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Paper text:
flank hernias are protrusions of abdominal visceral contents through weakened areas in the lateral abdominal wall .
they are most commonly caused by trauma but can also be caused by previous surgery , after which the hernia would be considered incisional .
flank hernias occur in 0.2% of blunt trauma patients   but are also seen after abdominal and thoracic operations . as a part of this group , lateral intercostal herniation following a surgical procedure has been reported in only six cases in world literature .
we present a rare case of an incisional flank hernia into the 11th and 12th intercostal space with strangulation of the large bowel .
this case illustrates the clinical picture of a patient with emergent strangulated hernia and highlights the critical steps in the management of this catastrophe .
a 79-year - old african american man was brought to the emergency department after being found unresponsive with labored breathing .
he had a past medical history of mechanical mitral valve replacement at age 61 , hypertension , congestive heart failure , prior upper gastrointestinal bleed while on warfarin , stroke at age 74 , and an open right nephrectomy at age 63 for renal cell carcinoma . on admission ,
the patient was noted to be hypotensive with altered mental status and a glasgow coma scale of 12 ( eye : 4 , voice : 3 , motor : 5 ) .
blood and serological examinations showed metabolic acidosis with ph 7.21 , lactate 6.8  mmol / l , base deficit 14.4 , leukocytosis ( white blood cell count 43.9    10  k / mcl ) , supra - therapeutic international normalized ratio ( inr ) 8.9 , elevated aspartate aminotransferase ( ast ) 3517 , and elevated alanine aminotransferase ( alt ) 1503 .
computed tomography ( ct ) scan of the abdomen and pelvis without contrast showed herniation of the right colon through the right 11th and 12th ribs ( fig .
the diagnosis of bowel obstruction versus strangulated bowel was suspected secondary to the clinical picture of abdominal distention , and serology showing metabolic acidosis , leukocytosis , and lactic acidosis .
the patient was admitted to the surgical intensive care unit ( sicu ) for resuscitation and correction of his supra - therapeutic inr prior to surgical intervention . upon exploration of the abdomen ,
the hepatic flexure of the colon was prolapsed through a 2.5  cm defect in his right flank . a right hemi - colectomy followed by ileostomy with mucous fistula
the posterior fascia was then closed over the hernia defect with interrupted polydioxanone ( pds ) suture .
this patient had a complicated postoperative course secondary to multi - organ system failure and sepsis leading to progressive deterioration and death .
a comprehensive search of the pubmed database was done using the search terms  intercostal hernia  ,  incisional hernia  , and  flank hernia  . duplicates and non - human studies
abdominal wall hernias have a prevalence of 1.7% for all ages and 4% for those older than 45 years of age .
incisional hernias result from non - healing or late disruption of the fascial layers of the wound after previous surgical incision into the abdominal wall .
protrusion of abdominal or chest contents through the area of weakened abdominal wall into the intercostal space is a rare possibility .
incisional intercostal flank hernias are most commonly caused by trauma , but have also been reported as spontaneous .
there are only six previously described cases of incisional intercostal flank herniation after a surgical procedure .
contents of the hernia sac in previous reports include small bowel , large bowel , , , , and liver , while our patient had herniation of the right colon .
the herniation was most commonly right sided and was left sided in two cases , .
the indication for surgery was most commonly renal cell carcinoma , but other indications were angiomyolipoma , marsupialization of liver hydatid cyst , and abdominal aortic aneurysm repair .
the location of herniation was most commonly 10th or 11th intercostal space but the 9th intercostal space was the location in one case .
causes of intercostal herniation include penetration of the intercostal muscle , dislocation of the costo - transverse joint , paralysis of the thoracic muscle caused by intercostal nerve injury , injury to the costal cartilage , and excessive abdominal pressure which can be associated with obesity , ascites , and bowel obstruction , .
the diagnosis can be made upon physical examination and ultrasonography . when these results are inconclusive , a definitive diagnosis of flank herniation can be made using ct , .
operative correction is indicated in patients with symptomatic herniation , incarcerated / strangulated herniation , or asymptomatic herniation that directly affects the patient 's quality of life .
once a hernia has become incarcerated , emergent surgical management is necessary to avoid strangulation and small bowel obstruction .
this rate increases to 23.4 per 100,000 for all hernias with an associated mortality rate of 7% for patients over 60 years of age .
the surgeon must pay close attention to the repair of intercostal incisional hernias due to an exceptionally high recurrence rate of 28.6% .
urgent diagnosis and management in the setting of strangulation is paramount given the associated increase in morbidity and mortality .
this patient had a complicated postoperative course secondary to multi - organ system failure and sepsis leading to progressive deterioration and the patient s untimely death .
after an extensive two month long search for relatives of the deceased , we were unable to find any relatives .
highlightsurgent abdominal examination with palpation of the region is necessary in the diagnosis of strangulated hernias but may be misleading so further studies are necessary.serological testing of a patient with a strangulated hernia may show lactic acidosis and leukocytosis.operative management is necessary for strangulated hernias especially in patients with altered mental status and a clinical picture showing decline.intercostal incisional herniation following a previous surgical procedure is a rare entity which should be diagnosed and treated rapidly.this case highlights the clinical picture associated with an emergent strangulated hernia and highlights the critical steps in its management .