Thoracolaparoscopic management of a traumatic subacute transdiaphragmatic intercostal hernia. Second case reported

Abstract

Background: Transdiaphragmatic intercostal hernias are extremely rare. Their physiopathology is different from traumatic diaphragmatic ruptures, and their clinical presentation and management strategies place them in a different category than abdominal intercostal hernias.

Case presentation: A 56 yo female presented to the outpatient trauma clinic with a symptomatic, subacute left sided transdiaphragmatic intercostal hernia secondary to a motor vehicle crash almost 3 months prior to presentation. The injury was managed with a combined thoracoscopic and laparoscopic approach, only the second time ever this has been reported. She was discharged on POD#3, and after 6 months of follow up continues to do well, without clinical evidence of hernia recurrence.

Conclusion: Minimally invasive management of this rare pathology is possible and should be encouraged.

Keywords: Intercostal pleuroperitoneal hernia; Laparoscopic bioprosthetic hernioplasty; TAWH; Transdiaphragmatic intercostal hernia; Traumatic abdominal wall hernia; Traumatic diaphragmatic rupture.

Fig. 1

Coronal reconstruction of the preoperative axial computed tomography of the patient, showing the injury. The arrow points to the antrum, that can be followed herniating into the chest. 9 and 10 are the ninth and tenth ribs respectively. The splenic flexure can be seen herniating into the 9th intercostal space.

Fig. 2

Another more posterior coronal reconstruction of the preoperative axial computed tomography of the patient, showing the injury. The gastric fundus is highlighted, in close apposition to the pericardium and the pericardial fatpad. Close adherences were found in the operation.

Fig. 3

Sagittal reconstruction of the preoperative axial computed tomography of the patient, showing the diaphragmatic component of the injury in relation to the anterior mediastinum. The gastric fundus is seen herniating and bringing in the upper pole of the spleen into the chest.

Fig. 4

Caudal laparoscopic view of the injury after adhesiolysis. The thoracic port is visualized through the diaphragmatic defect.

Fig. 5

Medial closeup laparoscopic view of the injury after adhesiolysis. 9 and 10 are the ninth and tenth ribs. Note the angle of separation between the ribs, marking the beginning of the hernia defect in the chest. The fat remnants on the intercostal space are omental leftovers after adhesiolysis.

Fig. 6

Coronal reconstruction of the postoperative axial computed tomography (4 months postop), showing satisfactory reconstruction of the left costodiaphragmatic recess, without lung herniation and resolution of the seroma. Arrows point to the bioprosthesis.