PDF(Pubmed)
Abstract：
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.
摘要：
膈肌肋间疝是一种罕见的损伤，可能与钝性创伤有关。自1946年文献中的第一份文献以来，报告的病例不到50例。我们介绍了一例涉及一名56岁女性的病例，她向我们的创伤中心介绍了由高速T骨车辆碰撞造成的钝性创伤引起的跨the肌肋间疝。在介绍时，她表现出双侧呼吸音；然而，呼吸紧张，胸痛,和缺氧。最初的胸部X光片解释显示存在“左下叶浸润”，随后的计算机断层扫描成像确定了“左腹部中部有一个小的外侧疝”。初步复苏后,她的病情恶化了,表现出呼吸窘迫和变得越来越大碳，需要插管.影像学检查显示，左半膈肌破裂，结肠和胃的胸腔内疝通过第九和第十根肋骨之间的胸壁。因此,在手术室进行了开胸手术，显示两根肋骨之间的大缺陷，肋间肌破坏和肋骨空间移位。肺和网膜通过破裂的肋骨间隙疝出，diaphragm肌破裂向前减弱，尺寸11x6cm。在减少了突出的器官后,放置生物猪网片,并对胸壁疝进行中间复杂闭合.病人后来被拔管,她受伤后康复，没有并发症，并出院。经膈肋间疝的发病率较低,没有规范的手术管理。最近的文献表明，这些损伤应该用网状物管理，而不仅仅是缝合，由于复发率高。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，密切检查计算机断层扫描。
