title: An enigma of spontaneous combined transdiaphragmatic, intercostal and abdominal wall hernia.
abstract: BACKGROUND
  Cough can be associated with many complications.
  
  
  METHODS
  We present a 59-year-old male patient with a very rare combination of a cough-related stress fracture of the ninth rib and herniation through the diaphragm and abdominal wall to the subcutaneous tissue of the chest wall. We suggest thoracotomy through the affected intercostal defect as a surgical approach. The diaphragm, chest wall and abdominal tears were repaired separately, and the abdominal wall was reinforced with mesh. Technical aspects were discussed.
  
  
  CONCLUSIONS
  Though each individual injury is well documented in the literature, this is a rare combination of defects, requiring early recognition to provide repair before incarceration and further enlargement of the defects occur.
authors.affiliation: Department of General Surgery, Hadassah-Hebrew University Medical Center, PO Box 12000, 91120 Jerusalem, Israel.
authors.forename: M
authors.initials: M
authors.lastname: Abu-Gazala
authors.forename: A
authors.initials: A
authors.lastname: Ratnayake
authors.forename: S
authors.initials: S
authors.lastname: Abu-Gazala
authors.forename: M
authors.initials: M
authors.lastname: Bala
mesh_terms: D003371:Cough / Q000150:complications*; D046449:Hernia, Abdominal / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D006548:Hernia, Diaphragmatic / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012253:Rib Fractures / Q000000981:diagnostic imaging / Q000209:etiology; D014057:Tomography, X-Ray Computed