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S

Chest Wall Hernias Michael C. Smith

Kings County Hospital

October 23, 2014

Case Presentation

64 year old male presents to clinic with

bulging in right anterior chest wall for

roughly one year associated which varies

with respiration, causing pain.

History

S PMH: HTN, HLD, CAD, CHF, DM, OSA, COPD

S PSH: Right VATS for Thymoma

S All: NKDA

S Meds: Amlodipine, Losartan, ASA, Isosorbide Dinitrate,

Coreg, Crestor, Spironolactone, Lasix

S Social: 20 pack-year Smoker (Quit 1998)

Physical Exam

S Vital Signs normal

S Multiple scars in right chest consistent with surgical

history

S Soft bulge in right anterior chest best appreciated with

Valsalva Maneuver

Imaging

Imaging

Operation

SRepair of Chest Wall Hernia with

Gore-Tex Mesh

SOR Time 1:45

S EBL 25 cc

S Fluid 1200 cc

Operation

2nd

Rib Lung

4th Rib

Operation

Operation

Operation

Operation

Postoperative Course

S Extubated in OR

S Chest XR performed in PACU – no pneumothorax

S Discharged home POD #0

S Seen in clinic on POD #8, asymptomatic

Questions?

S

Chest Wall Hernias Michael C. Smith

Kings County Hospital

October 23, 2014

SCORE

History

S First described in 1499 by Roland

History

S American Civil War: 3 cases

S South African Civil War: 1 case

S World War II: 11 cases

Classification

Morel-Lavelle, 1845

S Location:

S Cervical

S Thoracic

S Diaphragmatic

S Etiology:

S Congenital

S Acquired

Diagnosis

S History

S Bulging Mass

S Increases with Coughing/Valsalva

S History of trauma, surgery, or repeated coughing

S Symptoms variable

S Physical

S Soft mass with crepitus

S Varies with breathing/Valsalva

Differential Diagnosis

SNeoplasms

SAbscess

SSubcutaneous Emphysema

Imaging

Imaging

Imaging

Imaging

Operative Techniques

Operative Techniques

Operative Techniques

Operative Techniques

Operative Techniques

Types of Mesh

Types of Mesh

Biomaterials

Biomaterials

Biomaterials

Biomaterials

Soft Tissue Flaps

Muscle Artery Use

Latissimus Dorsi Thoracodorsal Anterior/Lateral

Pectoralis Major Thoracoacromial Anterior/Midline

Serratus Anterior Lateral Thoracic Lateral

Rectus Abdominus Superior Epigastric Anterior/Midline

Omentum Gastroepiploic Midline

Questions?

References

Acute Innovations. (2012). BioBridge Resorbable Chest Wall Stabilization Plate [Brochure]. Hillsboro, OR: Author.

Coates, J. B., Berry, F. B., McFetridge, E. M., & Heaton, L. D. (1963). Thoracic surgery. Washington, D.C.: Office of the Surgeon General,

Dept. of the Army.

Detorakis, E. E., & Androulidakis, E. (2014). Intercostal Lung Herniation - The Role of Imaging. Journal of Radiology Case Reports, 8(4), 16-24.

doi: 10.3941/jrcr.v8i4.1606

Kaiser, L. R., Kron, I. L., & Spray, T. L. (2007). Mastery of cardiothoracic surgery. Philadelphia: Lippincott, Williams & Wilkins.

Lord, F. T. (1915). Diseases of the bronchi, lungs, and pleura. Philadelphia: Lea & Febiger.

Macedo, A. C., Kay, F. U., Terra, R. M., Campos, J. R., Aranha, A. G., & Funari, M. B. (2013). Transdiaphragmatic intercostal hernia:

Imaging aspects in three cases. Jornal Brasileiro De Pneumologia, 39(4), 513-517. doi: 10.1590/S1806-37132013000400016

Marlow, S., Campbell, T., Davis, A., & Patel, H. R. (2013). Emergency ultrasound in the diagnosis of traumatic extrathoracic lung herniation.

The American Journal of Emergency Medicine, 31(3), 633.e1-633.e2. doi: 10.1016/j.ajem.2012.09.030

Miller, D. L., Force, S. D., Pickens, A., Fernandez, F. G., Luu, T., & Mansour, K. A. (2013). Chest Wall Reconstruction Using Biomaterials.

The Annals of Thoracic Surgery, 95(3), 1050-1056. doi: 10.1016/j.athoracsur.2012.11.024

Munnell, E. R. (1968). Herniation of the Lung. The Annals of Thoracic Surgery, 5(3), 204-212. doi: 10.1016/S0003-4975(10)66333-3

Reardon, M. J., Fabré, J., Reardon, P. R., & Baldwin, J. C. (1998). Video-Assisted Repair of a Traumatic Intercostal Pulmonary Hernia. The

Annals of Thoracic Surgery, 65(4), 1155-1157. doi: 10.1016/S0003-4975(98)00035-6

Shields, T. W. (2005). General thoracic surgery. Philadelphia: Lippincott Williams & Wilkins.

Zardo, P., Zhang, R., Freermann, S., & Fischer, S. (2014). Properties of Novel Composite Meshes in Chest Wall Reconstruction: A

Comparative Animal Study. Annals of Thoracic Medicine, 9(3), 158-161. doi: 10.4103/1817-1737.134071