Skip to main content
Log in

Abdominal wall bulging after thoracic surgery, an underdiagnosed wound complication

  • Review
  • Published:
Hernia Aims and scope Submit manuscript

Abstract

Background

Complications after thoracic surgery have well been established, pain being the most prominent. Intercostal nerves are mixed type nerves combining motor and sensory functions. This notion is not consistent with the incidence of PTPS compared to the incidence of muscle paresis or paralysis. We would hypothesize that abdominal wall paresis or paralysis is underdiagnosed.

Methods

In our hospital, three patients developed abdominal wall paralysis after thoracic surgery and consequent nerve damage. Their cases are discussed, and a review of the literature was conducted concerning (intercostal) nerve damage on a cellular level, the anatomy of the intercostal nerve, prevention of intercostal nerve damage and surgical techniques.

Results

A cellular cascade known as Wallerian degeneration and regeneration determine whether a damaged nerve can function again. The recovery of the nerve is highly dependent on the correct function of activated Schwann cells and macrophages and is related to the amount of damage that has taken place. The anatomy of the intercostal nerve makes it susceptible to injury. Retractor placement during open thoracic surgery has shown to effect compression injury and induced mechanical deformation and damage. Given the known factors of pathophysiology and anatomy, a number of preventive measures have been tested to reduce intercostal nerve damage. Several techniques have been proposed, but the most used technique, the video-assisted thoracic surgery, has been the most effective in reducing nerve damage.

Conclusion

Abdominal wall paralysis is an underdiagnosed complication after thoracic surgery. The amount of stress on the intercostal nerves could be reduced with less invasive techniques such as the VATS technique.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Rogers ML, Duffy JP (2000) Surgical aspects of chronic post-thoracotomy pain. Eur J Cardiothorac Surg 18:711–716

    Article  PubMed  CAS  Google Scholar 

  2. Miyazaki T, Sakai T, Tsuchiya T, Yamasaki N, Tagawa T, Mine M, Shibata Y, Nagayasu T (2010) Assessment and follow-up of intercostal nerve damage after video-assisted thoracic surgery. Eur J Cardiothorac Surg 39:1033–1039

    Google Scholar 

  3. Harraf F, Ward K, Man W, Rafferty G, Mills K, Polkey M, Moxham J, Kalra L (2008) Transcranial magnetic stimulation study of expiratory muscle weakness in acute ischemic stroke. Neurology 71:2000–2007

    Article  PubMed  CAS  Google Scholar 

  4. Wax MK, Rosenthal EL, Takaguchi R, Cohen JI, Andersen PE, Futran N (2002) Pulmonary atelectasis after reconstruction with a rectus abdominis free tissue transfer. Arch Otolaryngol Head Neck Surg 128:249–252

    PubMed  Google Scholar 

  5. Villamizar NR, Darrabie MD, Burfeind WR, Petersen RP, Onaitis MW, Toloza E, Harpole DH, D’Amico TA (2009) Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J Thorac Cardiovasc Surg 138:419–425

    Article  PubMed  Google Scholar 

  6. Kwan MK, Wall EJ, Massie J, Garfin SR (1992) Strain, stress and stretch of peripheral nerve. Rabbit experiments in vitro and in vivo. Acta Orthop Scand 63:267–272

    Article  PubMed  CAS  Google Scholar 

  7. Schultz GS, Sibbald RG, Falanga V, Ayello EA, Dowsett C, Harding K, Romanelli M, Stacey MC, Teot L, Vanscheidt W (2003) Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 11(Suppl 1):S1–S28

    Article  PubMed  Google Scholar 

  8. Burnett MG, Zager EL (2004) Pathophysiology of peripheral nerve injury: a brief review. Neurosurg Focus 16:E1

    Article  PubMed  Google Scholar 

  9. Gaudet AD, Popovich PG, Ramer MS (2011) Wallerian degeneration: gaining perspective on inflammatory events after peripheral nerve injury. J Neuroinflamm 8:110

    Article  Google Scholar 

  10. Sulaiman OA, Gordon T (2000) Effects of short- and long-term Schwann cell denervation on peripheral nerve regeneration, myelination, and size. Glia 32:234–246

    Article  PubMed  CAS  Google Scholar 

  11. Rogers ML, Henderson L, Mahajan RP, Duffy JP (2002) Preliminary findings in the neurophysiological assessment of intercostal nerve injury during thoracotomy. Eur J Cardiothorac Surg 21:298–301

    Article  PubMed  CAS  Google Scholar 

  12. Patila T, Sihvo EI, Rasanen JV, Ramstad R, Harjula A, Salo JA (2009) Paralysis of the upper rectus abdominis muscle after video-assisted or open thoracic surgery: an underdiagnosed complication? Ann Thorac Surg 88:1335–1337

    Article  PubMed  Google Scholar 

  13. Gray H, Goss CM (1973) Anatomy of the human body. Lea & Febiger, Philadelphia

    Google Scholar 

  14. Hardy PA (1988) Anatomical variation in the position of the proximal intercostal nerve. Br J Anaesth 61:338–339

    Article  PubMed  CAS  Google Scholar 

  15. Benedetti F, Vighetti S, Ricco C, Amanzio M, Bergamasco L, Casadio C, Cianci R, Giobbe R, Oliaro A, Bergamasco B, Maggi G (1998) Neurophysiologic assessment of nerve impairment in posterolateral and muscle-sparing thoracotomy. J Thorac Cardiovasc Surg 115:841–847

    Article  PubMed  CAS  Google Scholar 

  16. Rogers ML, Duffy JP (2000) Surgical aspects of chronic post-thoracotomy pain. Eur J Cardiothorac Surg 18:711–716

    Google Scholar 

  17. Cerfolio RJ, Bryant AS, Patel B, Bartolucci AA (2005) Intercostal muscle flap reduces the pain of thoracotomy: a prospective randomized trial. J Thorac Cardiovasc Surg 130:987–993

    Article  PubMed  Google Scholar 

  18. Cerfolio RJ, Bryant AS, Maniscalco LM (2008) A nondivided intercostal muscle flap further reduces pain of thoracotomy: a prospective randomized trial. Ann Thorac Surg 85: 1901–1906, discussion 1906–1907

  19. Cerfolio RJ, Price TN, Bryant AS, Sale Bass C, Bartolucci AA (2003) Intracostal sutures decrease the pain of thoracotomy. Ann Thorac Surg 76: 407–411, discussion 411–402

    Google Scholar 

  20. Allama AM (2010) Intercostal muscle flap for decreasing pain after thoracotomy: a prospective randomized trial. Ann Thorac Surg 89:195–199

    Article  PubMed  Google Scholar 

  21. Wu N, Yan S, Wang X, Lv C, Wang J, Zheng Q, Feng Y, Yang Y (2010) A prospective, single-blind randomised study on the effect of intercostal nerve protection on early post-thoracotomy pain relief. Eur J Cardiothorac Surg 37:840–845

    Article  PubMed  Google Scholar 

  22. Nomori H, Horio H, Suemasu K (1999) Anterior limited thoracotomy with intrathoracic illumination for lung cancer: its advantages over anteroaxillary and posterolateral thoracotomy. Chest 115:874–880

    Article  PubMed  CAS  Google Scholar 

  23. McKenna RJ Jr, Houck W, Fuller CB (2006) Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 81: 421–425, discussion 425–426

    Google Scholar 

  24. Furrer M, Rechsteiner R, Eigenmann V, Signer C, Althaus U, Ris HB (1997) Thoracotomy and thoracoscopy: postoperative pulmonary function, pain and chest wall complaints. Eur J Cardiothorac Surg 12:82–87

    Article  PubMed  CAS  Google Scholar 

  25. Kirby TJ, Mack MJ, Landreneau RJ, Rice TW (1995) Lobectomy–video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. J Thorac Cardiovasc Surg 109: 997–1001, discussion 1001–1002

    Google Scholar 

  26. Landreneau RJ, Mack MJ, Hazelrigg SR, Naunheim K, Dowling RD, Ritter P, Magee MJ, Nunchuck S, Keenan RJ, Ferson PF (1994) Prevalence of chronic pain after pulmonary resection by thoracotomy or video-assisted thoracic surgery. J Thorac Cardiovasc Surg 107: 1079–1085, discussion 1085–1076

    Google Scholar 

  27. Wildgaard K, Ravn J, Nikolajsen L, Jakobsen E, Jensen TS, Kehlet H (2011) Consequences of persistent pain after lung cancer surgery: a nationwide questionnaire study. Acta Anaesthesiol Scand 55:60–68

    Article  PubMed  CAS  Google Scholar 

  28. Sedrakyan A, van der Meulen J, Lewsey J, Treasure T (2004) Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised clinical trials. BMJ 329:1008

    Article  PubMed  Google Scholar 

  29. Demmy TL, Nwogu C (2008) Is video-assisted thoracic surgery lobectomy better? Quality of life considerations. Ann Thorac Surg 85:S719–S728

    Article  PubMed  Google Scholar 

  30. Boffa DJ, Allen MS, Grab JD, Gaissert HA, Harpole DH, Wright CD (2008) Data from the Society of Thoracic Surgeons General Thoracic Surgery database: the surgical management of primary lung tumors. J Thorac Cardiovasc Surg 135:247–254

    Article  PubMed  Google Scholar 

  31. Paiva JM, Wright GM (2004) Hand-assisted thoracoscopic surgery causes less postoperative pain than limited thoracotomy after cessation of epidural analgesia. Heart Lung Circ 13:374–378

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We state that no grants, financial support and technical or other assistance were used, granted or gathered to write and complete this article.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to L. Timmermans.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Timmermans, L., Klitsie, P.J., Maat, A.P.W.M. et al. Abdominal wall bulging after thoracic surgery, an underdiagnosed wound complication. Hernia 17, 89–94 (2013). https://doi.org/10.1007/s10029-012-0971-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10029-012-0971-9

Keywords

Navigation