Abdominal wall pseudohernia following video-assisted thoracoscopic surgery: a case report and literature review
Highlight box
Key findings
• Abdominal wall pseudohernia is a rare but potential complication after thoracic surgery by intercostal approach.
What is known and what is new?
• Herpes zoster or a variety of abdominal surgery may cause abdominal wall pseudohernia.
• We report a rare abdominal wall pseudohernia caused by an intercostal incision, and we conducted a literature review for it caused by thoracic surgery.
What is the implication, and what should change now?
• Our case report findings will be useful for doctors who have no experience with it. We should understand this clinical complication more deeply.
Introduction
Since the early 1990s, video-assisted thoracoscopic surgery (VATS) has been used to diagnose and treat thoracic conditions (1). Moreover, the intercostal approach for thoracic surgery (TS) is safe and reliable, with a low complication rate (2). When a patient presents with an abdominal wall bulge or an abdominal mass, an abdominal wall hernia caused by surgery is suspected to be the underlying cause. However, the results of the physical examination and ancillary test for pseudohernia showing a characteristic absence or decrease in the density of the rectus abdominis muscle are confirmatory. In addition, intercostal nerve (ICN) injury causes denervation of the abdominal wall muscles, resulting in pseudoherniation.
Herein, we report the rare case of abdominal pseudohernia in a 68-year-old Chinese patient who underwent VATS. Additionally, we conducted a literature review of the available diagnostic and treatment strategies for abdominal wall pseudohernia (AWP) caused by TS. The findings of our case report may help clinicians and surgeons to understand this clinical entity better. We present this case in accordance with the CARE reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-24-3/rc).
Case presentation
A 68-year-old man underwent surgery at our hospital for a 13-mm nodule in the right middle lobe. The patient weighed 57 kg and had a body mass index (BMI) of 21.7 kg/m2, with no significant medical, family, or genetic history. We made an incision of about 2 cm in the right posterior axillary line at the 8th intercostal space (ICS) for observation and a 3 cm incision at the 5th ICS in the anterior axillary line for surgery. We performed a wedge resection of the right middle lobe + lymph node sampling of N2, considering the patient’s comorbid coronary artery disease. Chest X-ray findings showed no evidence of pulmonary complications on day 1 postoperatively. Routine histopathological findings confirmed the diagnosis of invasive lung adenocarcinoma [tumor, node, metastasis (TNM) stage: T1bN0M0]. Postoperatively, the patient reported no particular discomfort except for pain at the 8th ICS, where the chest tube was fixed. The surgery was successful, and the patient was discharged on day 4 postoperatively.
The patient complained of an abdominal bulge with distention and pain on day 1 post-discharge. The abdominal ultrasound findings showed no abnormality; however, the patient was re-examined in our outpatient clinic. The abdominal bulge was prominent when standing and reduced when lying down (Figure 1).
![Click on image to zoom](http://cdn.amegroups.cn/journals/vats/files/journals/26/articles/9371/public/9371-PB6-6038-R1.jpg/w300)
A posterior abdominal computed tomography (CT) showed a marked decrease in muscle density and visible atrophy of the right mid-upper rectus abdominis muscle (Figure 2), with no abnormalities reported in the rest of the body or other laboratory tests. We suggested electromyography to clarify the etiology; however, the patient denied it. A surgeon specializing in hernia repair later confirmed the diagnosis of pseudohernia and advised the patient to undergo a conservative treatment using a lap band. The patient was followed up weekly by telephone. Six months later, the patient came to the clinic for a follow-up. There was no change in body weight. Although the sensory function was restored, the size of the abdominal bulge did not change significantly (Figure 3), causing esthetic and psychological distress that did not interfere with the activities of daily living (Figure 4).
![Click on image to zoom](http://cdn.amegroups.cn/journals/vats/files/journals/26/articles/9371/public/9371-PB7-6837-R1.jpg/w300)
![Click on image to zoom](http://cdn.amegroups.cn/journals/vats/files/journals/26/articles/9371/public/9371-PB8-9389-R1.jpg/w300)
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Publication of this case report and accompanying images was waived from patient consent according to the Medical Ethics Committee of The First Affiliated Hospital of Soochow University.
A patient perspective letter is added as supplementary file (Appendix 1). In the attached file, the patient explains how he has experienced his disease, his mindset on the treatments, and the impact of his life.
Discussion
Chiew and Pawa (3) analyzed 34 cases and concluded that abdominal muscle paralysis due to herpes zoster involving the lower thoracic dermatomes leads to AWP. Moreover, AWPs are one of the manifestations of radiculopathy in patients with diabetes (4). AWPs frequently occur after various abdominal surgeries, such as thoracolumbar, aortic, hepatobiliary, and renal surgeries, where the lateral abdominal wall incision is oblique. According to Crouzet et al. (5), of the 100 patients who underwent laparoscopic and open partial nephrectomy, the ICNs were frequently damaged along the incision due to downward separation, resulting in denervation of the muscles lining the abdominal wall. We searched PubMed and Web of Science databases for articles on TS using the following keywords: “abdominal wall pseudohernia”, “abdominal muscle paralysis”, “abdominal muscle atrophy”, or “abdominal bulge”. The literature on TS related to “abdominal wall pseudohernia”, “abdominal muscle paralysis”, “abdominal muscle atrophy”, or “abdominal bulge” was searched. Articles published only in English involving humans were included. Two authors independently reviewed the full text of the selected articles (Table 1). Nine articles on the development of AWPs and other related conditions after TS were retrieved (6-14).
Table 1
Author, year, country | Sex | Age, years | Operation name | Procedure | Incision site | Postoperative symptoms | Follow-up, months | Treatment | Recovery at the final visit |
---|---|---|---|---|---|---|---|---|---|
Our study, 2024, China | M | 68 | Wedge resection of lung | VATS | 5th and 8th | Abdominal bulge | 6 | Conservative treatment | Partial resolution |
Gu, 2022, Korea (6) | M | 61 | Pulmonary nodule biopsy | VATS | 6th, 8th and 9th | Abdominal bulge, pain, and hypoesthesia | 15 | Electrical stimulation therapy | Unimproved |
Wildemeersch, 2021, Belgium (7) | M | 55 | Lobectomy | RA-VATS | 6th and 7th | Abdominal flank bulge and hypoesthesia | 12 | Physical therapy | Unimproved |
Prins, 2021, the Netherlands (8) | M | 69 | Intercostal neurectomy | – | 8th | Abdominal flank bulge and pain | 12 | Physical therapy and wear the abdominal belt | Unimproved |
Lee, 2020, Korea (9) | M | 52 | – | Thoracotomy | 9th | Abdominal flank bulge | – | – | – |
Cho, 2018, Korea (10) | M | 42 | Segmentectomy | VATS | 5th, 7th and 8th | Abdominal flank bulge and hypoesthesia | 24 | – | Unimproved |
Timmermans, 2013, the Netherlands (11) | M | 54 | Plication of the diaphragm | Thoracotomy | 8th | Abdominal wall asymmetry and hypoesthesia | 3 | Conservative treatment | Complete resolution |
M | 54 | Lobectomy | Thoracotomy | 5th and 6th | Abdominal flank bulge and hypoesthesia | 8 | Conservative treatment | Partial resolution | |
M | 64 | Decortication | Thoracotomy | Just above diaphragm | Abdominal flank bulge | 12 | Conservative treatment | Unimproved | |
Antonescu, 2011, Canada (12) | M | 16 | Bullectomy | VATS | 4th, 7th and 5th | Abdominal wall asymmetry | 12 | – | Unimproved |
Pätilä, 2009, Finland (13) | M | 17 | Bullectomy | VATS | 5th and 7th | paralysis of the rectus abdominis muscle | 12 | – | Complete resolution |
M | 51 | Decortication | Thoracotomy | 6th | Abdominal wall asymmetry and pain | 12 | – | Partial resolution | |
Durham-Hall, 2009, Britain (14) | M | 61 | Pleurodesis | VATS | 8th | Abdominal bulge, pain and hypoesthesia | 12 | – | Partial resolution |
We reviewed nine articles related to the abdominal wall pseudohernia after thoracic surgery. M, male; –, unknown; VATS, video-assisted thoracoscopic surgery; RA, robot-assisted.
Anatomy
Since the ICNs or thoracoabdominal nerves are part of the somatic nervous system, they contribute to muscle contraction and return sensory information from the skin and wall pleura. The 7th to 12th ICNs leave the ICS and enter the abdominal wall, innervating the external abdominal obliques, internal abdominal obliques, transversus abdominis, and rectus abdominis. The 11th and 12th ICNs contribute the most to the anterolateral abdominal wall muscle innervations (15-17). In our patient, the incision site was almost always between the 7th and 12th ICN. Although Pätilä et al. (13) reported that the incision site was in the 6th ICS only, this patient’s electromyography showed severe acute deficits of the T7 and T8 motor axons and a minor injury to the T9 ICN. Indeed, as the extent of surgery under the 7th ICS increases, the potential for rectus abdominis muscle injury increases. Although rare, with only a few cases reported worldwide, any surgical intervention in the 7th ICS and the following intercostals may result in the formation of AWP. This reminds us that the intercostal uniportal VATS and subxiphoid VATS surgery can be considered when opting specific surgical procedures because they do not involve the thoracoabdominal nerves. Despite the prolonged operation time, theoretically, subxiphoid VATS surgery is a better approach to avoid AWP (18,19).
Physiological mechanisms
Typically, the degree to which nerve regeneration and recovery are impaired is directly proportional to the severity of the injury (20,21). Intraoperative ICN injuries are usually neurological disuse and tend to be associated with painful sensory abnormalities that recover within a few months. However, if compression is persistent, the neuromuscular disorder becomes permanent as the nerve dies and loses its function (11). In 2 of these 13 cases, complete motor recovery function was reported after some time. Four patients reported partial relief at the final follow-up; significantly improved sensory functions, such as pain; and decreased abnormal skin sensation. Six patients showed no improvement even after >1 year of follow-up and were considered to have permanent nerve injury. One patient was lost to follow-up.
Intraoperative ICN resection at the incision site by open chest or assisted endoscopy, sustained compression damage, or thermal or electrical damage caused by electrosurgical knives may also cause permanent nerve dissection. Precision bipolar electrocoagulation reduces the possibility of permanent nerve damage. Even the ICNs in the intercostal grooves may be included during suturing of the intercostal muscles, which can lead to ischemic neuritis and false hernias.
Nasseh et al. (22) found a correlation between neurological complications and surgery duration, with the highest decrease in hemoglobin values and neurological occurrence after pelvic and renal surgery. Although no correlation exists between BMI and AWPs, its incidence in obese patients may be underestimated clinically (23).
Diagnosis
Our findings are similar to previous case reports in which the patients underwent open, VATS, and robot-assisted VATS (RA-VATS) procedures. However, there are no clear diagnostic criteria. Postoperative pseudohernias are diagnosed clinically. Meanwhile, ultrasound, CT and magnetic resonance imaging (MRI) can rule out a true hernia or underlying organ mass and confirm the extent of abdominal muscle atrophy and hypodensity (3,24). Electromyography can be used if diagnostic doubts remain (25).
Treatment
Evidence is lacking on the management of postoperative AWPs. Abdominal pseudohernias resulting from herpes zoster and diabetes mellitus tend to regress within 6–12 months of treatment (26). Similarly, abdominal pseudohernias caused by nerve damage during surgery or trauma present with mild symptoms that do not affect the activities of daily living. Of course, nonsurgical treatments such as pain relief, physiotherapy with electrical stimulation, and mechanical support with a tight corset or lap band can slow disease progression. Still, more importantly, it depends on the regenerative capacity of the nerve. Theoretically, some of the nerve injuries are reversible; however, the previous results do not appear promising, with only two cases reporting complete resolution of abdominal pseudohernias within 1 year (11,13). Pseudohernias that persist for more than one year suggest permanent, irreversible nerve damage, necessitating surgical intervention (23,24). Surgical repair of pseudohernia through longitudinal plication of the rectus abdominis muscle, transverse plication of the lateral muscles, and reinforcement of the lateral laxity with mesh has been demonstrated previously (27). Alternatively, the lax internal oblique and transversus abdominis muscles were either folded or resected directly, followed by mesh placement (28-30). Lastly, surgical treatment has not been attempted in the cases reported so far.
Conclusions
In conclusion, owing to the lack of general awareness among thoracic surgeons, abdominal wall muscle atrophy after surgery caused by ICN injury remains clinically underestimated. Despite many available techniques designed to minimize ICN injury after surgery, patients should be informed about the possibility of AWP after TS. The surgeons need to recognize that AWP after TS rarely occurs; however, it is a potential and perhaps an underdiagnosed complication of TS. At the same time, it reminds us that the intercostal uniportal VATS and subxiphoid VATS surgery have a unique advantage in this regard. Of course, more articles are needed.
Acknowledgments
We thank Bullet Edits Limited for the linguistic editing and proofreading of the manuscript.
Funding: The study was supported by application of AI target reconstruction technology in accurate screening and diagnosis of pulmonary ground glass nodules in a population with physical examination;
Footnote
Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-24-3/rc
Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-24-3/prf
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-24-3/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Publication of this case report and accompanying images was waived from patient consent according to the Medical Ethics Committee of The First Affiliated Hospital of Soochow University.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Li Q, Li Y, Lin L, et al. Evolution of minimally invasive thoracic surgery. Ann Cardiothorac Surg 2023;12:128-9. [Crossref] [PubMed]
- Kim D, Woo W, Shin JI, et al. The Uncomfortable Truth: Open Thoracotomy versus Minimally Invasive Surgery in Lung Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023;15:2630. [Crossref] [PubMed]
- Chiew YR, Pawa C. Abdominal paresis and pseudo-hernia secondary to herpes zoster infection: A case report and systematic analysis. Heliyon 2023;9:e13578. [Crossref] [PubMed]
- Chakraborty PP, Singha A, Bhattacharjee R, et al. Abdominal pseudohernia: a manifestation of diabetic truncal radiculoneuropathy. BMJ Case Rep 2016;2016:bcr2016215605. [Crossref] [PubMed]
- Crouzet S, Chopra S, Tsai S, et al. Flank muscle volume changes after open and laparoscopic partial nephrectomy. J Endourol 2014;28:1202-7. [Crossref] [PubMed]
- Gu M, Oh MW, Kim HT, et al. Rectus Sheath Hematoma after Contralateral Intercostal Neuropathy as a Complication of Video-Assisted Thoracoscopic Surgery in a Patient with Asthma: A Case Report. J Electrodiagn Neuromuscul Dis. 2022;24:38-41. [Crossref]
- Wildemeersch D, Yogeswaran SK, Vyncke G, et al. Upper rectus abdominis paralysis after robot-assisted thoracic oncology surgery with cryoanalgesia: A rare complication. JTCVS Tech 2021;10:534-7. [Crossref] [PubMed]
- Prins JTH, Wijffels MME. Abdominal flank bulge following intercostal neurectomy for symptomatic rib fracture nonunion. BMJ Case Rep 2021;14:e242041. [Crossref] [PubMed]
- Lee JH, Lee SS. Rectus abdominis muscle atrophy after thoracotomy. Yeungnam Univ J Med 2020;37:133-5. [Crossref] [PubMed]
- Cho HM, Sim HJ, Kim DH, et al. Paralysis of the Rectus Abdominis Muscle after a Video-Assisted Thoracoscopic Surgery. Ann Thorac Cardiovasc Surg 2018;24:40-2. [Crossref] [PubMed]
- Timmermans L, Klitsie PJ, Maat AP, et al. Abdominal wall bulging after thoracic surgery, an underdiagnosed wound complication. Hernia 2013;17:89-94. [Crossref] [PubMed]
- Antonescu I, Baird R. Paralysis of the rectus abdominis muscle after video-assisted thoracoscopic surgery for recurrent spontaneous pneumothorax. J Pediatr Surg 2011;46:2397-400. [Crossref] [PubMed]
- Pätilä T, Sihvo EI, Räsänen JV, et al. Paralysis of the upper rectus abdominis muscle after video-assisted or open thoracic surgery: an underdiagnosed complication? Ann Thorac Surg 2009;88:1335-7. [Crossref] [PubMed]
- Durham-Hall A, Wallis S, Butt I, et al. Abdominal wall pseudohernia following video-assisted thoracoscopy and pleural biopsy. Hernia 2009;13:93-5. [Crossref] [PubMed]
- Ozel L, Marur T, Unal E, et al. Avoiding abdominal flank bulge after lumbotomy incision: cadaveric study and ultrasonographic investigation. Transplant Proc 2012;44:1618-22. [Crossref] [PubMed]
- Mol FMU, Lataster A, Scheltinga M, et al. Anatomy of abdominal anterior cutaneous intercostal nerves with respect to the pathophysiology of anterior cutaneous nerve entrapment syndrome (ACNES): A case study. Translational Research in Anatomy 2017;8-9:6-10. [Crossref]
- Mull AB, Nicoson MC, Moore AM, et al. Rectus Abdominis Motor Nerves as Donor Option for Free Functional Muscle Transfer: A Cadaver Study and Case Series. Hand (N Y) 2018;13:150-5. [Crossref] [PubMed]
- Cai H, Xie D, Al Sawalhi S, et al. Subxiphoid versus intercostal uniportal video-assisted thoracoscopic surgery for bilateral lung resections: a single-institution experience. Eur J Cardiothorac Surg 2020;57:343-9. [PubMed]
- Yang X, Wang L, Zhang C, et al. The Feasibility and Advantages of Subxiphoid Uniportal Video-Assisted Thoracoscopic Surgery in Pulmonary Lobectomy. World J Surg 2019;43:1841-9. [Crossref] [PubMed]
- Burnett MG, Zager EL. Pathophysiology of peripheral nerve injury: a brief review. Neurosurg Focus 2004;16:E1. [Crossref] [PubMed]
- Sonawane K, Dixit H, Thota N, et al. "Knowing It Before Blocking It," the ABCD of the Peripheral Nerves: Part B (Nerve Injury Types, Mechanisms, and Pathogenesis). Cureus 2023;15:e43143. [Crossref] [PubMed]
- Nasseh H, Pourreza F, Saberi A, et al. Focal neuropathies following percutaneous nephrolithotomy (PCNL)--preliminary study. Ger Med Sci 2013;11:Doc07. [PubMed]
- Zhou DJ, Carlson MA. Incidence, etiology, management, and outcomes of flank hernia: review of published data. Hernia 2018;22:353-61. [Crossref] [PubMed]
- Sharobaro VI, Ivanov YV, Sharobaro VI, et al. Abdominal pseudohernia: diagnosis and treatment. Khirurgiia (Mosk) 2021;72-80. [Crossref] [PubMed]
- Tirelli LL, Luna PC, Larralde M. Postherpetic abdominal pseudohernia. Presentation of a clinical case and literature review. Int J Dermatol 2019;58:497-9. [Crossref] [PubMed]
- Yeap E, Hodgkins B, Suhardja TS. Abdominal Pseudohernia Secondary to Herpes Zoster: a Systematic Review. Indian J Surg 2022; [Crossref]
- Hoffman RS, Smink DS, Noone RB, et al. Surgical repair of the abdominal bulge: correction of a complication of the flank incision for retroperitoneal surgery. J Am Coll Surg 2004;199:830-5. [Crossref] [PubMed]
- Kaiwa Y, Maida K, Sekiguchi S. Laparoscopic decision-making concerning the repair area for traumatic abdominal wall pseudohernia: A case report. Asian J Endosc Surg 2020;13:234-7. [Crossref] [PubMed]
- Pineda DM, Rosato EL, Moore JH Jr. Flank bulge following retroperitoneal incisions: a myofascial flap repair that relieves pain and cosmetic Sequelae. Plast Reconstr Surg 2013;132:181e-3e. [Crossref] [PubMed]
- Purnell CA, Park E, Turin SY, et al. Postoperative Flank Defects, Hernias, and Bulges: A Reliable Method for Repair. Plast Reconstr Surg 2016;137:994-1001. [Crossref] [PubMed]
Cite this article as: Shen S, He Z, Li G, Jia X, Lu Z, Shi Y, Pu J, Huang H. Abdominal wall pseudohernia following video-assisted thoracoscopic surgery: a case report and literature review. Video-assist Thorac Surg 2024;9:34.