J. Kuckelman1, M. Lallemand1, M. Martin1, R. Karmy-Jones2, E. Windell2, S. Izenberg2, W. Long2 2Legacy Good Samaritan Medical Center,Trauma,Portland, OR, USA 1Madigan Army Medical Center,General Surgery,Tacoma, WA, USA
Introduction: Traumatic Rib Cage Hernias (TRCH) are an extremely rare but challenging problem in thoracic trauma. The original Morel-Lavelle criteria used only location and etiology for classification. However, this fails to quantify the size of the hernia or associated tissue damage, and does not help guide the optimal repair.
Methods: Retrospective review of all TRCH over a 32 year period. The presenting characteristics, type of repair undertaken, and postoperative courses were evaluated. A new TRCH grading system is proposed that includes size and associated tissue/bone injury, and can guide surgical repair.
Results: We identified 20 patients (16 blunt, 4 penetrating), all of whom underwent operative repair. We grouped injuries into 5 TRCH grades based on the extent of tissue/bone damage, size of hernia, and location. The most commonly herniated organs and tissues were lung (89%), liver (5%), and pericardial fat (5%). The types of operative repair were well clustered by the assigned TRCH grade. Most repairs required prosthetic mesh (74%) and/or mechanical rib plating (84%). A complex tissue flap reconstruction was required in 10% of cases. Operative time, EBL, and length of stay showed good correlation with the proposed TRCH grading system. All patients survived and there were no recurrences identified.
Conclusion: The size and degree of tissue/bone injury has important implications in the optimal surgical management of TRCHs. We propose an expansion of the TRCH classification to include these factors. This system may be useful in operative decision making when dealing with these complex and rare injuries.
