Abdominal wall pseudohernia following video-assisted thoracoscopic surgery: a case report and literature review
Case Report

Abdominal wall pseudohernia following video-assisted thoracoscopic surgery: a case report and literature review

Shiyu Shen1, Ziyi He1, Guangbin Li1, Xinyu Jia1, Zihao Lu1, Yichao Shi1, Jianhong Pu2, Haitao Huang1

1Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China; 2Health Management Center, The First Affiliated Hospital of Soochow University, Suzhou, China

Contributions: (I) Conception and design: S Shen, H Huang; (II) Administrative support: J Pu, H Huang; (III) Provision of study materials or patients: Z He, G Li; (IV) Collection and assembly of data: S Shen, Y Shi; (V) Data analysis and interpretation: X Jia, Z Lu; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Jianhong Pu, MD. Health Management Center, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, China. Email: pujianhong1970@sina.cn; Haitao Huang, PhD. Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215005, China. Email: huanghaitao@suda.edu.cn.

Background: Abdominal wall pseudohernia (AWP) has become a rare but potential complication of thoracic surgery (TS) performed using the intercostal approach. Additionally, intercostal nerve (ICN) injury causes abdominal wall muscle atrophy. Moreover, it is challenging for surgeons to diagnose this clinical entity, considering the lack of existing data on similar cases.

Case Description: A 68-year-old Chinese man presented with an abdominal bulge and abnormal skin sensation after thoracoscopic surgery. Computed tomography (CT) findings showed decreased muscle density of the abdominal wall, which confirmed the diagnosis of an AWP. The patient underwent abdominal band compression therapy for 6 months. Although the sensory function was restored, no significant improvement was observed in the abdominal bulge. Fortunately, activities of daily living remained unaffected.

Conclusions: Our case highlights a rare complication, the AWP, that occurs after TS. We conducted a literature review of AWP caused by TS. The denervation of abdominal wall muscles caused by ICN injury is considered the underlying mechanism. Imaging studies and electromyography are essential diagnostic modalities for AWP. The treatment options include both nonsurgical and surgical approaches. Our case report findings may help surgeons better understand this clinical complication because we focused on the anatomy, physiological mechanisms, diagnosis, and treatment for AWP.

Keywords: Pseudohernia; video-assisted thoracoscopic surgery (VATS); intercostal nerve injury (ICN injury); abdominal bulge; case report

Received: 13 January 2024; Accepted: 29 March 2024; Published online: 03 June 2024.

doi: 10.21037/vats-24-3

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).

Figure 1 The patient’s first postoperative visit. (A) The patient had a prominent bulge in the abdominal wall while standing and combined with loss of skin sensation. (B) The bulge disappears when the patient lies flat. The arrows emphasize the contrast in abdominal findings.

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).

Figure 2 Postoperative abdominal CT. (A) Abdominal CT showed a significant decrease in the density of the right rectus abdominis muscle. (B) Abdominal CT showed mild atrophy of the adjacent rectus abdominis muscle relative to the left side. CT, computed tomography.
Figure 3 Six months after the surgery. (A) The abdominal bulge had not significantly improved. (B) The bulge still disappears when lying down. The arrows emphasize the contrast in abdominal findings after 6 months.
Figure 4 Timeline of major events. CT, computed tomography.

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

Literature review

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; the Science and Technology Plan of Suzhou, Jiangsu Province (No. SKY2022044) and Nurturing Project of Health Talents in Gusu District (No. GSWS2019027).

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/.

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doi: 10.21037/vats-24-3
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.

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