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J Thorac Cardiovasc Surg 2006;132:189-190
© 2006 The American Association for Thoracic Surgery
Brief Communication |
a Cardiothoracic Surgery Unit, Clinica Pineta Grande Castelvolturno (CE), Naples, Italy
b Cardiothoracic Surgery Unit, University Federico II, Naples, Italy
Received for publication February 11, 2006; accepted for publication March 15, 2006. * Address for reprints: Francesco Petteruti, MD, via Lauria 38, 81100 Caserta, Italy. (Email: tea41273{at}libero.it).
Pulmonary hernia is a rare occurrence and may be congenital or acquired, the latter usually being a consequence of thoracic trauma. We report an unusual case of large lateral pulmonary hernia through a chest wall defect in a 70-year-old man involved in a motorcycle accident.
Clinical Summary
A 70-year-old obese man was involved in a high-speed motorcycle accident. Initial evaluation at the scene revealed a Glasgow Coma score of 14, left shoulder luxation, cranial trauma with left hemophthalmos, and multiple rib fractures. His blood pressure was 110/65 mm Hg, and his heart rate was 105 heart beats/min. At admission to our hospital, the patient had severe chest pain and dyspnea. Physical examination revealed a large subcutaneous emphysema involving the chest, neck, and left superior arm. He was in severe respiratory acidosis. Radiography examination revealed a left humerus fracture, a left pneumothorax, multiple rib fractures, a large left-sided effusion, and a huge subcutaneous emphysema. A total-body computed tomography (CT) scan revealed a left orbital fracture, a left pneumothorax, multiple rib fractures, a left hemothorax, and a large lateral lung hernia protruding through a chest wall defect between the sixth and seventh ribs with contralateral pulmonary contusion (Figure 1).
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Lung hernia, protrusion of pulmonary parenchyma with pleural membranes through a defect of the thoracic wall, is a rare entity. The cause is acquired in approximately 80% of cases and of traumatic origin, and this may not become apparent for several weeks to years after the trauma. Sixty-five per cent of lung hernias have a thoracic location.
1
The thoracic cage has inherent weakness anteriorly, near the sternum, and posteriorly, near the vertebral bodies, where there is a single layer of intercostal muscle. The anterior part of the chest wall is involved in the majority of cases because, presumably, it lacks the muscular support supplied posteriorly by the trapezius, latissimus dorsi, and rhomboideus muscles.
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Symptoms are usually minimal, and sometimes the patient may be asymptomatic. Chest radiography is helpful in establishing the diagnosis even if subcutaneous posttraumatic emphysema and chest wall hematoma may confuse the clinical picture.
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CT scan is useful because it defines the dimensions of the lung hernia and provides valuable information on the thoracic cage and pleural spaces.
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Small pulmonary hernia can be treated conservatively by thoracic strapping, even if primary suture and fixation of adjacent ribs may lead to an early recovery. Larger hernias, with persistent pain and/or entrapped lung, require surgical intervention and may require the use of muscle flaps
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or prosthetic mesh to close the defect.
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This case was unusual because the lung hernia was located on the lateral side of the chest, which is usually protected by 2 muscles, the intercostal and serratus, and because it was missed on the plain chest radiography. The entrapment of lung parenchyma on fractured ribs, as in our patient, is unusual,
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and we completely freed the lung without any pulmonary resection but by suturing the torn parenchyma to prevent air leaks. The use of a large Prolene mesh stabilized the surgical correction.
Conclusion
CT scan is mandatory for an early and complete diagnosis, and prompt surgical management without lung resection. The use of a prosthetic mesh can give excellent immediate and long-term results.
References
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