Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, South Yorkshire, UK.
Department of Cardiothoracic Surgery, St Georges Hospital, London, UK.
Eur J Cardiothorac Surg. 2019 Jul 1;56(1):150-158. doi: 10.1093/ejcts/ezz020.
Taxonomy of injuries involving the costal margin is poorly described and surgical management varies. These injuries, though commonly caused by trauma, may also occur spontaneously, in association with coughing or sneezing, and can be severe. Our goal was to describe our experience using sequential segmental analysis of computed tomographic (CT) scans to perform accurate assessment of injuries around the costal margin. We propose a unifying classification for transdiaphragmatic intercostal hernia and other injuries involving the costal margin. We identify the essential components and favoured techniques of surgical repair.
Patients presenting with injuries to the diaphragm or to the costal margin or with chest wall herniation were included in the study. We performed sequential segmental analysis of CT scans, assessing individual injury patterns to the costal margin, diaphragm and intercostal muscles, to create 7 distinct logical categories of injuries. Management was tailored to each category, adapted to the individual case when required. Patients with simple traumatic diaphragmatic rupture were considered separately, to allow an estimation of the relative incidence of injuries to the costal margin compared to those of the diaphragm alone.
We identified 38 patients. Of these, 19 had injuries involving the costal margin and/or intercostal muscles (group 1). Sixteen patients in group 1 underwent surgery, 2 of whom had undergone prior surgery, with 4 requiring a novel double-layer mesh technique. Nineteen patients (group 2) with diaphragmatic rupture alone had a standard repair.
Sequential analysis of CT scans of the costal margin, diaphragm and intercostal muscles defines accurately the categories of injury. We propose a 'Sheffield classification' in order to guide the clinical team to the most appropriate surgical repair. A variety of surgical techniques may be required, including a single- or double-layer mesh reinforcement and plate and screw fixation.
肋缘损伤的分类描述较差，手术治疗方法也各不相同。这些损伤虽然通常是由外伤引起的，但也可能自发发生，与咳嗽或打喷嚏有关，而且可能很严重。我们的目标是描述我们使用连续节段性 CT 扫描分析来对肋缘周围损伤进行准确评估的经验。我们提出了一种统一的分类方法，用于描述膈疝和其他肋缘损伤。我们确定了手术修复的基本组成部分和首选技术。
研究纳入了膈或肋缘或胸壁疝患者。我们对 CT 扫描进行连续节段性分析，评估肋缘、膈和肋间肌的个体损伤模式，创建了 7 个不同的逻辑损伤分类。根据每个类别进行治疗，根据个体情况进行调整。对单纯外伤性膈破裂患者进行了单独评估，以估计肋缘损伤与单纯膈损伤的相对发生率。
我们共纳入 38 例患者。其中 19 例肋缘和/或肋间肌损伤（组 1）。组 1 中有 16 例患者接受了手术，其中 2 例患者曾接受过手术，其中 4 例需要使用新型双层网片技术。19 例单纯膈破裂患者（组 2）接受了标准修复。
对肋缘、膈和肋间肌的 CT 扫描进行连续分析可以准确确定损伤分类。我们提出了一种“谢菲尔德分类”，以指导临床团队选择最合适的手术修复方法。可能需要多种手术技术，包括单层或双层网片加固、钢板和螺钉固定。
