Ho Joshua, Cheng Abigail W, Dadon Noam, Chestovich Paul J
Kirk Kerkorian School of Medicine at UNLV, Department of General Surgery, 625 Shadow Ln, Las Vegas, NV 89106, United States of America.
Trauma Case Rep. 2024 Apr 3;51:101016. doi: 10.1016/j.tcr.2024.101016. eCollection 2024 Jun.
Transdiaphragmatic intercostal herniation is a rare injury that can be associated with blunt trauma. Since its first documentation within the literature in 1946, there have been less than 50 cases reported. We present a case involving a 56-year old female who presented to our Trauma Center with transdiaphragmatic intercostal herniation caused by blunt trauma from a high-velocity T-bone vehicular collision. Upon presentation, she exhibited bilateral breath sounds; however, with labored breathing, chest pain, and hypoxia. The initial chest radiograph interpretation indicated the presence of "left lower lobe infiltrates", and subsequent computed tomography imaging identified "a small lateral hernia along the left mid abdomen". After initial resuscitation, her condition deteriorated, exhibiting respiratory distress and becoming increasingly hypercarbic, requiring intubation. Review of the imaging showed disruption of the left hemidiaphragm with intrathoracic herniation of colon and stomach through the thoracic wall between the ninth and tenth ribs. Consequently, a thoracotomy was performed in the operating room, revealing a large defect between the two ribs with disruption of the intercostal muscles and inferior displacement of rib space. Lung and omentum had herniated through the disrupted rib space and the diaphragmatic rupture was attenuated anteriorly, measuring 11x6cm. After reduction of the herniated organs, a biologic porcine mesh was placed and an intermediate complex closure of the thoracic wall hernia was performed. The patient was later extubated, recovered from her injuries with no complications and was discharged. With the low incidence of transdiaphragmatic intercostal herniation, there is no standardized surgical management. Recent literature suggests that these injuries should be managed with mesh, rather than sutures only, due to high rates of recurrence. Furthermore, diaphragmatic injuries may suffer a delay in diagnosis. Therefore, a high index of suspicion should be maintained in patients with respiratory distress following a blunt trauma, with close review of computed tomography.
经膈肋间疝是一种罕见的损伤，可能与钝性创伤有关。自1946年首次在文献中记载以来，报告的病例不到50例。我们报告一例56岁女性患者，因高速T型汽车碰撞导致钝性创伤，出现经膈肋间疝，前来我院创伤中心就诊。就诊时，她双侧呼吸音存在；然而，伴有呼吸费力、胸痛和低氧血症。最初的胸部X线片解读显示“左下叶浸润”，随后的计算机断层扫描成像发现“左中腹部外侧有一个小疝”。经过初步复苏，她的病情恶化，出现呼吸窘迫，二氧化碳潴留日益加重，需要插管。影像学检查显示左半膈肌破裂，结肠和胃通过第九和第十肋之间的胸壁疝入胸腔。因此，在手术室进行了开胸手术，发现两根肋骨之间有一个大的缺损，肋间肌断裂，肋间隙向下移位。肺和网膜通过破裂的肋间隙疝出，膈肌破裂在前部变窄，大小为11×6cm。将疝出的器官复位后，放置了生物猪网片，并对胸壁疝进行了中间复杂缝合。患者随后拔管，受伤后康复，无并发症，出院。由于经膈肋间疝的发病率较低，目前尚无标准化的手术治疗方法。最近的文献表明，由于复发率高，这些损伤应采用网片治疗而不是仅用缝线。此外，膈肌损伤可能会延迟诊断。因此，对于钝性创伤后出现呼吸窘迫的患者，应保持高度怀疑，并仔细复查计算机断层扫描。
