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Video Presentation - 6
Thoracoscopic repair of a rare pediatric intercostal lung herniation: case report with video presentation
Çiğdem Ulukaya Durakbaşa, Gonca Gerçel, Furkan Ersoy, Arzu Asadzade İşler
Department of Pediatric Surgery, Istanbul Medeniyet University, Faculty of Medicine, Goztepe Prof Dr Suleyman Yalcin City Hospital, Istanbul, Türkiye
Aim: Protrusion of pulmonary parenchyma together with pleura through a thoracic wall defect is rare. We present a case successfully managed through a thoracoscopic approach.
Video method and results: A 13-year-old girl presented with a history of a progressively enlarging, non-tender swelling over the left anterior chest wall, which became prominent with coughing. She was born at 27 weeks of gestation weighing 930 grams and underwent PDA ligation on postnatal day 10. A physical examination revealed a left-sided 3×4 cm thoracal bulge apparent only by coughing and a palpable defect mainly located on the second mid-clavicular intercostal space superior to the previous incision scar. The swelling was a source of significant concern for the patient. Radiology was unremarkable. Based on clinical findings, a diagnosis of intercostal lung herniation was established. A thoracoscopic exploration revealed that the lung tissue was adherent to the thoracal wall at the level of the hernia. Upon releasing it, the fascial defect was detected to include the level of PDA ligation scar as well and measured 9 cm on vertical axis. A composite polypropylene mesh (Covidien, Mansfield, MA) was trimmed accordingly, inserted into the thorax to be placed covering the defect. It was secured to the endothoracic fascia by deploying multiple absorbable tacks (AbsorbaTack™, Covidien, Mansfield, MA) and further fixation was achieved by nonabsorbable 2/0 polyester hand-sewn sutures. The patient was discharged on postoperative day 3 and her 6th month follow up was uneventful.
Conclusion: Lung herniation is the protrusion of the lung beyond the normal boundaries of the thoracic cavity. Although uncommon, prior thoracal surgery is a known causative factor. There is no clear consensus on the management of asymptomatic cases but a potential risk of strangulation of the entrapped lung. Diagnosis is primarily clinical, as imaging findings are frequently inconclusive. Thoracoscopic mesh repair represents a safe and feasible minimally invasive option, associated with low morbidity and excellent outcomes.