A 20-year-old man with no remarkable past medical history was brought to the emergency department (ED) of a resource-limited hospital by ambulance with bilateral, anterior thoracic stab-wound lacerations ().\nThe patient was awake and responsive with a Glasgow Coma Scale of 15; he had a heart rate of 84 beats per minute, blood pressure of 90/60 millimeters of mercury, 22 breaths per minute, and oxygen saturation of 97% on room air. He complained of bilateral chest pain and shortness of breath. Physical exam primary survey revealed decreased breath sounds on the left, with bilateral large anterior chest wall lacerations. The left chest laceration had lung parenchyma protruding, and it expanded with each inspiration (). There were no other traumatic injuries or active hemorrhage on further primary survey, and secondary survey was unremarkable.\nCloser examination of the wounds showed the right chest wound at the ninth intercostal space (ICS) with no evidence of exposed lung, and the left chest wound also at the ninth ICS but clearly exposing lung parenchyma. Bedside focused assessment with sonography for trauma (FAST) did not demonstrate a pericardial effusion or intra-abdominal free fluid. The standard blood tests for trauma patients were collected in this patient and were unremarkable, including initial hemoglobin of 13.6 grams (g) per deciliter (dL) (reference range: 12.0 – 16.0 g/dL).\nInitial management included fluid resuscitation with one liter of normal saline (NS), analgesia with ketoprofen and tramadol intravenously, and oxygen facemask at six liters per minute. His blood pressure improved, and he did not require blood products or intubation in the ED. The eviscerated lung portion was left in place and covered with saline-saturated sterile towels. A portable radiograph machine was not immediately available, and CT was not performed because of concerns for clinical instability occurring while in CT. Instead the patient was assessed by the trauma team, which recommended immediate surgical intervention.\nThe patient was taken to the operating room (OR), and under general anesthesia the chest was explored using a left anterolateral thoracotomy at the fifth ICS. Injury to the heart, great vessels, and diaphragm was ruled out; surgical exploration revealed only a small amount of hemothorax. The left lung had no signs of laceration, necrosis, or thrombosis. The eviscerated portion of the lung was determined to be the lingula. After confirming the integrity of the vasculature, the lingula of the lung was retrieved back into the left hemithorax, the left hemithorax was irrigated with two liters of NS, and the patient was ventilated by the anesthesia team to assess the anatomic integrity of the parenchyma. Once the lung showed no signs of air leakage during the insufflation test, the NS irrigation and secretions were suctioned, and closure of the left thoracotomy incision was performed. A thoracostomy tube was placed in the left hemithorax and attached to underwater seal drainage. After 48 hours, a chest radiograph was obtained for evaluation of re-expansion of the lung ().\nThe patient was kept under observation for 12 hours in the postoperative care unit and spent the rest of his hospital stay in the general surgery ward, not requiring intermediate or intensive care unit admission. He received tramadol for analgesia, prophylactic antibiotics with ampicillin-sulbactam three grams intravenously every six hours for seven days as an in-patient, and then continued with amoxicillin-clavulanic acid 875/125 milligrams orally every 12 hours for three days upon hospital discharge. He had an uneventful postoperative course, with a fully expanded lung on postoperative radiograph and steady functional and cosmetic improvement at 15- and 30-day follow-up outpatient visits.
A 46-year-old obese man (body mass index: 40.2) was presented to our emergency department with moderate left-sided chest pain that started immediately after heavy lifting 2 days before the examination. The patient had no history of trauma, surgical procedures in his thoracic wall, or COPD. His comorbidities were arterial hypertension, congestive heart failure, and type II diabetes mellitus. At the time of admission, the patient was alert and oriented. His vital signs were as follows: blood pressure – 140/90 mmHg, heart rate – 90 per minute, respiratory rate – 18 per minute, and body temperature – 36.7°C. Physical examination revealed a swelling of the left flank (from mid-thorax to the gluteus) with red-bluish colorization of the skin and tenderness on palpation []. On auscultation, diminished breath sounds on the left were established.\nChest X-ray presented stable intercostal lung herniation – through sixth intercostal space []. Subsequent chest computed tomography (CT) confirmed the stable left intercostal lung herniation. Moreover, hematoma of the left flank, displaced fracture of the seventh left rib, and fluid into the left costophrenic angle with a density of 21 Hounsfield units were found [Figure and ]. The spirometry test was performed with volume of a FEV1 of 2.42 L (64% of predictive) and FEV1/FVC of 72%.\nThe patient was hospitalized and operated on the 2nd day of his hospitalization. Left mid-lateral thoracotomy under general anesthesia with intubation with a double-lumen endotracheal tube was performed. The incisional line was made over the side of the thoracic wall defect (through sixth intercostal space). Exploration of the left hemothorax revealed thoracic wall hematoma, lung herniation through the sixth intercostal space with compressed herniated part of the lung, minimal hemothorax in costophrenic angle (<150 ml), dislocated fracture of the left seventh rib-type “costochondral joint separation,” and laceration of the diaphragm (approximately 4 cm and close to esophageal hiatus), with herniation of a small portion of the great omentum into the pleural cavity.\nBlood from costophrenic angle was sucked out. The herniated part of the great omentum was reponated back into the peritoneal cavity, and the defect of the diaphragm was closed by nonabsorbable interrupted sutures. The pleural cavity was irrigated with sterile saline solution. The thoracic cage was closed with pericostal sutures around the 6th and 7th ribs, after inserting a chest tube drain. Thoracic wall hematoma, along the incisional line, was cleaned, and the soft tissues were irrigated with povidone-iodine 10 % solution.\nThe patient was discharged on the 9th postoperative day in a good condition. Control chest CT 2 years after the operation found no deformation of the thorax or recurrence of the lung herniation.\nWritten informed consent was obtained from the patient for his anonymized information to be published.