A 23-year-old healthy Greek male, came to the outpatient clinic of our hospital for a routine examination for employment. During the examination, he mentioned that his right chest wall protruded whenever he performed a Valsalva's maneuver (). He said that it happened since he was a child and he had been informed that it was a benign condition. The rest of the clinical examination, pulse oximetry as well as spirometry were normal. His chest radiography revealed that the 8th and 9th ribs on the right departed from each other leaving a gap (). This configuration could explain the transient lung herniation that happened whenever the intrathoracic pressure was increased (e.g. during cough, Valsalva's maneuver etc).\nAs the patient was asymptomatic, no further intervention was considered.
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.