TTIH is rare sequelae of injury. In 1911 Gerster already challenged this concept. He reviewed 10 cases and concluded “that the occurrence of these herniae is not as rare as the few published communications on this subject would lead one to believe” . TTIH are most commonly the result of penetrating injuries [5, 13–15] or high energy and focused blunt strikes [1–13]. More frequently seen on the left side, TTIH may contain omentum, colon, spleen, stomach, and/or small bowel. The diagnosis of TTIH has historically been difficult to make, with delayed diagnosis to up to several years [5, 13]. On initial clinical examination, intercostal hernias have been mistaken for lipomas or hematomas . In these cases, it was not until a CT that the diagnosis of intercostal herniation was confirmed.
We know of no reports in the literature in which a TTIH was associated with liver strangulation. The closest, albeit clearly different, reported cases being a left TTIH due to coughing with infarcted omentum found at elective repair  and a patient with Chilaiditi’s syndrome who required ileocecal resection during repair of a non-traumatic intercostal incisional hernia . Conservative management of TTIH has been reported. Most often the patient presents with pain and increasing lump size and the repair is then considered .
The decision to elect the non-interventional approach despite liver strangulation was dictated by the patient’s comorbidities, severe lung contusion, non-operatively managed abdominal solid organ injuries (kidney, liver), partial thickness skin necrosis and the lack of compromised liver function. More aggressive operative approach could have prevented later readmissions but also could have resulted in severe complications such as major bleeding, respiratory failure and wound/mesh infection. This dilemma cannot be addressed by case studies of this rare injury, but our example highlights what can be expected with conservative approach. Whether this is applicable to a given patient to a given time requires the informed judgement of the treating surgeon.
Several repair techniques have been described: endogenous tissue repair , prosthetic mesh reinforced by cable banding around the ribs , open transthoracic mesh repair  and tension free laparoscopic absorbable mesh repair . We favoured the laparoscopic tension-free approach and the use of a non absorbable dual layer mesh. The choice of a running suture for mesh fixation to the diaphragm was based upon manufacturer warnings, which contraindicate helical tacks for use in tissues less than 4 mm thick. The thickness of the diaphragm has been measured by ultrasound as low as 2 mm . As a matter of fact, a fatal injury of the heart has been reported during hiatus hernia repair with helical tack .