Treatment of chronic mini-thoracotomy wound pain and lung herniation with intercostal cryoablation and surgical mesh repair: a case report

Treatment of chronic mini-thoracotomy wound pain and lung herniation with intercostal cryoablation and surgical mesh repair: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Treatment of chronic mini-thoracotomy wound pain and lung herniation with intercostal cryoablation and surgical mesh repair: a case report Eun Yeung Jung, Seok Soo Lee This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4018753/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 19 You are reading this latest preprint version Abstract Background: The incidence of minimally invasive heart surgery via mini-thoracotomy (MT; right anterior thoracotomy) is on the rise, accompanied by an increase in post-MT intercostal nerve neuralgia and the risk of lung herniation through the incision site. While various methods have been proposed to address these issues, none have been commonly effective. In this case report, we attempted to simultaneously address these problems by performing IC and mesh repair. Case presentation: A 43-year-old male patient was referred to our hospital for chronic post-thoracotomy neuralgia following heart surgery via MT, involving patch closure of an atrial septal defect and tricuspid annuloplasty. He presented with intercostal nerve neuralgia and lung herniation accompanied by severe pain. Despite medication and lidocaine injections, there was no relief. Consequently, he underwent surgical treatment with IC for chronic MT wound pain and simultaneously underwent mesh repair for a lung hernia. He was discharged from hospital free of complications. Subsequently, he no longer required further pain medication and experienced a favorable recovery. Conclusion: Our findings suggest that concurrent IC and mesh repair can effectively relieve chronic post-MT intercostal nerve neuralgia and severe lung herniation pain in patients who underwent MT surgery, leading to a decrease in opioid medication usage. Minimally invasive surgery Thoracotomy Neuralgia Intercostal cryoablation Surgical mesh Figures Figure 1 Figure 2 Background Mini-thoracotomy (MT) has been advocated as an alternative approach to heart surgery without sternotomy. However, MT is associated with severe post-thoracotomy intercostal nerve neuralgia (PTN) pain, which can lead to respiratory complications such as hypoventilation, hypoxia, atelectasis, pulmonary infections, and respiratory failure [ 1 , 2 ]. The methods for treating PTN include oral medication, intravenous opioids, intercostal nerve blocks, and epidural analgesia. However, these methods have a short duration of action and may provoke complications such as respiratory depression, neurotoxicity, and epidural hematoma. Intercostal cryoablation (IC) is also known to be effective in managing intercostal neuralgia [ 3 ]. It has resulted in reduced opioid requirements and postoperative visual analogue pain scores (VAS) [ 4 ]. While this method has traditionally been used for relieving pain in patients who underwent a Nuss procedure or those with rib fractures [ 5 , 6 ], its benefit has rarely been demonstrated in patients underwent MT. Another potential complication that may occur after MT is lung herniation through the incision site [ 7 ]. Frequently associated symptoms with this condition include pain, persistent cough, shortness of breath and hemoptysis, nevertheless, many of these hernias can be completely asymptomatic [ 8 ]. If this causes symptoms such as pain or lung injury, surgical approach may be necessary. We present a case report of the post-MT patient with chronic PTN pain and intercostal lung herniation treated by IC and mesh repair. Case presentation A 43-year-old male patient was referred to the General Thoracic Surgery (GTS) department in May 2023 for chronic PTN, which was provoked after heart surgery in November 2021. He had a surgical history of patch closure of an atrial septal defect and tricuspid annuloplasty surgery via MT 1 year ago in the Cardiovascular Surgery department. His computed tomography (CT) scan before the heart surgery revealed no chronic lung disease or other underlying conditions. His postoperative course was uneventful, and he was discharged on the 14th postoperative day after heart surgery. Six months later, he visited the hospital for pain at the MT site. His VAS score was 8 out of 10. There was no sign of redness or infection at the thoracotomy wound. A physical examination revealed tenderness at the level of the 4th and 5th ribs. Laboratory values were normal, and a chest X-ray showed no abnormalities. He was prescribed nonsteroidal anti-inflammatory drug (NSAID) medications and went back. After 4 months, he visited again because the pain at the MT site had not disappeared. Lidocaine was injected at the 4th intercostal space (ICS), and he was prescribed opioids and neuralgia analgesics. He was also recommended to visit a pain clinic. In May 2023, after 18 months post-heart surgery, he visited the GTS department for chronic pain at the operation site. He complained that it was not relieved and was getting worse. The chest CT revealed an intercostal lung hernia through the 4th ICS (Fig. 1 A). We planned the surgical treatment for pain relief by IC and mesh repair of lung hernia. The intercostal nerves of the 4th and 5th ribs were identified by video-assisted thoracoscopy and cryoablated using a cryoanalgesia probe (CRYO2, AtriCure, Mason, OH, USA) approximately 4 cm lateral to the spine (Fig. 2 A). The probe was applied directly to the neurovascular bundle at − 60°C for 120 seconds per intercostal nerve (Fig. 2 B). Pleural space was repaired with Bard Mesh (Davol, Inc., Warwick, RI, USA), and ICS was closed by Vicryl #1 − 0. A 16 Fr. chest tube was placed at the end of the procedure. The chest tube was removed on the following day without complications. On the 2nd postoperative day, the patient no longer required opioid medication. His chest pain was rated 2 out of 10. He had no difficulty with breathing or sensory. He was discharged on the 7th postoperative day with a prescription for NSAIDs to be taken as needed for pain. He was visited on the 14th postoperative day. The patient reported his pain level as 3 out of 10, but he had no other discomfort. He did not require any medication for pain and received a prescription just in case. At his 8-week follow-up, the patient reported his pain level remained at 2 out of 10, and he no longer required medication. A follow-up chest CT revealed the disappearance of the intercostal lung herniation (Fig. 1 B). He still had no tingling or paresthesia. Discussion MT has been advocated as an alternative approach to sternotomy for heart surgery. This method offers advantages such as reduced bone bleeding and increased thoracic stabilization. However, it also has some disadvantages. The duration of anesthesia and surgery can be prolonged due to technical difficulties, and the detection of accidental trouble can be delayed because of the limited surgical field of view [ 9 ]. These issues can be improved with increased surgeon experience. However, problems such as severe PTN pain, provoked by the MT incision, present another challenge that must be overcome, as it can lead to respiratory complications or other morbidity. Recently, with the increasing number of minimally invasive surgery via MT, there has been a growing interest in PTN control. IC is considered one of the viable treatments for PTN management. Cryoablation has traditionally been used under various conditions for the treatment of rib fractures, Nuss operation, and post-full thoracotomy pain [ 4 ]. This method is considered an effective means to alleviate PTN and has shown positive results in this case patient. After surgery via MT, other potential side effects may occur due to thoracotomy, aside from PTN, including pulmonary hernia, rib fracture, and intercostal hemorrhage. Surgeons and patients must always consider these complications alongside PTN. If some cause symptoms such as pain, cough, shortness of breath, and hemoptysis, a surgical approach may be necessary. In this case, the patient presented with chronic PTN pain and a lung hernia after MT surgery. Despite opioid medication and local anesthetic injections, the pain persisted and even increased. For such patients, surgical IC treatment and repair of the hernia can be a viable option. It has been shown to provide excellent analgesia along with decreased hospital length of stay and reduced use of narcotics, thereby improving the patient's quality of life. Our findings indicate that concurrent IC and mesh repair can effectively relieve chronic PTN pain in MT patients and lead to a reduction in opioid medications. Abbreviations CT computer tomography VATS video-assistant thoracic surgery MT mini-thoracotomy IC intercostal cryoablation PTN post-thoracotomy intercostal nerve neuralgia VAS visual analogue pain score GTS General Thoracic Surgery CT computed tomography NSAID nonsteroidal anti-inflammatory drug ICS intercostal space Declarations Ethics approval and consent to participate This study was reviewed and approved by the Institutional Review Board of Yeungnam University Hospital (IRB No. 2023-09-036). The requirement for informed consent was waived. We conducted this study in compliance with the principles of the Declaration of Helsinki. Consent for publication The requirement for informed consent was waived by the IRB. Data availability The data is stored in our database and can be provided at any time upon request. Competing interests The authors declare no competing interests. Funding None. Author contributions Conception and design: EYJ; Collection and assembly of data: EYJ; Data interpretation: EYJ; Prepared figures: SSL; Manuscript writing: All authors; Final approval of manuscript: All authors. All authors read and approved the final version of the manuscript. References Kelsheimer B, Williams C, Kelsheimer C. New emerging modalities to treat post-thoracotomy pain syndrome: a review. Mo Med. 2019;116(1):41–4. l-Hag-Aly MA, Hagag MG, Allam HK. If post-thoracotomy pain is the target, integrated thoracotomy is the choice. Gen Thorac Cardiovasc Surg. 2019;67(11):955–61. Joucken K, Michel L, Schoevaerdts JC, Mayne A, Randour P. Cryoanalgesia for post-thoracotomy pain relief. Acta Anaesthesiol Belg. 1987;38(2):179–83. Lau WC, Shannon FL, Bolling SF, Romano MA, Sakwa MP, Trescot A, et al. Intercostal Cryo Nerve Block in Minimally Invasive Cardiac Surgery: The Prospective Randomized FROST Trial. Pain Ther. 2021;10(2):1579–92. Graves CE, Moyer J, Zobel MJ, Mora R, Smith D, O'Day M, et al. Intraoperative intercostal nerve cryoablation during the Nuss procedure reduces length of stay and opioid requirement: A randomized clinical trial. J Pediatr Surg. 2019;54(11):2250–56. Daemen JHT, de Loos ER, Vissers YLJ, Bakens MJAM, Maessen JG, Hulsewé KWE. Intercostal nerve cryoablation versus thoracic epidural for postoperative analgesia following pectus excavatum repair: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2020;31(4):486–98. Forty J, Wells FC. Traumatic intercostal pulmonary hernia. Ann Thorac Surg. 1990;49(4):670–71. Bhardwaj H, Bhardwaj B, Youness H. A painful sneeze: spontaneous thoracic lung herniation induced by vigorous sneeze. J Bronchol Intervent Pulmonol. 2014;21(1):61–4. Brown LJ, Mellor SL, Niranjan G, Harky A. Outcomes in minimally invasive double valve surgery. J Card Surg. 2020;35(12):3486–502. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 30 Apr, 2024 Reviews received at journal 28 Apr, 2024 Reviewers agreed at journal 21 Apr, 2024 Reviews received at journal 21 Apr, 2024 Reviewers agreed at journal 21 Apr, 2024 Reviews received at journal 21 Apr, 2024 Reviewers agreed at journal 17 Apr, 2024 Reviews received at journal 15 Apr, 2024 Reviews received at journal 14 Apr, 2024 Reviewers agreed at journal 14 Apr, 2024 Reviewers agreed at journal 13 Apr, 2024 Reviewers agreed at journal 11 Apr, 2024 Reviews received at journal 11 Apr, 2024 Reviewers agreed at journal 11 Apr, 2024 Reviewers agreed at journal 10 Apr, 2024 Reviewers invited by journal 10 Apr, 2024 Editor assigned by journal 06 Mar, 2024 Submission checks completed at journal 06 Mar, 2024 First submitted to journal 05 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4018753","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":276782757,"identity":"d8e90c4e-f3a9-49db-ae53-426ce5ee2464","order_by":0,"name":"Eun Yeung Jung","email":"","orcid":"","institution":"Yeungnam University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Eun","middleName":"Yeung","lastName":"Jung","suffix":""},{"id":276782758,"identity":"c54740b3-7ced-407e-a39f-476cf1254a9b","order_by":1,"name":"Seok Soo Lee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYHACAyCWqG9jZj5AkhYbxj72tgSStKQxzuM5Y0Ccev7Zzds+fKg5zMwmkfPtwc82m3wG9sNHN+DTInHnWPHMGccOs7FJ5G437G1Ls2zgSUu7gdeaGznGzDxsh3mAWrZJ8Jw5bMAgwWOGV4s8SMuff4clgA57JvnnzH/CWgxAWhjb0gzYeM6wSfNUHCCsxfBGWjFjb59NAht7m5m0TEUyUC8Bv8jdSN7M8OObRIJ8M/MzyTcGdgb87IeP4fc+BmAjTfkoGAWjYBSMAmwAACeURP7V3RfFAAAAAElFTkSuQmCC","orcid":"","institution":"Yeungnam University Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Seok","middleName":"Soo","lastName":"Lee","suffix":""}],"badges":[],"createdAt":"2024-03-05 23:04:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4018753/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4018753/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52298005,"identity":"5f3086fd-e325-4ae0-b51e-71fa70cd99cb","added_by":"auto","created_at":"2024-03-08 18:10:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2268478,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePerioperative CT image\u003c/strong\u003e (a) Preoperative chest computed tomography (CT) shows an intercostal lung hernia through the 4th intercostal space (arrow). (b) Postoperative chest CT demonstrates the disappearance of the intercostal lung herniation (arrow).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4018753/v1/cb1de389abb1bc8f2cbbb84a.png"},{"id":52298033,"identity":"64ddbb35-f775-4f8e-96f4-a3e7329fbc5b","added_by":"auto","created_at":"2024-03-08 18:10:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2856270,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntercostal cryoablation\u003c/strong\u003e (a) The intercostal nerves of the 4th (arrow) and 5th (dash arrow) ribs were identified by video-assisted thoracoscopy. (b,c) Intercostal cryoablation was performed using a cryoanalgesia probe approximately 4 cm lateral to the spine. The probe was applied directly to the neurovascular bundle at −60°C for 120 seconds per intercostal nerve.\u003c/p\u003e","description":"","filename":"Figuer2.png","url":"https://assets-eu.researchsquare.com/files/rs-4018753/v1/508fb4e0fa8a4260cdacc2e1.png"},{"id":52298671,"identity":"58a5c7a5-e8b9-4efc-8957-6bd5b3ee27c2","added_by":"auto","created_at":"2024-03-08 18:17:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1443068,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4018753/v1/e418c937-aa10-406a-8d04-6d1dbdad5378.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Treatment of chronic mini-thoracotomy wound pain and lung herniation with intercostal cryoablation and surgical mesh repair: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003eMini-thoracotomy (MT) has been advocated as an alternative approach to heart surgery without sternotomy. However, MT is associated with severe post-thoracotomy intercostal nerve neuralgia (PTN) pain, which can lead to respiratory complications such as hypoventilation, hypoxia, atelectasis, pulmonary infections, and respiratory failure [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The methods for treating PTN include oral medication, intravenous opioids, intercostal nerve blocks, and epidural analgesia. However, these methods have a short duration of action and may provoke complications such as respiratory depression, neurotoxicity, and epidural hematoma. Intercostal cryoablation (IC) is also known to be effective in managing intercostal neuralgia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It has resulted in reduced opioid requirements and postoperative visual analogue pain scores (VAS) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. While this method has traditionally been used for relieving pain in patients who underwent a Nuss procedure or those with rib fractures [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], its benefit has rarely been demonstrated in patients underwent MT. Another potential complication that may occur after MT is lung herniation through the incision site [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Frequently associated symptoms with this condition include pain, persistent cough, shortness of breath and hemoptysis, nevertheless, many of these hernias can be completely asymptomatic [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. If this causes symptoms such as pain or lung injury, surgical approach may be necessary. We present a case report of the post-MT patient with chronic PTN pain and intercostal lung herniation treated by IC and mesh repair.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 43-year-old male patient was referred to the General Thoracic Surgery (GTS) department in May 2023 for chronic PTN, which was provoked after heart surgery in November 2021. He had a surgical history of patch closure of an atrial septal defect and tricuspid annuloplasty surgery via MT 1 year ago in the Cardiovascular Surgery department. His computed tomography (CT) scan before the heart surgery revealed no chronic lung disease or other underlying conditions. His postoperative course was uneventful, and he was discharged on the 14th postoperative day after heart surgery. Six months later, he visited the hospital for pain at the MT site. His VAS score was 8 out of 10. There was no sign of redness or infection at the thoracotomy wound. A physical examination revealed tenderness at the level of the 4th and 5th ribs. Laboratory values were normal, and a chest X-ray showed no abnormalities. He was prescribed nonsteroidal anti-inflammatory drug (NSAID) medications and went back. After 4 months, he visited again because the pain at the MT site had not disappeared. Lidocaine was injected at the 4th intercostal space (ICS), and he was prescribed opioids and neuralgia analgesics. He was also recommended to visit a pain clinic. In May 2023, after 18 months post-heart surgery, he visited the GTS department for chronic pain at the operation site. He complained that it was not relieved and was getting worse. The chest CT revealed an intercostal lung hernia through the 4th ICS (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). We planned the surgical treatment for pain relief by IC and mesh repair of lung hernia. The intercostal nerves of the 4th and 5th ribs were identified by video-assisted thoracoscopy and cryoablated using a cryoanalgesia probe (CRYO2, AtriCure, Mason, OH, USA) approximately 4 cm lateral to the spine (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). The probe was applied directly to the neurovascular bundle at \u0026minus;\u0026thinsp;60\u0026deg;C for 120 seconds per intercostal nerve (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Pleural space was repaired with Bard Mesh (Davol, Inc., Warwick, RI, USA), and ICS was closed by Vicryl #1\u0026thinsp;\u0026minus;\u0026thinsp;0. A 16 Fr. chest tube was placed at the end of the procedure. The chest tube was removed on the following day without complications. On the 2nd postoperative day, the patient no longer required opioid medication. His chest pain was rated 2 out of 10. He had no difficulty with breathing or sensory. He was discharged on the 7th postoperative day with a prescription for NSAIDs to be taken as needed for pain. He was visited on the 14th postoperative day. The patient reported his pain level as 3 out of 10, but he had no other discomfort. He did not require any medication for pain and received a prescription just in case. At his 8-week follow-up, the patient reported his pain level remained at 2 out of 10, and he no longer required medication. A follow-up chest CT revealed the disappearance of the intercostal lung herniation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). He still had no tingling or paresthesia.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMT has been advocated as an alternative approach to sternotomy for heart surgery. This method offers advantages such as reduced bone bleeding and increased thoracic stabilization. However, it also has some disadvantages. The duration of anesthesia and surgery can be prolonged due to technical difficulties, and the detection of accidental trouble can be delayed because of the limited surgical field of view [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These issues can be improved with increased surgeon experience. However, problems such as severe PTN pain, provoked by the MT incision, present another challenge that must be overcome, as it can lead to respiratory complications or other morbidity. Recently, with the increasing number of minimally invasive surgery via MT, there has been a growing interest in PTN control. IC is considered one of the viable treatments for PTN management. Cryoablation has traditionally been used under various conditions for the treatment of rib fractures, Nuss operation, and post-full thoracotomy pain [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This method is considered an effective means to alleviate PTN and has shown positive results in this case patient.\u003c/p\u003e \u003cp\u003eAfter surgery via MT, other potential side effects may occur due to thoracotomy, aside from PTN, including pulmonary hernia, rib fracture, and intercostal hemorrhage. Surgeons and patients must always consider these complications alongside PTN. If some cause symptoms such as pain, cough, shortness of breath, and hemoptysis, a surgical approach may be necessary. In this case, the patient presented with chronic PTN pain and a lung hernia after MT surgery. Despite opioid medication and local anesthetic injections, the pain persisted and even increased. For such patients, surgical IC treatment and repair of the hernia can be a viable option. It has been shown to provide excellent analgesia along with decreased hospital length of stay and reduced use of narcotics, thereby improving the patient's quality of life. Our findings indicate that concurrent IC and mesh repair can effectively relieve chronic PTN pain in MT patients and lead to a reduction in opioid medications.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; computer tomography\u003c/p\u003e\n\u003cp\u003eVATS \u0026nbsp; \u0026nbsp; video-assistant thoracic surgery\u003c/p\u003e\n\u003cp\u003eMT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;mini-thoracotomy\u003c/p\u003e\n\u003cp\u003eIC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;intercostal cryoablation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePTN \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;post-thoracotomy intercostal nerve neuralgia\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVAS \u0026nbsp; \u0026nbsp; \u0026nbsp; visual analogue pain score\u003c/p\u003e\n\u003cp\u003eGTS \u0026nbsp; \u0026nbsp; \u0026nbsp; General Thoracic Surgery\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; computed tomography\u003c/p\u003e\n\u003cp\u003eNSAID \u0026nbsp;nonsteroidal anti-inflammatory drug\u003c/p\u003e\n\u003cp\u003eICS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;intercostal space\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Institutional Review Board of Yeungnam University Hospital (IRB No. 2023-09-036). The requirement for informed consent was waived.\u003c/p\u003e\n\u003cp\u003eWe conducted this study in compliance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe requirement for informed consent was waived by the IRB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data is stored in our database and can be provided at any time upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design: EYJ; Collection and assembly of data: EYJ; Data interpretation: EYJ; Prepared figures: SSL; Manuscript writing: All authors; Final approval of manuscript: All authors. All authors read and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKelsheimer B, Williams C, Kelsheimer C. New emerging modalities to treat post-thoracotomy pain syndrome: a review. Mo Med. 2019;116(1):41\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003el-Hag-Aly MA, Hagag MG, Allam HK. If post-thoracotomy pain is the target, integrated thoracotomy is the choice. Gen Thorac Cardiovasc Surg. 2019;67(11):955\u0026ndash;61.\u003c/li\u003e\n\u003cli\u003eJoucken K, Michel L, Schoevaerdts JC, Mayne A, Randour P. Cryoanalgesia for post-thoracotomy pain relief. Acta Anaesthesiol Belg. 1987;38(2):179\u0026ndash;83.\u003c/li\u003e\n\u003cli\u003eLau WC, Shannon FL, Bolling SF, Romano MA, Sakwa MP, Trescot A, et al. Intercostal Cryo Nerve Block in Minimally Invasive Cardiac Surgery: The Prospective Randomized FROST Trial. Pain Ther. 2021;10(2):1579\u0026ndash;92.\u003c/li\u003e\n\u003cli\u003eGraves CE, Moyer J, Zobel MJ, Mora R, Smith D, O\u0026apos;Day M, et al. Intraoperative intercostal nerve cryoablation during the Nuss procedure reduces length of stay and opioid requirement: A randomized clinical trial. J Pediatr Surg. 2019;54(11):2250\u0026ndash;56.\u003c/li\u003e\n\u003cli\u003eDaemen JHT, de Loos ER, Vissers YLJ, Bakens MJAM, Maessen JG, Hulsew\u0026eacute; KWE. Intercostal nerve cryoablation versus thoracic epidural for postoperative analgesia following pectus excavatum repair: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2020;31(4):486\u0026ndash;98.\u003c/li\u003e\n\u003cli\u003eForty J, Wells FC. Traumatic intercostal pulmonary hernia. Ann Thorac Surg. 1990;49(4):670\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eBhardwaj H, Bhardwaj B, Youness H. A painful sneeze: spontaneous thoracic lung herniation induced by vigorous sneeze. J Bronchol Intervent Pulmonol. 2014;21(1):61\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eBrown LJ, Mellor SL, Niranjan G, Harky A. Outcomes in minimally invasive double valve surgery. J Card Surg. 2020;35(12):3486\u0026ndash;502.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Minimally invasive surgery, Thoracotomy, Neuralgia, Intercostal cryoablation, Surgical mesh","lastPublishedDoi":"10.21203/rs.3.rs-4018753/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4018753/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe incidence of minimally invasive heart surgery via mini-thoracotomy (MT; right anterior thoracotomy) is on the rise, accompanied by an increase in post-MT intercostal nerve neuralgia and the risk of lung herniation through the incision site. While various methods have been proposed to address these issues, none have been commonly effective. In this case report, we attempted to simultaneously address these problems by performing IC and mesh repair.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003eA 43-year-old male patient was referred to our hospital for chronic post-thoracotomy neuralgia following heart surgery via MT, involving patch closure of an atrial septal defect and tricuspid annuloplasty. He presented with intercostal nerve neuralgia and lung herniation accompanied by severe pain. Despite medication and lidocaine injections, there was no relief. Consequently, he underwent surgical treatment with IC for chronic MT wound pain and simultaneously underwent mesh repair for a lung hernia. He was discharged from hospital free of complications. Subsequently, he no longer required further pain medication and experienced a favorable recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eOur findings suggest that concurrent IC and mesh repair can effectively relieve chronic post-MT intercostal nerve neuralgia and severe lung herniation pain in patients who underwent MT surgery, leading to a decrease in opioid medication usage.\u003c/p\u003e","manuscriptTitle":"Treatment of chronic mini-thoracotomy wound pain and lung herniation with intercostal cryoablation and surgical mesh repair: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-08 18:06:25","doi":"10.21203/rs.3.rs-4018753/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-30T08:44:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-29T02:50:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16783a59-b84c-4fbd-baf1-5f303763715a","date":"2024-04-22T03:08:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-21T18:49:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"d2ec0c85-7ac6-4860-8c3d-20710b84e9f5","date":"2024-04-21T18:27:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-21T05:22:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"d18424e6-1c62-45d0-9d65-f94d3e508b88_SNPRID","date":"2024-04-17T05:51:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-15T14:00:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-14T16:33:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5a1beb75-5f36-48ca-a0da-e513dbae7693","date":"2024-04-14T16:23:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8a0ad982-6eeb-448c-88f4-076fb7a8a0be","date":"2024-04-13T13:43:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39d498ce-9a5b-4eae-8d59-790c837e96ab","date":"2024-04-11T13:14:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-11T12:38:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6f3a7e44-6977-4e61-a2fe-b1175b2fc05b","date":"2024-04-11T11:28:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"0e5eec2d-e957-4c8d-ae1f-e453811b6d25","date":"2024-04-10T16:39:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-10T15:10:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-06T14:37:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-06T14:37:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2024-03-05T22:53:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2a72cbd3-241b-4a75-8f06-6005b22c32cb","owner":[],"postedDate":"March 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-14T16:21:08+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-08 18:06:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4018753","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4018753","identity":"rs-4018753","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}