Eur J Cardiothorac Surg 2008;33:774-776. doi:10.1016/j.ejcts.2008.01.027
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Lung herniation: a rare complication in minimally invasive cardiothoracic surgery
Kalliopi Athanassiadi*,
Erik Bagaev,
Andre Simon,
Axel Haverich
Department of Cardiac, Thoracic, Transplantation & Vascular Surgery, Hanover Medical School, Hanover, Germany
Received 1 October 2007;
received in revised form 23 December 2007;
accepted 16 January 2008.
* Corresponding author. Address: Konstantinoupoleosstr. 34A Holargos, 15562 Athens, Greece. Tel.: +30 210 6510388; fax: +30 210 6547695. (Email: kallatha{at}otenet.gr).
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Abstract
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Objective: Lung herniation, defined as a protrusion of the lung parenchyma with pleural membranes through a defect of the thoracic wall, is a rare entity. As minimally invasive cardiac procedures evolve, different complications may be evident such as lung herniation. A retrospective review of all patients submitted to minimally invasive cardiac or transplant surgery through anterior mini-thoracotomy at our department revealed 16 patients with lung herniation and this experience is analyzed. Materials and methods: From 1996 through 2007, 12 male (75%) and 4 female ranging in age between 23 and 77 years submitted prior either to minimally invasive cardiac or transplant surgery were admitted at our department for a lung hernia. The location was right in eight cases, left in six, and in two cases the herniation was bilateral. The majority of our patients were symptomatic. Twelve of them (75%) complained of pain. The bulge was present regardless of straining. Diagnosis was confirmed by chest X-ray and tomographic scan in all of them. The surgical procedure included identification of the hernial sac and reconstruction of the defect. A variety of materials were used for chest wall reconstruction such as Vicryl and Goretex mesh. Results: There was no perioperative mortality or morbidity. Patients were discharged within 5–7 days postoperatively and in a follow up of 3 months to 8 years no recurrence was observed. Conclusions: (1) Since the thoracic cage has inherent weakness anteriorly near the sternum, attention is needed when the anterior approach is used. (2) Hernias with persistent pain and entrapped lung usually need reconstruction with a patch in order to avoid late complications such as recurrent pulmonary infections and hemoptysis due to strangulation.
Key Words: Lung herniation • Minimally invasive cardiac surgery • Anterior thoracotomy
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1. Introduction
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Lung herniation, defined as a protrusion of the lung parenchyma with pleural membranes through a defect of the thoracic wall, is a rare entity [1,2]. As minimally invasive cardiothoracic procedures evolve, different complications may be evident such as lung herniation.
A retrospective single institution review of all patients submitted to minimally invasive cardiac or transplant surgery through anterior mini-thoracotomy revealed 16 patients with lung herniation who required operations because of the complaints and potential complications. The authors analyzed the sequence and treatment.
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2. Materials and methods
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From 1996 through 2007, 12 males (75%) and 4 females ranging in age between 23 and 77 years submitted prior either to minimally invasive cardiac surgery or to double lung transplantation through a minimal access were admitted at our department for a lung hernia. All congenital hernias were excluded. The length of the anterior mini-thoracotomy ranged from 5 to 8 cm in the different procedures and the location was right in eight cases, left in six, and in two cases the herniation was bilateral. The majority of our patients were symptomatic. Twelve of them (75%) complained with chest wall pain after coughing or sneezing, one had hemoptysis, while another presented recurrent infections.
Physical examination revealed a well-demarcated deformity either in the left or right parasternal region at admission. The bulge was present regardless of straining in all cases and the chest wall defect was easily palpated.
The diagnosis was confirmed by chest X-ray. A right-sided pleural effusion was seen only in one case. Chest tomographic scan showed that a large portion of the lung had herniated through the parasternal defect in the chest wall in all of them and defined the extent of the hernia (Fig. 1
).
All patients underwent right, left or bilateral anterior thoracotomy according to the location of the hernia, followed by resection of the scar of the previous incision. No cartilage or rib excision had taken place in the previous operation. The surgical procedure included identification of the hernial sac and the defect so that the lung was freed from adhesions and pulled into the pleural cavity (Fig. 2
). There had been no need of atypical resection of the herniated lung in our cases. The type of reconstruction depended on the size of the defect and the requirement of skeletal support and soft tissue coverage. In eight cases a Vicryl patch was used, while in two a Goretex patch was placed.
The patch was usually placed deep into the bony thorax and fixed to the rib margins medially and laterally with interrupted sutures (Fig. 3
). No suture wires were used. In three cases a partial decortication was needed. Wound closure included separate layer closures for the pectoralis muscles, deep dermal, and subcuticular layers with running absorbable sutures. Chest drains were placed through a separate stab incision.
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3. Results
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There was no perioperative mortality or morbidity. The majority of patients were immediately extubated in the operating room and led to the ward. They recovered successfully and treated with intensive physiotherapy and systemic analgesics. Patients were discharged within 5–7 days postoperatively. In a follow up of 3 months to 8 years no recurrence was observed.
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4. Comments
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Pulmonary hernias may be congenital (rib or intercostal hypoplasia) 18%, acquired-traumatic 52% and acquired-pathologic or spontaneous 30% [3,4]. They are also classified according to their location as cervical, thoracic, abdominal or thoracoabdominal and according to their cause, spontaneous, traumatic or postthoracotomy ones [5]. Spontaneous lung hernias usually develop as a consequence of a sudden increase of intrathoracic pressure during coughing, sneezing, singing, blowing into a musical instrument or heavy lifting resulting in rib or cartilage fracture [6–8]. The mechanism of acquired lung hernias involves intercostal muscle weakness in combination with situations that increase intrathoracic pressure such as coughing and strenuous lifting. Predisposing factors include both environmental and operative trauma, chronic obstructive pulmonary disease, inflammatory or neoplastic processes and chronic steroid use [1,9].
It is well known that the lateral side of the chest is protected by the following muscles, the intercostal ones, the serratus and partially by the latissimus dorsi [1]. However, the thoracic cage has inherent weakness anteriorly near the sternum, medial to the costochondral junction, and posteriorly, near the vertebral bodies, where there is a single layer of intercostal muscles [1,7].
Iatrogenic postoperative lung hernias are commonly reported anteriorly after less extensive surgical procedures, such as thoracoscopy [10] or minimally invasive cardiac surgery [11–13]. The surgical approach of choice in less extensive procedures is the anterior ‘mini’ thoracotomy because it provides both a safe and effective alternative to extracorporeal circulation and to long and painful incisions. Additionally, it offers not only improved cosmesis and lower overall hospital costs, but also shorter length of stay [11].
In these cases of ‘mini’ anterior thoracotomy, other factors that may contribute include fracture or avulsion of the costal cartilages from the sternum resulting in chest wall instability and possible lung herniation [8,11], which was not the case in our series. The authors implicated as risk factors the extent of the operative trauma due to less ‘meticulous closure’ of the mini invasions as suggested by Weissberg and Refaely [8], intensive cauterization of the intercostal muscles or insufficient dissection, and previous steroid use in cases of transplantation.
It is usually not very difficult to diagnose the disease with the knowledge of the patient's history and the specific clinical symptoms and physical examination [7,8,13]. The patient may present with a well-circumscribed bulge increasing in size by expiration and decreasing by inspiration or may be evident during coughing or Valsalva maneuver [4,14].
Diagnosis is usually made by chest radiography using also oblique views and confirmed by chest-computed tomography that provides valuable information regarding the thoracic wall and pleural space and better defines the dimensions of the hernia [8,14,15]. Prevention is still the best method in order to avoid a lung hernia. The authors suggest that the anterior thoracotomy wound closure should include separate layer closures for the intercostal and pectoralis muscles and additionally deep dermal and subcuticular layers with running absorbable sutures with respect to every tissue. In our opinion, intercostal sutures did not prove to be effective.
Controversy still exists concerning the role of surgical repair, since intercostal hernias do not pose a serious threat unless incarceration [9] and strangulation with resultant hemoptysis and pain occur [1,8,11]. Both surgical and conservative management are recommended, but lung herniation is unlikely to recover spontaneously [16]. It is generally accepted that chest wall defects under the scapula and cases occurring in the supraclavicular location usually require no treatment [8]. The authors agree with Brock and Heitmiller [7] that surgery is indicated for all anterior hernias, even if asymptomatic, to avoid extension of the hernia into the abdominal wall resulting in a thoracoabdominal hernia with a higher morbidity and complexity in repairing it. In the present series, the majority of patients agreed to minimally invasive surgery because of the cosmesis they had been offered and considered the hernia also cosmetically unacceptable.
There are different methods repairing the defect. Jacka and Luison [17] placed wire sutures in addition to an intrathoracic polytetrafluoroethylene patch. Some authors suggested approximation of ribs with monofilament sutures [6–8,11]. Approximation of ribs and restoration of costal margin continuity, unfortunately, are only possible in cases of traumatic hernias that are recognized early. Munnell [18] recommended the use of autologous tissues whenever possible. A variety of absorbable and non-absorbable materials were used with a great success for chest wall reconstruction such as Vicryl, PTFE, Dacron, Marlex and Goretex mesh, especially, where local tissues were of poor quality. In our series, both absorbable and non-absorbable patches were used depending on the surgeon's personal preference. Also thoracoscopic repair of a traumatic hernia is mentioned in the literature [19], but the authors found no indication in cases of reoperation. There was no recurrence in the follow-up period and all patients of this series recovered uneventfully.
In conclusion, the authors would like to stress the following points:
- (1) Since the thoracic cage has inherent weakness anteriorly near the sternum, where there is a single layer of intercostal muscles, attention is needed when the anterior approach is used.
- (2) Hernias with persistent pain and entrapped lung need surgical intervention in order to avoid serious complications such as recurrent pulmonary infections and hemoptysis due to strangulation.
- (3) The use of a prosthetic mesh to close the defect is suggested because of favorable late results.
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Footnotes
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Presented at the 21st Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007.
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Top
Abstract
1. Introduction
