Acquired abdominal intercostal hernia (AAIH) is a rare disease phenomenon where intra-abdominal contents reach the intercostal space directly from the peritoneal. INDICATIONS The Ventralex The board certified surgeons at the Midwest Hernia Institute specialize in the use of the Kugel patch for inguinal hernia repairs, the Ventralex mesh for umbilical. Mesh removal after hernia repair. As the prophylene mesh is not suiting her. Personal Injury Lawyer Blog & Updates Hernia Patch Lawsuits: Claims reviewed for all Davol ring and dual-mesh hernia patches A Case Report and Literature Review. The Stanley Dudrick Department of Surgery, Saint Mary. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Acquired abdominal intercostal hernia (AAIH) is a rare disease phenomenon where intra- abdominal contents reach the intercostal space directly from the peritoneal cavity through an acquired defect in the abdominal wall musculature and fascia. We discuss a case of a 5. She gave a history of a stab wound to the area 1. A CT scan revealed a fat containing intercostal hernia with no diaphragmatic defect. An open operative approach with a hernia patch was used to repair this hernia. These hernias are difficult to diagnose, so a high clinical suspicion and thorough history and physical exam are important. This review discusses pathogenesis, clinical presentation, complications, and appropriate treatment strategies of AAIH. Introduction. Intercostal hernias are rare phenomena caused by a disruption or weakness in the thoracoabdominal wall musculature resulting in herniation of fascia layers between adjacent ribs. Historically, these hernias have been characterized by their contents. They may only be an empty sac comprised solely of fascia elements . Intercostal hernias have also been categorized on the basis of their etiology, with majority resulting from trauma (blunt injury . Rarely, they occur spontaneously or with congenital syndromes . Recently intercostal hernias have been divided into two types: those with a diaphragmatic defect and those without a diaphragmatic defect . Many authors, however, do not distinguish between the two . We, however, believe that the term . When viscera herniate through a diaphragmatic defect, the term . Since the two types may have overlapping but distinct clinical presentations, pose unique therapeutic challenges, and may require different surgical strategies, they should remain as separate pathologic entities. Case Report. This is a fifty- one- year- old obese and hypertensive female who presented with a painful mass at her left upper abdominal quadrant and lower chest for about 2. In addition to pain, she complained of nausea but denied vomiting or changes in bowel habits. She reported a history of stab injury to her left chest about fifteen years ago. She has had this mass for several years but had remained asymptomatic. Workup by her primary care in the past including a computed tomography (CT) scan concluded that the mass was most likely a lipoma. On physical examination, the patient was noted to be obese with a tender, firm, and nonreducible mass at the left upper quadrant and lower chest measuring about 8 . A new CT scan was obtained showing an abdominal intercostal hernia between the 1. The hernia content was comprised of omentum, and no evidence of a diaphragmatic defect was seen on CT (Figures 1 and 2). Figure 1: Axial CT view: intercostal hernia between 1. Figure 2: Coronal CT view: intercostal hernia between 1. The patient was taken to the operative room where she was placed in a right lateral position. Under general anesthesia an incision was made over the hernia along the intercostal space. The hernia sac was identified and dissected clean of the surrounding subcutaneous tissue (Figures 3 and 4). Figure 3: Exposure of the hernia sac. Figure 4: Dissection of the hernia sac of the surrounding subcutaneous tissue. The hernia sac was opened and found to contain omentum, which was reduced back into the peritoneal cavity. The sac was subsequently excised, exposing a clear defect between the tenth rib and eleventh rib (Figure 5). Figure 5: Exposure of defect. A self- expanding polypropylene and e. PTFE hernia patch (VENTRALEX Hernia Patch) (Figure 6) was then used to secure the defect, and the fascia of the intercostal and external oblique was approximated on top of the mesh using interrupted Vicryl stiches (Figure 7). Discussion. Acquired abdominal intercostal hernia (AAIH) is an extremely rare phenomenon having only 1. By definition, AAIH does not involve a defect in the diaphragm, which, if present, is called transdiaphragmatic intercostal hernia (TIH). The diagnosis of the AAIH was confirmed with computed topography (CT) scan and an open intercostal hernia repair with patch was performed. Abdominal intercostal hernias (AIH) are due to weakened or torn muscular layers of the thoracoabdominal wall, which is unable to provide adequate resistance to the outward forces of visceral contents pressing against it during variations in internal pressure . The outer layers of the hernia sac itself in AIH include the transthoracic fascia, transversalis fascia, and peritoneum . One mechanism causing tissue disruption, and accounting for 6. AAIH . Such sudden or chronic increases in pressures may cause microtrauma to the fascia or muscles of thoracoabdominal wall . Rib fractures can complicate the picture of AAIH because, in some instances, the jagged edges of the fractured ribs penetrate abdominal wall tissue, predisposing to a traumatic intercostal herniation. Other rare pathophysiological mechanisms that weaken the chest wall include congenital conditions decreasing tissue strength such as Ehlers- Danlos syndrome . It is likely that a combination of weakened tissues in the event of sudden increases in intra- abdominal pressure results in intercostal hernias or incarceration of previously reducible ones. This may explain why some patients with a distant history of anterior abdominal wall trauma, like in the case presented here, suddenly develop complications after years of being asymptomatic. The time interval between trauma and hospitalization for abdominal intercostal hernia, spontaneous or acquired, is highly variable. Some authors report hospitalization within the same day after trauma . In the present case, the patient was hospitalized 1. While it is not clear what triggered the sudden incarceration of the hernia and the subsequent symptoms in our patient, obesity was a notable risk factor. This case also emphasizes the importance of a thorough history, as this patient. The chest wall is weak anteriorly from the costochondral junction to the sternum, as it lacks the support of the external intercostal muscle. Posteriorly, the internal intercostal muscles are absent from the costal angle to the vertebrae, contributing to another weak point . Interestingly, our patient. Most AAIH are located under the 9th rib without a preference to side, and main symptoms include chest swelling (8. If bowel herniates, symptoms of obstruction may be present, with the most specific sign for this being the presence of bowel sounds in the chest . For this reason, CT is the best diagnostic tool, since it not only provides excellent visualization but also offers a reliable means to establish a preoperative plan to repair the defect . Other complications include a missed diaphragmatic tear or defect, which can predispose patients to recurrent intercostal hernias . Although deaths have not been reported in cases of AAIH, they have been reported in transdiaphragmatic intercostal hernias, mostly occurring as a consequence of hemorrhage from other associated injuries . Rarely, conservative management is warranted in elderly patients with multiple comorbidities who pose a high surgical risk. Conservative management has been reported in some asymptomatic patients . The surgeon must account for many factors about the patient and the injury before deciding on a repair technique. Closure of the defect can be achieved by the direct approach, as in the present case, which consists of a thoracotomy (open intercostal incision) performed along the intercostal space. It can also be done by an indirect approach, which consists of laparoscopy or open abdominal incision (laparotomy) . A combined open (direct) and laparoscopic (indirect) method was also successfully performed . Techniques to repair the defect include primary closure, absorbable and nonabsorbable meshes and patches, and prosthetic mesh reinforced by cable banding . Laparoscopic repair has also been performed in emergent settings where a visceral injury was present or could not be determined preoperatively . Laparoscopy has its advantages, as it enables adequate management of compromised hernia contents, allows treatment of other intraperitoneal injuries, and is minimally invasive. However, its disadvantages make it less favorable than the open intercostal approach in noncomplicated cases . Such disadvantages include a greater level of expertise required, the placement of the mesh intra- abdominally, and a reported increased risk of bowel injury and pain . The application of prosthetic reinforcement is favored in most cases, especially for very large or recurrent defects . For our patient, we opted to use an 8. Some surgeons advocate the application of fibrin glue, instead of sutures or tacks, to anchor the mesh in an attempt to limit postoperative discomfort and mesh migration . They report no hernia recurrence or discomfort at 2- year followup. Although these results are a reassuring alternative to sutures, more controlled studies are needed to determine the short term and long term clinical effectiveness of fibrin glue in AAIH repairs. While Losanoff et al. However, some authors advocate its use under special circumstances: when a displaced rib creates a widened intercostal space, when there is a very large defect, or when the periosteum of the ribs provides a more secure anchoring structure than the tissue around the defect, which in some patients may be weakened by scar tissue, comorbidities, or congenital syndromes that compromise tissue integrity. In the preoperative planning for our patient, we decided that the use of cables was unnecessary, since there was no displaced or fractured rib to create a widened intercostal space; also, we wanted to avoid the risk of chronic pain symptoms in the patient.
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