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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 4  |  Page : 120-122

Spontaneous intercostal hernia: A rare occurrence


1 Department of Surgery, All India Institute of Medical Sciences (AIIMS), Nagpur, Maharashtra, India
2 Department of Surgery, MGM Institute of Health Sciences, Navi Mumbai, Maharashtra, India

Date of Submission15-Apr-2020
Date of Acceptance05-Jun-2020
Date of Web Publication11-Nov-2020

Correspondence Address:
Prof. Siddharth P Dubhashi
A2/103, Shivranjan Towers, Someshwarwadi, Pashan, Pune - 411 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_19_20

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  Abstract 


Intercostal hernias can occur with or without diaphragmatic defects. This is a case of a spontaneous intercostal hernia in a 55-year-old diabetic, with a defect in the right 8th intercostal space, along with an asymptomatic umbilical hernia. After CT imaging, the patient was managed with a tension-free mesh repair. A high index of clinical suspicion is warranted in all cases presenting with palpable reducible chest wall swelling. The occurrence of a spontaneous intercostal hernia is rare and hence reported.

Keywords: CT scan abdomen, hernia mesh repair, spontaneous intercostal hernia


How to cite this article:
Dubhashi SP, Kumar A. Spontaneous intercostal hernia: A rare occurrence. Arch Int Surg 2019;9:120-2

How to cite this URL:
Dubhashi SP, Kumar A. Spontaneous intercostal hernia: A rare occurrence. Arch Int Surg [serial online] 2019 [cited 2020 Nov 27];9:120-2. Available from: https://www.archintsurg.org/text.asp?2019/9/4/120/300559




  Introduction Top


Abnormal protrusion of the thoracic or abdominal viscera, through an intercostal space resulting from weakness of the wall musculature or fascia, is a rare condition. Intercostal hernia can be associated with or without a diaphragmatic defect.[1],[2] It can result from blunt or penetrating trauma, rib fractures, previous surgical procedures, in association with congenital syndromes, or can occur spontaneously.[3],[4],[5],[6] It is essential to recognize and treat intercostal hernias.


  Case Report Top


A 55-year-old gentleman presented to the surgical outpatient clinic with a swelling over the right lower anterior chest wall and upper abdomen for 3 months, which was progressing in size [Figure 1]. There was no history of trauma or pain associated with the swelling, chronic cough, constipation, or straining at micturation. His diabetes mellitus was well-controlled. On examination, an 8 × 10 cm swelling was noted over the right 8th intercostal space in the anterior axillary line, with a positive cough impulse and partial reducibility. An asymptomatic umbilical hernia with a defect of 1 cm was an incidental finding. Thoracic computed tomography (CT) scan with upper abdominal imaging revealed a 5 cm defect in right 8th intercostal space in anterior axillary line. The sac contained omentum and hepatic flexure of colon, but there was no diaphragmatic defect [Figure 2]. Under general anesthesia, with the patient in left lateral position, an oblique incision was made along the right 8th intercostal space overlying the swelling. The sac was dissected, opened, and the omentum and colon were reduced into the peritoneal cavity. The sac was excised after closure of its neck and the defect was closed with non absorbable suture. A polypropylene mesh of size 15 × 15 cm (PROLENE) was placed over the sutured defect and secured to the periosteum of the adjacent ribs with non absorbable suture [Figure 3], [Figure 4], [Figure 5]. A suction drain was placed in- situ over the mesh. The skin was closed using mattress non absorbable suture. The umbilical hernia was also closed with Mayo's repair. The post operative course was uneventful. To date, the patient has remained asymptomatic over a 2-year follow-up period.
Figure 1: Right intercostal hernia

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Figure 2: CT Scan showing defect of 5 cm

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Figure 3: Intra-operative finding: hernia defect

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Figure 4: Closure of defect

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Figure 5: Mesh placement over sutured defect

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  Discussion Top


The terms acquired abdominal intercostal hernia (AAIH) and trans-diaphragmatic intercostal hernia (TIH) have been used to describe intercostal hernia.[1],[2] When the intra-abdominal contents protrude through the acquired defect in the abdominal fascia or musculature, it is called AAIH. In case the contents protrude through a diaphragmatic defect, it is termed as TIH. The extent of the chest wall from the costochondral junction to the sternum is anatomically weak due to absence of external intercostal muscle support. Similarly, extent from costal angle posteriorly to the vertebrae is another weak area due to absence of internal intercostal muscles.[7]

The predominant age group affected as reported in literature ranges from 19 to 75 years, with a male preponderance. Right-sided intercostal hernias are less common compared to left-sided ones, as the right side of the diaphragm enjoys the buttressing effect of the right lobe of liver.[6],[8] Our case was an unusual right side presentation. Various etiological factors for intercostal hernia have been noted: blunt and penetrating trauma, deceleration injuries, and fractured ribs.[1],[8],[9] An overall incidence of 52% has been reported for the association of intercostal hernias with rib fractures (commonly between 8th and 10th ribs), a factor which can precipitate traumatic intercostal herniation.[8] Reports have noted few predisposing factors such as diabetes mellitus, chronic obstructive pulmonary disease, increased abdominal pressure, advanced age, and treatment with steroids.[6] Diabetes was a comorbidity noted in our case without any other risk factor. Congenital conditions associated with intercostal hernias include Ehlers-Danlos syndrome and Poland syndrome[1],[10] CT scan is a useful imaging modality, providing details regarding the defect, its content and associated pathologies, thereby, facilitating formulation of plans for precise surgical intervention. Our case is a spontaneous intercostal hernia along with an umbilical hernia, indicating soft-tissue weakness. Similar case has been reported by Unlu et al.,[6] in which an inguinal hernia was also noted. Cross and Mehta[11] have described a case of spontaneous lateral detachment of the right hemidiaphragm from the chest wall along with fracture of the 9th rib. They coined the term intercosto-pleuroperitoneal hernia. Dobradin and Bello have reported a case of cough-induced intercostal hernia.[12]

Around 15% cases of AAIH are complicated by incarceration and strangulation.[13] Our case had a history of swelling for 3 months and the patient opted for consultation as soon as he noticed that swelling was progressively increasing in size. The defect can be tackled by a laparoscopic approach or laparotomy/thoracotomy.[1],[7],[8],[14] An ideal reconstruction should provide a tension-free repair, incorporated with the remaining abdominal wall with a dynamic muscle support.[15] We performed an open tension-free mesh repair. Absence of prosthetic support is associated with high recurrence rate and maximum recurrences have been seen up to 12 months post-repair, with a rate of 28.6%.[1],[13] No recurrence has been noted in our case.


  Conclusion Top


Surgeons should have a high index of suspicion for abdominal and trans-diaphragmatic intercostal hernias in patients presenting with a chest wall bulge. Careful history taking can provide significant clue. CT imaging is an essential diagnostic tool and surgical operation is the mainstay of treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his 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 Top

1.
Abbunaja S, Chysna K, Shaikh I, Tripodi G. Acquired abdominal intercostal hernia: A case report and literature review. Case Rep Sur 2014;2014:456053. doi: 10.1155/2014/456053.  Back to cited text no. 1
    
2.
Bobbio A, Ampollini L, Prinzi G, Sarli L. Endoscopic repair of an abdominal intercostal hernia. Surg Laparosc Endosc Percutan Tech 2008;18:523-5.  Back to cited text no. 2
    
3.
Best IM. Complications of the retroperitoneal approach: Intercostal abdominal hernia. Am Surg 2001;67:635-6.  Back to cited text no. 3
    
4.
Cubukcu A, Gonullu NN, Arslan A, Alponat A. Post-traumatic combined transdiaphragmatic intercostal and lumbar hernia. Int J Clin Pract 2001;55:223-4.  Back to cited text no. 4
    
5.
Nabi G, Seenu V, Misra MC. Intercostodiaphragmatic hernia secondary to a bull gore injury: A delayed detection. Indian J Chest Dis Allied Sci 2002;44:187-9.  Back to cited text no. 5
    
6.
Unlu E, Temizoz O, Cagli B. Acquired spontaneous intercostal abdominal hernia: Case report and a comprehensive review of the world literature. Australa Radiol 2007;51:163-7.  Back to cited text no. 6
    
7.
Saw EC, Yokoyama T, Lee BC, Sargent EN. Intercostal pulmonary hernia. Arch Surg 1976;111:548-51.  Back to cited text no. 7
    
8.
Sharma OP, Duffy B, Wadas J. Transdiaphragmatic intercostal hernia: Review of the world literature and presentation of a case. J Trauma 2001;50:1140-3.  Back to cited text no. 8
    
9.
Abu-Gazala M, Ratnayake A, Abu-Gazala S, Bala M. An enigma of spontaneous combined transdiaphragmatic, intercostal and abdominal wall hernia. Hernia 2013;17:415-8.  Back to cited text no. 9
    
10.
De Weerd L, Kjaeve J, Gurgia L, Weum S. A large abdominal intercostal hernia in a patient with vascular type Ehlers-Danlos syndrome: A surgical challenge. Hernia 2012;16:117-20.  Back to cited text no. 10
    
11.
Croce EJ, Mehta VA. Intercostal pleuroperitoneal hernia. J Thoracic Cardiovasc Surg 1979;77:856-7.  Back to cited text no. 11
    
12.
Dobradin A, Bello J. Clinicoradiological diagnosis of cough-induced intercostal hernia. J Surg Tech Case Rep 2013;5:106-8.  Back to cited text no. 12
    
13.
Erdas E, Licheri S, Calo PG, Pomata M. Acquired abdominal intercostal hernia: Case report and systematic review of the literature. Hernia 2014;18:607-15.  Back to cited text no. 13
    
14.
Dan D, Ramraj P, Solomon V, Ramnarine M, Kawal T, Bascombe N, et al. Laparoscopic repair of a rare acquired abdominal intercostal hernia. Int J Surg Case Rep 2014;5:1041-3.  Back to cited text no. 14
    
15.
DiBello JN, Moore JH. Sliding myofascial flap of the rectus abdominis muscle for the closure of recurrent ventral hernias. Plast Reconstr Surg 1996;98:464-9.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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