fixation, since traumatic fixation (tacks or penetrating sutures) should be avoided in the diaphragm to avoid lethal complications;[11,12] furthermore, we avoid the use of traumatic fixation in the thoracic wall in order to prevent postoperative pain and nerve damage. Therefore, in the present case, the mesh was fixed with superficial sutures or glue to the thoracic wall, and no hernia recurrence was observed at 8-month follow-up, and the postoperative chronic pain was minimal.

 Conclusion



Surgeons should maintain a high index of suspicion for AIH in patients of prior thoracic trauma or surgery, and CT is the essential diagnostic instrument for detecting coexist abdominal injury and surgery planning. In selected cases, laparoscopic repair with mesh is safe and effective to decrease the postoperative pain and recurrence. Atraumatic mesh fixation methods (glue and superficial suture) should be applied in this special hernia to minimize morbidity and pain.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Erdas E, Licheri S, Calò PG, Pomata M. Acquired abdominal intercostal hernia: Case report and systematic review of the literature. Hernia 2014;18:607-15.
2Abunnaja S, Chysna K, Shaikh I, Tripodi G. Acquired abdominal intercostal hernia: A case report and literature review. Case Rep Surg 2014;2014:456053.
3Wang SC, Singh TP. Robotic repair of a large abdominal intercostal hernia: A case report and review of literature. J Robot Surg 2017;11:271-4.
4Unlu E, Temizoz O, Cagli B. Acquired spontaneous intercostal abdominal hernia: Case report and a comprehensive review of the world literature. Australas Radiol 2007;51:163-7.
5Sharma OP, Duffy B. Transdiaphragmatic intercostal hernia: Review of the world literature and presentation of a case. J Trauma 2001;50:1140-3.
6Fiane AE, Nordstrand K. Intercostal pulmonary hernia after blunt thoracic injury: Two case reports. Eur J Surg 1993;159:379-81.
7Rogers 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.
8Smith E, Spain L, Ek E, Farrell S. Post-traumatic inter-costal liver herniation. ANZ J Surg 2018;78:615-6.
9Gundara JS, Ip JC, Lee JC. Unusually complicated chest infection: Colon containing intercostal hernia. ANZ J Surg 2012;82:851-2.
10Bobbio A, Ampollini L, Prinzi G, Sarli L. Endoscopic repair of an abdominal intercostal hernia. Surg Laparosc Endosc Percutan Tech 2008;18:523-5.
11Li J, Cheng T. Mesh erosion into urinary bladder, rare condition but important to know. Hernia 2019;23:709-16.
12Köckerling F, Schug-Pass C, Bittner R. A word of caution: Never use tacks for mesh fixation to the diaphragm! Surg Endosc 2018;32:3295-302.