3D virtual planning and use of botulinum toxin A in prehabilitation of transdiaphragmatic intercostal hernia: a multidisciplinary approach.

Transdiaphragmatic intercostal hernias represent rare injuries resulting most commonly from blunt trauma. When extending into the intercostal and diaphragmatic regions, these hernias pose significant diagnostic and reconstructive challenges. We report the case of a patient with a right thoracoabdominal mass that was identified on a CT scan 4 months after blunt thoracic trauma. Imaging revealed a large right posterior transdiaphragmatic hernia with intercostal extension between the 8th and 9th ribs, avulsion of the internal oblique and transversus abdominis muscles, and costal cartilage disinsertion. The hernia sac contained a small bowel segment, cecum, ascending colon and part of the right liver lobe, with a defect volume of more than 25% of the total abdominal volume. A multidisciplinary surgical management was performed, including prehabilitation with botulinum toxin A and combined abdominal wall and thoracic reconstruction aided by 3D virtual planning.