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CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 2  |  Page : 97-99

A case report of thoracic pulmonary hernia


Department of General Surgery, Unit III, Dow University of Health Sciences, Civil Hospital, Karachi, Pakistan

Date of Web Publication25-Oct-2016

Correspondence Address:
Fatima Ali Asghar
Flat A6, Bridge Apartment, Frere Town, Near Clifton Bridge, Karachi - 75600
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0521.193015

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  Abstract 

Pulmonary hernia extending into the chest wall is a rarely seen disease, occurring mostly after trauma associated with the fracture of ribs. It can present immediately after the injury or even years later. Symptoms are usually minimal and infrequent. Patient can present to us with a soft reducible bulge on the chest, moving and altering with respiration, coughing and straining, pain dyspnea, and chest infections. The diagnosis is made clinically and radiographically. Conservative management for smaller hernias with no symptoms and surgical interventions for larger, symptomatic hernias posing threats of strangulation or incarceration is indicated. We report a case of a 40-year-old male who had suffered a blunt chest trauma and later presented to us with an acquired traumatic thoracic lung hernia.

Keywords: Hernia, lung, nonpenetrating, thoracic injuries, thoracic wall, wounds


How to cite this article:
Memon AS, Khan NA, Asghar FA. A case report of thoracic pulmonary hernia. Saudi J Health Sci 2016;5:97-9

How to cite this URL:
Memon AS, Khan NA, Asghar FA. A case report of thoracic pulmonary hernia. Saudi J Health Sci [serial online] 2016 [cited 2019 Jun 18];5:97-9. Available from: http://www.saudijhealthsci.org/text.asp?2016/5/2/97/193015


  Introduction Top


Lung hernia refers to the protrusion of lung tissue lined by visceral and parietal pleura, beyond the normal confines of the thoracic cage into the chest wall, mediastinum, or diaphragm. Pulmonary hernias are classified as cervical, intercostal/thoracic, and diaphragmatic. Each can either be congenital or acquired. Acquired hernias are further divided etiologically into spontaneous, traumatic, and pathologic. [1] Most of the cases fall into acquired traumatic category. Clinical presentation can vary among patients. Symptoms, if appear at all, range from merely a chest bulge to chest wall pain, dyspnea, and recurrent infections. We are putting forward a case of thoracic lung hernia after a blunt chest trauma in a middle-aged man.


  Case report Top


A 40-year-old male was admitted through the outpatient department with the complaints of swelling in the upper left side of the chest. He had a history of blunt trauma to the chest by a cartwheel 3½ months before he got admitted. Since then, he noticed a reducible swelling which appeared on forced expiration and coughing. He also suffered from episodes of recurrent chest infections after his injury. There was no history of any pain, hemoptysis, or respiratory distress associated with the swelling.

Local examination revealed a scar mark on the upper left side of the chest and a soft, reducible, nontender bulge from the second to fourth intercostal spaces on the left side, just lateral to the sternum. Crepitus was present. Cough impulse was positive. Valsalva maneuver was performed during which the bulge enlarged. On auscultation, there was normal vesicular breathing with bilaterally equal air entry and no added sounds [Figure 1].
Figure 1: A 40-year-old man with a pulmonary hernia on the upper left side of the chest after a blunt trauma on the chest

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On the chest X-rays (anteroposterior and lateral views), there were nonunited fractures seen in the left second and third ribs. Computed tomographic (CT) scan showed pulmonary herniation beyond the thoracic cavity [Figure 2].
Figure 2: Arrows showing nonunited fractures of the second and third ribs in the chest X-ray of the 40-year-old man

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The patient underwent prolene mesh repair surgery after about 15 days. Under general anesthesia, an incision was given over the defect from the left second to fourth intercostal spaces. Inspection of thoracic cavity showed a sizable portion of the upper lobe in the defect caused by fractured ribs. Hernia was reduced; defect was repaired using a submuscular prolene mesh. The pleura stitched and supported at places with flaps of muscles from the local musculature. The defect in the ribs was approximated with steel wires. Redivac drain was placed in the chest followed by closure of the cavity. The surgery was uneventful, and the patient's complaints did not recur.


  Discussion Top


A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity. Hernias can occur at different sites such as abdomen and brain, but lungs would be the last region to appear in the mind. Roland was the first one to report a case of pulmonary herniation, and Maurer and Blades clearly defined it as "a protrusion of pleura-covered lung outside its normal boundaries through an abnormal opening in the thoracic cage." If the pleura are missing in the herniated portion, it is termed as a lung prolapse. Morel-Lavallee took a step forward in classifying lung hernias both according to location as cervical, thoracic, and diaphragmatic and according to etiology as traumatic or postoperative, spontaneous, and pathological. [2],[3] Spontaneous hernias occur at the weakest area in thoracic wall or due to an abnormally high intrathoracic pressure. Pathological variety, as the name indicates, occurs after abscesses, empyema, emphysema, tuberculosis, or forceful coughing. A pulmonary tissue needs adhesions to remain herniated as otherwise it would get sucked in with respiration. [4] In the presented case, the patient had acquired traumatic lung hernia. His symptoms were not severe, but he was concerned about repeated chest infections and swelling. The diagnosis of such hernias is not problematic. On clinical examination, if a crepitant mass which is present on chest wall moves with respiration and becomes more obvious with forced expiration, then it is likely to be a lung hernia. It can be confirmed by a chest X-ray or a CT scan. [5],[6] Regarding the management, it is acceptable to treat smaller asymptomatic hernias conservatively, as spontaneous regression have been observed in such case, although there lies a controversy in it. However, surgery is indicated in cases of larger, symptomatic hernias associated with recurrent infections and those which have a risk of strangulation as in the reported situation. [7] Open surgical procedure is usually carried out; however, nowadays, video-assisted thoracoscopic surgery is gaining popularity.

For the closure of the defect, the use of autologous tissues such as periosteum, muscles, fascia lata, or synthetic materials such as Dacron, Ivalon, Teflon, Marlex mesh, or polytetrafluoroethylene patch can be used. [8] Studies have shown that prosthetic herniorrhaphy is not associated with an increased risk of postoperative complications. We had used prolene mesh in our patient to repair the defect, and the results were satisfactory.

Although pulmonary hernia is not a grave disease, there is always a small risk of strangulation. The reason behind reporting this case is to increase awareness about an infrequent disease such as lung hernia and its treatment modalities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kao LS. Traumatic lung hernia. In: Jones RK, Nathens A, Stern E, editors. Thoracic Trauma and Critical Care. Berlin: Springer Science and Business Media; 2012. p. 257-9.  Back to cited text no. 1
    
2.
Shields TW. Lung hernias of the chest wall. In: Shields TW, Lo Cicero J, Reed CE, Feins RH, editors. General Thoracic Surgery. USA: Lippincott Williams and Wilkins; 2011. p. 629-31.  Back to cited text no. 2
    
3.
Maurer E, Blades B. Hernia of the lung. J Thorac Surg 1946;15:77-98.  Back to cited text no. 3
    
4.
Wright FW. Radiology of the Chest and Related Conditions. UK: CRC Press; 2001. p. 239-40.  Back to cited text no. 4
    
5.
Tamburro F, Grassi R, Romano S, Del Vecchio W. Acquired spontaneous intercostal hernia of the lung diagnosed on helical CT. AJR Am J Roentgenol 2000;174:876-7.  Back to cited text no. 5
    
6.
Detorakis EE, Androulidakis E. Intercostal lung herniation - The role of imaging. J Radiol 2014;8:16-24.  Back to cited text no. 6
    
7.
François B, Desachy A, Cornu E, Ostyn E, Niquet L, Vignon P. Traumatic pulmonary hernia: Surgical versus conservative management. J Trauma 1998;44:217-9.  Back to cited text no. 7
    
8.
Munnell ER. Herniation of the lung. Ann Thorac Surg 1968;5:204-12.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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