|Year : 2019 | Volume
| Issue : 1 | Page : 63-65
Traumatic lung herniation after ATV rollover
Roxanne Kyriakakis1, Geoffrey Lam2, Carrie Valdez2
1 Department of Surgery, Spectrum Health/Michigan State University General Surgery Residency, Grand Rapids, Michigan, USA
2 Department of Surgery, Michigan State University, Grand Rapids, Michigan, USA
|Date of Web Publication||30-Dec-2019|
Department of Surgery, Spectrum Health/Michigan State University General Surgery Residency, Grand Rapids, Michigan
Source of Support: None, Conflict of Interest: None
Traumatic pulmonary hernia is a rare entity that often presents immediately after the trauma but may appear years after the incident. We report a case of a 53-year-old female with polytrauma including a traumatic pulmonary hernia following an all-terrain vehicle (ATV) rollover. Left pulmonary hernia reduction, rib plating, and pectoralis flap were performed. After the surgery, the patient's pain and respiratory status drastically improved, and the patient was able to leave the hospital without any supplemental oxygen requirements. Pulmonary hernia is a rare etiology seen in blunt traumas involving the chest. These often can be associated with rib fractures, pulmonary contusions, and clavicular fractures. There are multiple techniques for surgical repair including using autologous tissues, synthetic materials, and even minimally invasive techniques. Although pulmonary hernia is rare, every trauma and thoracic surgeon should be aware of the etiology of this condition and the options available for surgical repair.
Keywords: Chest wall injury, pneumocele, pulmonary hernia
|How to cite this article:|
Kyriakakis R, Lam G, Valdez C. Traumatic lung herniation after ATV rollover. J Cardiothorac Trauma 2019;4:63-5
| Introduction|| |
Pulmonary hernia or pneumocele is a rare entity discussed fewer than 300 times in the literature and was first described by Roland in 1499. Morel-Lavelle classified pulmonary hernias into two categories: congenital and acquired. Acquired pulmonary hernias can be divided into traumatic or pathologic/spontaneous. Traumatic hernias occur more commonly than spontaneous/pathologic. These types of hernias can be due to penetrating or blunt injuries. They occur anteriorly or posteriorly, medial to the beginning of the costal cartilage where the intercostal muscles exist as a single internal or external layer only, leaving it susceptible to injury.
| Case Report|| |
A 53-year-old morbidly obese female presented to the trauma bay after an ATV rollover as an unrestrained passenger going 30 miles/h. Her injuries included fractures of the right ribs one through eight with multiple bilateral costal cartilage/sternal-rib junction fractures and/or dislocations, fractures of left anterior ribs one through three, right pneumothorax, left pneumothorax, bilateral pulmonary contusions, anterior left lung herniation through the first three ribs [Figure 1], bilateral comminuted clavicle fractures, scalp laceration/hematoma, left radial head fracture, Grade 4 liver laceration, and left forearm laceration. Bilateral chest tubes were placed, and the patient was transferred to the surgical intensive care unit.
|Figure 1: Computed tomography of the chest demonstrating a pulmonary hernia|
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The patient demonstrated acute respiratory insufficiency requiring three liters of oxygen delivered by the nasal cannula. Her symptomatology was complicated by rib fractures, pulmonary contusions, and chest tubes. She required both ketamine infusion and patient-controlled anesthesia for pain control. Her respiratory status worsened, and her pain was not able to be controlled. She was intubated and sedated.
She was taken to the operating room for repair of her left lung hernia. In the operating room, there was evidence of sternocostal separation with multilevel herniation of the anterior left upper lobe without lung parenchymal injury, strangulation, or infarction. A pectoralis advancement flap was created and there was clear sternocostal separation with multilevel herniation of the anterior left upper lobe of the lung. The hernia was reduced. Next, an anterior plate was placed over the left and right second ribs incorporating the distal end of the fractures. The intercostal muscles were then approximated using 2–0 vicryl [Figure 2]. Anesthesia was placed an epidural on postoperative day (POD) 2.
|Figure 2: Postoperative chest X-ray demonstrating open reduction and internal fixation|
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The patient did well postoperatively. She was extubated POD 2. Her pain was better controlled after epidural placement. Bilateral chest tubes were removed on POD 2 and POD 3. Her epidural catheter was removed POD 6, and the patient was pain controlled with oral medications. She was discharged POD 7 to a subacute rehabilitation facility without supplemental oxygen requirements.
| Discussion|| |
Lung hernias are most commonly caused by trauma. They generally arise in the anterior or posterior thoracic cavity where only a single internal or external intercostal muscle is present. Posteriorly, there are supporting muscles including the trapezius, the rhomboids, and serratus anterior, so it is more common to see an anterior pulmonary hernia. In our scenario, the patient experienced a tremendous amount of intrathoracic pressure associated with her trauma.
Identification of these hernias can be determined with a computed tomography scan, which can identify the exact location and dimension of the hernia as well as any other associated injuries. Traumatic pulmonary hernias are often seen with other associated injuries including; pulmonary contusions, rib fractures, and clavicular fractures. The exact percentage of associated injuries is not documented in the literature.
There are different opinions as to the management of pulmonary hernias. These hernias can be treated conservatively with a watch-and-wait methodology or with surgery. Conservative treatment includes compressive pads and corsets. There have been reports of spontaneous regression but the literature supports surgical management if the patient is symptomatic from the hernia or if it grows in size. Small hernias increase the risk of incarceration and should be repaired expediently. These small hernias often have an iatrogenic origin. Video-assisted thoracoscopic surgery has led to an increase in the number of pulmonary hernias due to improperly closed port sites.,
There are multiple different techniques for surgical repair. The use of autologous tissues has been described by Forty and Wells. They describe the use of a fascia lata graft. Synthetic materials such as Dacron, Ivalon, Teflon, or Marlex have also been used when local tissue is poor quality. There is some discussion as to the technical aspects of repair. Pericostal fixation of the adjacent ribs has been used by Weissburg and Refaely for the repair of intercostal hernia without hernia recurrence in four of their patients. Jacka and Luison used a combination method for repair using pericostal wire sutures and placement of a synthetic mesh (polytetrafluoroethylene). Recently, minimally invasive management of traumatic lung hernias has been described. Pérez Castro et al. performed a video-assisted thoracoscopic surgery procedure to reduce the herniated lung and perform a resection of the ischemic lung tissue. They then created a longitudinal incision over the fractured rib and repaired it using a titanium plate. In our case, the lung was able to be reduced. Open reduction and internal fixation of the second ribs were performed, and the ribs were plated, followed by primary repair of the intercostal muscles.
| Conclusion|| |
Traumatic lung hernias are uncommon but should be kept in mind during any trauma causing increased intrathoracic pressures. Surgical treatment is often required, and the type of repair is at the discretion of the operating surgeon. The use of minimally invasive techniques has been described, but there are no data to support its use in trauma.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We would like to thank Alan T. Davis, PhD, for his expertise and assistance in preparing the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]