Spontaneous cough-induced right abdominal intercostal hernia with liver and colon herniation: a case report of eTEP-TAR hernia repair

Abdominal intercostal hernias are rare defects of the thoracoabdominal wall and, in most reported cases, are associated with trauma, rib fractures, previous surgery, or chronic conditions causing repeated increases in intra-abdominal and intrathoracic pressure. Cough-induced variants without direct external trauma and without previous abdominal or abdominal wall surgery are much less common. The optimal repair strategy for large lateral intercostal defects with herniation of the liver and colon also remains unclear, because no standardized reconstruction approach has been established for such cases. We present a 66-year-old woman with class II obesity who developed a large right-sided abdominal intercostal hernia after severe cough during an airplane flight. She denied previous trauma and any history of abdominal or abdominal wall surgery. Computed tomography demonstrated a right mesogastric hernia with a 139×118 mm defect and a 122×133 mm hernia sac containing loops of the colon and the right hepatic lobe. The patient underwent endoscopic totally extraperitoneal posterior component separation hernia repair (eTEP-TAR) with placement of a 30×30 cm macroporous Bard SoftMesh prosthesis in the retromuscular plane. Intraoperatively, a hernia measuring up to 15×22 cm was identified between the right 10th and 11th ribs. During mobilization of the hernia sac, the pleural cavity was opened in the projection of the right pleural sinus, resulting in capnothorax; the defect was closed with a two-layer continuous suture on a hyperventilated lung. No systemic infection developed. On postoperative day 5, with C-reactive protein of 40.6 mg/L and negative procalcitonin, an intramuscular seroma measuring 116×37×60 mm with a volume of 140 mL was detected; culture of the drainage fluid showed no microbial growth. The patient was discharged in satisfactory condition on postoperative day 6. At 12-month clinical follow-up, there were no signs of recurrence, recurrent seroma, or mesh infection. This case suggests that minimally invasive extraperitoneal retromuscular reconstruction may be feasible for selected rare cough-induced abdominal intercostal hernias with liver and colon herniation. However, conclusions from a single case should not be generalized, and the choice of repair should be individualized according to the anatomy of the defect, hernia contents, and surgical expertise.