Synthetic mesh placement - modality of choice in spontaneous intercostal pleural herniation: a case report

Hernia is defined as protrusion of a viscus or its part from the wall covering it and in some rare cases due to increased intercostal space there is spontaneous herniation of pleura and lung also known as extrathoracic lung hernia. A 48 year gentleman was admitted in our centre for chest wall swelling which has developed spontaneously 1 year back, painless, with cough impulse, further investigations like chest x-ray revealed nothing , subsequently CT thorax showed intercostal pleural hernia. He underwent surgery which diagnosed it as a case of intercostal pleural hernia having defect between 8th and 9th rib. Subsequently primary repair of defect was done with placement of monofilament mesh over it and then approximation of intercostal space was done with monofilament suture placed over 8th and 9th ribs. Post operatively patient had no complications and no recurrence of hernia. Spontaneous pleural herniation is a usually caused by coughing, heavy weight lifting, weakness of thoracic muscles by smoking, obesity etc. Ideal management is to treat the aetiology along with repair of the defect to prevent recurrence. In the present case the hernia developed after a bout of cough due to increased intercostal space between 8th and 9th ribs and also due to obesity leading to weak musculature. Intercostal pleural hernia repair can be achieved by primary repair of defect but it is advisable to use synthetic materials such as knitted monofilament polypropylene (Marlex) mesh to provide addition support to prevent recurrence.

Uniportal Video-Assisted Thoracoscopic Resection and Lobectomy for Infants With Pulmonary Sequestration: Case Series and Initial Experience

Background: The present study aimed to evaluate the safety and feasibility of uniportal video-assisted thoracoscopic surgery (U-VATS) for infants with pulmonary sequestration (PS).Methods: From January 2019 to July 2020, 19 infants with PS were admitted to a provincial hospital in the Fujian Province of China. A 1.5-cm utility port was created in the fifth intercostal space at the anterior axillary line. A rigid 30° 5-mm optic thoracoscope was used for vision, and two or three instruments were utilized through the port. Surgical options include standard lobectomy, wedge resection, and resection of the extralobar sequestration. Only one intercostal space was entered, and a chest tube was inserted through the same skin incision if necessary.Results: The procedure was successful in all patients with an average operation duration of 58.3 ± 31.5 min. The length of post-operative hospital stay was 5.4 ± 1.5 days, and no post-operative deaths or serious complications were observed. The mean post-operative drainage volume was 164.6 ± 45.9 mL, and the mean post-operative thoracic tube indwelling duration was 5.5 ± 1.0 days. No intraoperative conversion, surgical mortality, or major complications were identified among the patients.Conclusion: Our preliminary experience presented a series of U-VATS lobectomy, wedge resection, and resection of the PS for infants with satisfactory perioperative results.

A Case of Multiple Posterior Intercostal Artery Common Trunks in Conjunction with Additional Arterial Variations

Several thoracic vasculature variations were observed in an 81-year-old male cadaver during routine dissection. These included 5 common trunks of posterior intercostal arteries, a descending branch of the right vertebral artery, and atypical neurovascular relationships within intercostal spaces. On the right side, two common trunks of posterior intercostal arteries were observed supplying the 4th-7th intercostal spaces and 9th-11th intercostal spaces, respectively. There was also a small accessary branch supplying the 9th intercostal space. The first three posterior intercostal spaces on the right were supplied by a descending branch of the vertebral artery. On the left side, three common trunks of posterior intercostal arteries were encountered, supplying intercostal spaces 3-5, 6-7, and 11 plus the subcostal space. An atypical neurovascular relationship was observed in the right 6th intercostal space, as well as the left 2nd, 3rd, and 6th intercostal spaces. This is the first case report that presents 5 common trunks of posterior intercostal arteries, as well as common trunks in conjunction with other arterial variation in the posterior thoracic wall. These variations carry a high level of clinical significance and may be helpful in guiding decision-making related to surgical procedures related to the posterior thoracic cavity and spine.

Optimising endotracheal length in adult cats: a retrospective CT study

Objectives The aim of this study was to determine the maximal endotracheal insertion length by measuring the larynx to carina (L–C) distance by means of CT. An additional objective was to establish certain anatomical landmarks to optimise the process of endotracheal intubation (ETI). Methods Head, neck and thoracic CT images from adult cats at a single referral hospital between 2013 and 2020 were retrospectively evaluated. After standardising and identifying key markers (larynx, carina and first rib) the L–C, larynx to first rib (L–1R) and first rib to carina (1R–C) distances were measured. Results Forty-five adult cats were enrolled in the study, from which a total of nine different breeds were identified. The L–C distance was 14.3 ± 1.1 cm. This was longer in male (14.7 ± 1.1 cm) than in female cats (13.5 ± 0.7 cm). The first rib (1R) was 8.8 ± 0.7 cm from the larynx and the mean 1R–C distance was 5.4 ± 0.7 cm. The carina was found within the fifth intercostal space in 93.3% (n = 42) of the cats. Conclusions and relevance The process of ETI in adult cats may be guided by using the L–C and L–1R distance for a maximal and optimal endotracheal tube introduction, respectively. In addition, the maximal insertion length may be guided by estimating the position of the carina parallel to the fifth intercostal space.

Complex Regional Pain Syndrome with Aortic Distress after Thoracic Endovascular Aortic Repair and False Lumen Exclusion with “Candy Plug” Technique

A 41-year-old male presented for pain treated with oxycodone. A zone-2 thoracic endovascular aortic repair with distal PETTICOAT (provisional extension to induce complete attachment) for complicated Type-IIIb aortic dissection was performed 18 months before. Repeated hospitalizations did not show any issues to justify the recurrent pain. The aortic nature of the pain was suspected considering the plug as a pain trigger. Through a left thoracoabdominal incision in the eighth intercostal space, the candy plug was removed. Pain diminished after thoracoabdominal surgery steadily.

PSX-A-2 Late-Breaking: Acute Endotoxinemia May Increase Intercostal Temporary Mechanical Nociception in Wethers

Systemic inflammation induced by lipopolysaccharide (LPS; endotoxin) is associated with generalized hyperalgesia in humans and some animal models. However, the effects of endotoxin-induced inflammation on pain threshold in livestock, such as sheep, is unknown. Eight wethers [~1 year of age; 61.3 ± 0.5 kg BW] were administered saline (2 mL; n = 4) or endotoxin (2 mL; 400 ng of LPS / kg BW; n = 4) intravenously. A handheld algometric unit was used to administer temporary mechanical nociception (TMN) before (Day -2) and after (Day 1) treatment administration by the same person three times at two locations on the right thorax (intercostal spaces 6 and 9). Two-way ANOVA was completed in SAS v9.4 (Cary, NC). There were effects of day (P < 0.001) and location (P < 0.0001) on TMN, such that the force needed to induce TMN on Day -2 (2.04 +/- 0.15 kgF) was less than on Day 1 (2.93 +/- 0.15 kgF) and the force needed to induce TMN at intercostal space 6 (1.81 +/- 0.15 kgF) was less than at intercostal space 9 (3.15 +/- 0.15 kgF). While there was no effect of treatment (P = 0.96), or interaction of treatment and location (P = 0.19), day and location (P = 0.25), or treatment and day and location (P = 0.49), there was a tendency for an interaction of treatment and day (P = 0.06), such that TMN was not different on Day 1 (2.73 +/- 0.30 kgF) and Day -2 (2.24 +/- 0.30 kgF) for animals receiving saline but was greater on Day 1 (3.12 +/- 0.30 kgF) than Day -2 (1.83 +/- 0.30 kgF) for animals receiving LPS. While systemic inflammation is associated with reduced pain threshold in some models, acute LPS-induced inflammation may increase intercostal TMN in castrated sheep.

The Art of the Clinician

Background: The promotion of clinical abilities could represent a significant factor leading the clinicians to in making the correct diagnosis in a timely matter. Case: Our patient is a 42-year-old African male with a history of Hypertension, ESRD on hemodialysis via right-sided Permcath (PC), Mastoidectomy & Right ear surgery due to trauma in childhood, AV Fistula (Needed intervention 4 times) in left upper extremity, admitted due to witnessed seizures in the setting of hypertensive emergency. The patient denied family history and toxic habits. While the patient was at the emergency room, CT head revealed stable curvilinear hyper-attenuation thought to be a thrombosed developmental vein more likely than small subarachnoid hemorrhage. He was loaded with levetiracetam, received Ativan 1mg IV and HD done as per Nephrology. The patient was transferred to the floor he was not in acute distress and was asymptomatic, the cardiovascular (CV) examination showed regular pulse, normal S1, S2, S4+ appreciated with 2/4 diastolic murmur at second right intercostal space (ICS); 2/6 pansystolic murmur at third right intercostal space left parasternal border (LPSB) radiated to the right parasternal border (RPSB) and right mid-clavicular line (MCL); 3/6 systolic murmur at 5LICS MCL radiated to the posterior axillar line (PAL). Point of maximal impulse (PMI) displaced to mid axillar line (MAL). Parasternal heave present; the neurological exam was preserved. Endocarditis was suspected and echocardiogram was expedited, it showed severe aortic regurgitation, 1.60cm x 1.68cm mass in the tip of the catheter in the right atrium, possible vegetation in the tricuspid valve with mild regurgitation, moderate mitral valve regurgitation. Later, staphylococcus epidermidis was identified in blood cultures twice, as well as the culture from the PC. The transesophageal echocardiogram found 2.41 X 0.62 cm mass appears to be a fibrin sheath, possibly remnant of a prior catheter, small perforation in the non-coronary cusp likely in the setting of healed endocarditis. Infectious disease onboard for antibiotic management. Conclusion: The art of the clinician goes beyond the available technology; it could prevent the loss of critical time as well as unnecessary studies, guiding a better assessment and treatment of our patients and potentially improving their outcomes.

VASCULARIZATION OF THE HEART IN THE AMERICAN MINK

The heart of the American mink is oval in shape, it receives blood supply from the coronal right (d=2 mm) and left arteries (d=1 mm) coming from the ascending part of the aortic arch. The cranial border of the heart is located at the level of 6-7 ribs, and its tip is directed to the left, lies in the region of 8-10 intercostal space. By the nature of the branching of the coronary arteries, the heart of the mink has a left-ventricular type of vascularization, since the left coronary artery feeds most of the organ with blood.

Constant painful point in diseases of the liver and biliary tract. Sabatini (after ref. F. Chir., 1926, no. 1)

A constant painful point in diseases of the liver and biliary tract lies, according to Sabatini (according to ref. F. Chir., 1926, No. 1), in the X or XI intercostal space of the right side between the paravertebral and scapular lines, corresponding to the "lower point of the liver". Specified point, by authorv. has an important diagnostic value, especially in subacute cholecystitis.