Acquired Spontaneous Intercostal Hernia

Case
Report
ACQUIRED SPONTANEOUS INTERCOSTAL HERNIA
ZAFARULLAH KHAN
Department of Surgery, Bolan Medical College, Quetta
ABSTRACT
A case of acquired spontaneous intercostal hernia is being presented. The aetiology, clinical features, radiological
findings and management are discussed.
KEY WORDS: Hernia, Intercostal Hernia, Diaphragm, Mesh Repair
INTRODUCTION
Intercostal hernias are rare 1 . They are caused mainly
by trauma and cough, resulting in weakening of intercostal
muscles, detachment of the diaphragm and possibly
a rib fracture 1,2 . The patient usually presents with
a soft lump, which increases on coughing and straining.
Diagnosis is confirmed with chest X-ray, ultrasonography
and CT scan 3,4 . Treatment requires reduction of
the hernial contents and repair of intercostal and diaphragmatic
defects, possibly with prosthetic mesh reinforcement
5,6 .
wide clearly palpable defect between these ribs having
sharply defined borders (Fig.1b). Bowel sounds were
audible over the bulge. A clinical diagnosis of intercostal
hernia was made. A chest x-ray and an ultrasound
of the defect were inconclusive.
Fig.1. Bulge of the Intercostal Hernia (a),
with surface marking (b)
CASE REPORT
A 50 years old farmer presented with six months history
of a spontaneously appearing and gradually increasing
painless lump on the left side of his chest. It increased
on coughing, straining at defecation and while working
in the field but decreased on lying on the right side. He
was a chronic smoker and had a long-standing cough
that had increased over the past one year. There was no
history of trauma.
On examination, there was an oval bulge lying transversely
between the 11th and 12th ribs on the left side
of his chest, behind the posterior axillary line, having
a positive cough impulse (Fig.1a). There was a 6cms
Correspondence:
Dr. Zafarullah Khan, Senior Registrar Surgery,
Res: 168-I, Block-5, Satellite Town, Quetta.
Phones: 081-2828841, 0333-7810516.
E-mail: zafarkhanbabar@hotmail.com
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Acquired Spontaneous Intercostal Hernia
Exploration was planned and an incision made over the
defect in its long axis extending through the subcutaneous
tissue. The muscle fibres over the hernial sac were
found attenuated. These fibres were retracted and the
hernial sac was dissected free from the sharp edges of
the intercostal defect. There was no fracture of the ribs.
The sac was opened and found to contain splenic flexure
and adherent omentum. The diaphragm was found torn
away from its costal attachment and had retracted creating
a defect, through which splenic flexure and omentum
had entered the pleural cavity and bulged posteriorily
through the weakened intercostal muscles into the subcutaneous
tissue. The omentum and the splenic flexure
were reduced. The diaphragmatic defect was closed
with horizontal mattress sutures of polypropylene. A
chest tube was placed and the pleura closed. Approximation
of ribs was not required. The intercostal defect
was covered with a 6x11cms size polypropylene mesh
and the wound was closed in layers. The patient made
an uneventful recovery and was all right one year after
surgery.
DISCUSSION
Intercostal hernia is a rare occurrence 1 . It can be congenital
or acquired 7,8 . The latter can occur spontaneously
due to local weakness of chest wall or increased intrathoracic
pressure due to excessive coughing 1,5-7 . More
commonly, it occurs following trauma, surgery or chronic
pulmonary pathology.
Trauma can be penetrating or blunt, resulting in fracture
of ribs 3,9-15 . It can also occur as apart of the Seat-belt
syndrome 16 . Reported surgical causes of the intercostal
hernia include lumbar incision for the kidney, open lung
biopsy, tube thoracostomy, rib resection, and harvesting
of internal mammary artery 4,17-19 . Pathological conditions
causing intercostal hernia include chronic cough
due to chronic obstructive pulmonary disease, asthma,
pulmonary hemosiderosis, pulmonary tuberculosis and
caries of the ribs, empyema necessitans and chest wall
abscess 1,6,18,20-22 . Miscellaneous causes include blowing
of musical instruments, straining and weight lifting 22 .
Formation of transdiaphragmatic intercostal hernia
requires a chain of events 1,8,20-22 . Trauma denervates
and weakens the intercostal muscles and the peripheral
diaphragm supplied by these nerves. Rib fractures can
tear intercostal muscles and the adjacent diaphragm.
Chronic violent cough tears the intercostal muscles,
detaches the adjacent insertion of the diaphragm and
may even cause fracture of the overlying rib. Negative
intrathoracic pressure draws the intra-abdominal viscera
into the chest cavity where it eventually comes to
rest in the space created by the torn muscles. Increased
Zafarullah Khan
intra-thoracic pressure causes herniation through weak
areas of the chest wall. These areas occur anteriorily
from costo-chondral junction to the sternum because
of lack of external intercostal muscles and posteriorily
from costal angle to the vertebra because of lack of internal
intercostal muscles. Hernial contents include
lung, liver, small and large intestine and omentum.
These viscera may undergo strangulation and require
resection 1,6,17 .
Intercostal hernia can occur from childhood to late adult
hood 1,7,8,21,23 . It commonly presents as a slowly progressive
swelling but acute herniation following vigorous
coughing has been reported 1,6 . It can be painful as well
as asymptomatic 3 . The contents can be ascertained by
observing the size of the hernia during respiration 1 . The
hernia containing lung has paradoxical movement and
increases on Valsalva manoeuver. An increase in hernia
size with inspiration and a decrease with expiration
occurs when there is diaphragmatic injury with prolapse
of abdominal viscera into the thorax and out
through the chest wall 1,9 . It also increases on straining
and reduces on lying down. Both an anterior and a posterior
hernia may coexist 1 . Differential diagnosis includes
lipoma, empyema necessitans and cold abscess 22 .
On clinical examination the hernia appears as a bulge
between two divergent ribs. It is soft and reducible and
has a positive cough impulse. The defect in the chest
wall is palpable having sharply demarcated borders.
Bowel sounds may be audible over the bulge 1,4 .
Chest X-ray, ultrasonography and CT scan can confirm
the diagnosis of intercostal hernia 1-4,8,11,24 . Chest X-ray
shows divergent ribs at the hernia site with bowel gas
shadow beyond the confines of abdominal cavity. Ultrasonography
detects deficient intercostal muscles. CT
scan correctly identifies the hernia and its contents.
Small hernias may be missed by these investigations.
Helical CT is the investigation of choice for smaller
hernias 6 .
The treatment of intercostal hernia is mainly surgical
but spontaneous regression has been reported 12 . Surgery
is performed by making an incision over the hernia sac,
which can be extended as a thoraco-abdominal incision
if adhesions are present 1 . The sac formed by endothoracic
fascia and parietal pleura is opened. The contents
are reduced and the diaphragmatic defect is closed primarily
or with a prosthetic mesh. Divergent ribs may
require approximation. Raising periosteal flaps from
adjacent ribs can be used to close the chest wall defect 22 .
The intercostal muscles are attenuated and may require
reinforcement by a prosthetic non-absorbable (polypropylene)
mesh 1-4,11,22 .
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