Wijerathne Pradeep, Rao Jagan N, Wijffels Mathieu M E, Tamburrini Alessandro, Tenconi Sara, Edwards John Gurney
From the Sheffield Teaching Hospitals NHS Foundation Trust (P.W., J.N.R., S.T., J.G.E.), Sheffield, England; Erasmus Medical Centre (M.M.E.W.), Rotterdam, The Netherlands; and University Hospital of Southampton NHS Foundation Trust (A.T.).
J Trauma Acute Care Surg. 2024 Dec 1;97(6):861-868. doi: 10.1097/TA.0000000000004440. Epub 2024 Oct 15.
Costal margin rupture (CMR) injuries in association with intercostal hernia (IH) are rare and symptomatic and provide a significant surgical challenge. Surgical failure rates up to 60% are reported, and optimal techniques are unclear. We have characterized these injuries and describe the evolution of our surgical management techniques.
Patients characterized by the Sheffield Classification where CMR and IH were both present, either CMR-IH or transdiaphragmatic intercostal hernia (TDIH), were identified prospectively, and injury characteristics, patient management, and follow-up data were recorded. Surgical techniques evolved according to patient outcomes from suture repair without and then with extrathoracic mesh, to three iterations of double-layer mesh repair (DLMR). The third iteration involved DLMR with biologic mesh, titanium buttress plates applied to the ribs adjacent to the IH with intercostal nerve-sparing suture placement. Associated surgical stabilization of rib fractures, or surgical stabilization of nonunited rib fractures, was performed when required, with costal margin plate fixation where possible.
Of 25 patients with CMR-IH and 11 with TDIH, 25 patients underwent surgery, with 6 reoperations in 5 patients. There were 8 suture repairs and 3 extrathoracic mesh repairs: DLMR was performed in 14 patients (3 Mark [Mk] 1, 5 Mk 2, and 6 Mk 3) with 2, 1, and 0 reoperations, respectively. Costal margin stabilization with titanium plates was successful twice at the level of the seventh but failed twice out of three times at the ninth costal cartilage.Reoperation after a failed mesh repair is particularly challenging and may require the placement of titanium buttress plates, surgical stabilization of rib fractures, and the use of stainless steel wire sutures.
Repair of CMR-IH/TDIH is challenging, but experience-based evolution of techniques has led to a durable and reproducible Mk 3 repair.
Therapeutic/Care Management; Level IV.
肋缘破裂（CMR）合并肋间疝（IH）的损伤较为罕见且有症状，给手术带来了重大挑战。据报道手术失败率高达60%，最佳技术尚不清楚。我们已对这些损伤进行了特征描述，并介绍了我们手术管理技术的演变过程。
前瞻性地识别出符合谢菲尔德分类法、同时存在CMR和IH的患者，即CMR-IH或经膈肋间疝（TDIH），并记录损伤特征、患者管理及随访数据。手术技术根据患者预后情况不断演变，从最初的无胸外补片缝合修复，到使用胸外补片缝合修复，再到三次双层补片修复（DLMR）迭代。第三次迭代包括使用生物补片的DLMR、应用钛支撑板于与IH相邻的肋骨并进行保留肋间神经的缝线放置。必要时进行相关肋骨骨折的手术固定，或对不愈合的肋骨骨折进行手术固定，尽可能进行肋缘钢板固定。
25例CMR-IH患者和11例TDIH患者中，25例接受了手术，5例患者进行了6次再次手术。进行了8次缝合修复和3次胸外补片修复：14例患者接受了DLMR（3例Mark [Mk] 1、5例Mk 2和6例Mk 3），分别有2次、1次和0次再次手术。钛板肋缘固定在第七肋水平成功2次，但在第九肋软骨水平3次中有2次失败。补片修复失败后的再次手术极具挑战性，可能需要放置钛支撑板、肋骨骨折的手术固定以及使用不锈钢丝缝线。
CMR-IH/TDIH的修复具有挑战性，但基于经验的技术演变已产生了持久且可重复的Mk 3修复方法。
治疗/护理管理；四级。
