Acute intercostal pulmonary hernia following uniportal video-assisted thoracoscopic surgery for pulmonary conditions

Acute intercostal pulmonary hernia following uniportal video-assisted thoracoscopic surgery for pulmonary conditions | 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 Acute intercostal pulmonary hernia following uniportal video-assisted thoracoscopic surgery for pulmonary conditions Shaoqing Huang, Xu Song, Qiang Shi, Jie Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5324898/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Intercostal pulmonary hernia is an uncommon condition characterized by the protrusion of lung parenchyma through a compromised or defective chest wall into the thoracic cavity. The etiologies of pulmonary hernia can be categorized as traumatic, post-thoracotomy, and spontaneous occurrences. Treatment modalities for pulmonary hernia are classified into conservative management and surgical intervention. We present a case of acute intercostal pulmonary hernia in a patient following wedge resection of the left upper lobe via uniportal video-assisted thoracoscopic surgery, which was successfully addressed through manual reinsertion. Pulmonary hernia Uniportal video-assisted thoracoscopic surgery Manual reinsertion Figures Figure 1 Figure 2 Background Pulmonary hernia is characterized by the protrusion of lung parenchyma beyond the thoracic cavity due to a weakness or defect in the chest wall. The earliest documented case of pulmonary hernia was reported by Roland in 1499.[ 1 ] Subsequently, in 1845, Morel-Lavallee established a classification system based on an analysis of 32 patients admitted for pulmonary hernias, categorizing them into supraclavicular, thoracic, diaphragmatic, and congenital versus acquired hernias according to their anatomical location and underlying etiology.[ 2 ] Herein, we present a case of a left anterior thoracic fourth intercostal pulmonary hernia resulting from severe coughing following single-port thoracoscopic lung wedge resection, which was successfully managed through manual reinsertion. Case presentation A 57-year-old male patient with a history of smoking was admitted to the hospital due to pulmonary nodules identified one week prior, without any significant past medical history. The patient underwent wedge resection of the left upper lobe and lymph node dissection via uniportal video-assisted thoracoscopic surgery through the fourth intercostal space along the anterior axillary line. Postoperatively, a 26-gauge chest tube was placed for drainage of pleural effusion and air. Standard perioperative management protocols for thoracic surgery were implemented, leading to chest tube removal on postoperative day four. A chest X-ray performed on the morning of day five showed satisfactory results; however, by that afternoon, the patient developed an acute cough accompanied by high fever and reported pain at the left incision site. Physical examination revealed crepitus and shock-like sensations upon coughing at the incision site. Immediate assessment included pathogen detection and inflammatory marker evaluation alongside computed tomography (CT) imaging of the chest. CT findings indicated a left intercostal lung hernia, while blood tests demonstrated mildly elevated inflammatory markers. The patient received antipyretic therapy, penicillin-based antibiotic treatment for infection control, as well as manual reinsertion of the pulmonary hernia. Detailed Procedure: During the patient's coughing, we utilized our fingers to palpate the location of the pulmonary hernia, subsequently instructing the patient to take a deep inhalation while we retracted the hernia. Once the shock sensation subsided, pressure was applied to the chest incision using gauze and an elastic bandage. At this juncture, the patient reported a significant alleviation of left-sided chest pain. A follow-up chest computed tomography scan was performed to confirm that the pulmonary hernia had returned to its anatomical position within the thoracic cavity (Fig. 1 ). On postoperative day six, a positive nucleic acid test for Influenza A virus was obtained. The patient received oral antiviral treatment with marvaloxavir and exhibited satisfactory recovery. To date, there have been no recurrences of pulmonary hernia following discharge. Discussion Pulmonary hernia is an exceedingly rare condition, often asymptomatic or associated with chest pain. Congenital and acquired pulmonary hernias account for approximately 20% and 80% of cases, respectively.[3] Thoracotomy is a recognized cause of acquired pulmonary hernia. Previous reports indicate that intercostal pulmonary hernias typically manifest between three months and eight years post-thoracotomy;[4] however, the present case developed a pulmonary hernia on the fifth postoperative day, which diverges from prior findings. Chest computed tomography remains the gold standard for diagnosing pulmonary hernia, while physical examination may reveal crepitations upon palpation.[5] Early surgical intervention is recommended for anterior chest wall pulmonary hernias; nevertheless, the necessity of surgical repair continues to be a subject of debate.[4] In this case, the patient underwent uniportal video-assisted thoracoscopic surgery, which resulted in a muscle defect located between the left fourth intercostal space. Following the removal of the patient's chest tube, there was an enlargement of the intercostal defect space. Due to severe coughing, pleural pressure increased, causing lung displacement through the fourth intercostal space and leading to a pulmonary hernia. Chest computed tomography revealed that the diameter of the hernia sac neck measured approximately 4.88 centimeters, while the maximum diameter of the pulmonary hernia reached about 6.59 centimeters (Figure 2). The pulmonary hernia was identified promptly; given that there was no ischemic necrosis present, it could be repaired via manual reinsertion. Ultimately, we successfully made a clinical decision to manage acute pulmonary hernia through manipulation techniques. We recommend retracting the hernia during deep inhalation by expanding both thoracic cavity space and enhancing negative pressure within it—this facilitates effective retraction of the hernia. Additionally, when patients cough, any associated shock from lung displacement combined with chest pain should prompt reevaluation to ensure complete resolution of lung herniation. A follow-up chest computed tomography scan was performed to reconfirm successful retraction of the pulmonary hernia. In conclusion, we present a rare perioperative complication following uniportal video-assisted thoracoscopic surgery: pulmonary hernia. For the first time, we demonstrate that manual reinsertion of a pulmonary hernia in an emergency setting is both safe and feasible. This article also addresses critical aspects of the manual reinsertion procedure for pulmonary hernia. Declarations Ethics Statement: Ethics approval was obtained. Consent to Publish declaration: Applicable. Written informed consent to publish was obtained from the study participants. Conflict of Interest: The authors declare that they have no competing interests. Data Availability Statement: (This manuscript does not report data generation or analysis). Informed consent from all subjects for publication of identifying information/images in an online open-access publication under Consent for publication. Funding Declaration: This artical Supported by Zhu Xiu shan Talent Project of Ningbo No.2 Hospital(Grant No.2023HMYQ07) and Ningbo Top Medical and Health Research Program(Grant No.2022030208). References D. Weissberg, Y. Refaely, Hernia of the lung, Ann. Thoracic Surg. 74 (2002)1963–1966. Morel-Lavallee A. Hernies du poumon. Bull Mem Soc Chir Paris 1845;1:75–195. J. Forty, F.C. Wells, Traumatic intercostal pulmonary hernia, Ann. Thoracic Surg. 49 (1990) 670–671. Kalliopi Athanassiadi, Erik Bagaev, Andre Simon, Axel Haverich, Lung herniation: a rare complication in minimally invasive cardiothoracic surgery, European Journal of Cardio-thoracic Surgery 33 (2008) 774—776. Waqar S, Vaughan P, Edwards JG. Late presentation of a traumatic lung hernia. Ann Thorac Surg. 2010;90(5):1715. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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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-5324898","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":372031821,"identity":"f92c7cdf-6d93-47d8-8323-72aeb8d078b3","order_by":0,"name":"Shaoqing Huang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBACAwh1AIgZGxgY/9nw8PM3kKKFgS1NRnLGAaK1gADbYRuDhgT8Wswlkp89/PLnjjw/e3Lbwy8853kMGA4wfviYg1uL5Yw0c2PZtmeGM3sethvLSNzmMWduYJacuQ2Pw24kmElLNhxm3HAjsU1awuA2j2XDATZmXrxa0r9JS/w5bA/RknCOx+BAAiEtOWaSH9gOJ4K0SH44cIAILWfelEkzth1OBvqlTZqxIZlHcsbBZvx+OZ6+TfLHn8O2/ezpzyR/NtjZ8/M3H/zwEY8WEGDmAVMJMAYoTgkAxh9QLVDGKBgFo2AUjAJUAAC92VmUGBDA4wAAAABJRU5ErkJggg==","orcid":"","institution":"Ningbo No.2 Hospital","correspondingAuthor":true,"prefix":"","firstName":"Shaoqing","middleName":"","lastName":"Huang","suffix":""},{"id":372031822,"identity":"172cdbb9-8880-4d3a-8065-c60b94258a24","order_by":1,"name":"Xu Song","email":"","orcid":"","institution":"Ningbo No.2 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Song","suffix":""},{"id":372031823,"identity":"5c6f7b9a-5ebe-41b6-8ae0-7b6352f08ff0","order_by":2,"name":"Qiang Shi","email":"","orcid":"","institution":"Ningbo No.2 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qiang","middleName":"","lastName":"Shi","suffix":""},{"id":372031824,"identity":"2ed5aa73-2cde-47c7-8fd1-44272e41515c","order_by":3,"name":"Jie Li","email":"","orcid":"","institution":"Ningbo No.2 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jie","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-10-24 10:08:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5324898/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5324898/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69440448,"identity":"ee88d0c9-770b-4310-9365-eaffc35c231e","added_by":"auto","created_at":"2024-11-20 11:10:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":212977,"visible":true,"origin":"","legend":"\u003cp\u003ea: Pulmonary hernia; b: After manual correction; c: Pressure dressing；\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5324898/v1/9af3264cc7365695975d6974.png"},{"id":69440447,"identity":"6f27f3c4-f3b0-415e-8cee-685a9a5775b1","added_by":"auto","created_at":"2024-11-20 11:10:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":279006,"visible":true,"origin":"","legend":"\u003cp\u003eData of pulmonary hernia measurements\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5324898/v1/7384509ac3c343598fd3cf4c.png"},{"id":69442587,"identity":"2f9e6f6a-d2f6-4d99-b5e3-d8bc7b5bd998","added_by":"auto","created_at":"2024-11-20 11:26:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":789910,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5324898/v1/0cfb3994-945a-47a9-81f3-e6a58bd7ae63.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Acute intercostal pulmonary hernia following uniportal video-assisted thoracoscopic surgery for pulmonary conditions","fulltext":[{"header":"Background","content":"\u003cp\u003ePulmonary hernia is characterized by the protrusion of lung parenchyma beyond the thoracic cavity due to a weakness or defect in the chest wall. The earliest documented case of pulmonary hernia was reported by Roland in 1499.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Subsequently, in 1845, Morel-Lavallee established a classification system based on an analysis of 32 patients admitted for pulmonary hernias, categorizing them into supraclavicular, thoracic, diaphragmatic, and congenital versus acquired hernias according to their anatomical location and underlying etiology.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Herein, we present a case of a left anterior thoracic fourth intercostal pulmonary hernia resulting from severe coughing following single-port thoracoscopic lung wedge resection, which was successfully managed through manual reinsertion.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 57-year-old male patient with a history of smoking was admitted to the hospital due to pulmonary nodules identified one week prior, without any significant past medical history. The patient underwent wedge resection of the left upper lobe and lymph node dissection via uniportal video-assisted thoracoscopic surgery through the fourth intercostal space along the anterior axillary line. Postoperatively, a 26-gauge chest tube was placed for drainage of pleural effusion and air. Standard perioperative management protocols for thoracic surgery were implemented, leading to chest tube removal on postoperative day four. A chest X-ray performed on the morning of day five showed satisfactory results; however, by that afternoon, the patient developed an acute cough accompanied by high fever and reported pain at the left incision site. Physical examination revealed crepitus and shock-like sensations upon coughing at the incision site. Immediate assessment included pathogen detection and inflammatory marker evaluation alongside computed tomography (CT) imaging of the chest. CT findings indicated a left intercostal lung hernia, while blood tests demonstrated mildly elevated inflammatory markers. The patient received antipyretic therapy, penicillin-based antibiotic treatment for infection control, as well as manual reinsertion of the pulmonary hernia. Detailed Procedure: During the patient's coughing, we utilized our fingers to palpate the location of the pulmonary hernia, subsequently instructing the patient to take a deep inhalation while we retracted the hernia. Once the shock sensation subsided, pressure was applied to the chest incision using gauze and an elastic bandage. At this juncture, the patient reported a significant alleviation of left-sided chest pain. A follow-up chest computed tomography scan was performed to confirm that the pulmonary hernia had returned to its anatomical position within the thoracic cavity (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). On postoperative day six, a positive nucleic acid test for Influenza A virus was obtained. The patient received oral antiviral treatment with marvaloxavir and exhibited satisfactory recovery. To date, there have been no recurrences of pulmonary hernia following discharge.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePulmonary hernia is an exceedingly rare condition, often asymptomatic or associated with chest pain. Congenital and acquired pulmonary hernias account for approximately 20% and 80% of cases, respectively.[3] Thoracotomy is a recognized cause of acquired pulmonary hernia. Previous reports indicate that intercostal pulmonary hernias typically manifest between three months and eight years post-thoracotomy;[4] however, the present case developed a pulmonary hernia on the fifth postoperative day, which diverges from prior findings. Chest computed tomography remains the gold standard for diagnosing pulmonary hernia, while physical examination may reveal crepitations upon palpation.[5] Early surgical intervention is recommended for anterior chest wall pulmonary hernias; nevertheless, the necessity of surgical repair continues to be a subject of debate.[4]\u003c/p\u003e\n\u003cp\u003eIn this case, the patient underwent uniportal video-assisted thoracoscopic surgery, which resulted in a muscle defect located between the left fourth intercostal space. Following the removal of the patient's chest tube, there was an enlargement of the intercostal defect space. Due to severe coughing, pleural pressure increased, causing lung displacement through the fourth intercostal space and leading to a pulmonary hernia. Chest computed tomography revealed that the diameter of the hernia sac neck measured approximately 4.88 centimeters, while the maximum diameter of the pulmonary hernia reached about 6.59 centimeters (Figure 2). The pulmonary hernia was identified promptly; given that there was no ischemic necrosis present, it could be repaired via manual reinsertion. Ultimately, we successfully made a clinical decision to manage acute pulmonary hernia through manipulation techniques. We recommend retracting the hernia during deep inhalation by expanding both thoracic cavity space and enhancing negative pressure within it—this facilitates effective retraction of the hernia. Additionally, when patients cough, any associated shock from lung displacement combined with chest pain should prompt reevaluation to ensure complete resolution of lung herniation. A follow-up chest computed tomography scan was performed to reconfirm successful retraction of the pulmonary hernia.\u003c/p\u003e\n\u003cp\u003eIn conclusion, we present a rare perioperative complication following uniportal video-assisted thoracoscopic surgery: pulmonary hernia. For the first time, we demonstrate that manual reinsertion of a pulmonary hernia in an emergency setting is both safe and feasible. This article also addresses critical aspects of the manual reinsertion procedure for pulmonary hernia.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Statement: Ethics approval was obtained.\u003c/p\u003e\n\u003cp\u003eConsent to Publish declaration: Applicable.\u003c/p\u003e\n\u003cp\u003eWritten informed consent to publish was obtained from the study participants.\u003c/p\u003e\n\u003cp\u003eConflict of Interest: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eData Availability Statement: (This manuscript does not report data generation or analysis).\u003c/p\u003e\n\u003cp\u003eInformed consent from all subjects for publication of identifying information/images in an online open-access publication under Consent for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding Declaration: This artical Supported by Zhu Xiu shan Talent Project of Ningbo No.2 Hospital(Grant No.2023HMYQ07) and Ningbo Top Medical and Health Research Program(Grant No.2022030208).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eD. Weissberg, Y. Refaely, Hernia of the lung, Ann. Thoracic Surg. 74 (2002)1963\u0026ndash;1966.\u003c/li\u003e\n\u003cli\u003eMorel-Lavallee A. Hernies du poumon. Bull Mem Soc Chir Paris 1845;1:75\u0026ndash;195.\u003c/li\u003e\n\u003cli\u003eJ. Forty, F.C. Wells, Traumatic intercostal pulmonary hernia, Ann. Thoracic Surg. 49 (1990) 670\u0026ndash;671.\u003c/li\u003e\n\u003cli\u003eKalliopi Athanassiadi, Erik Bagaev, Andre Simon, Axel Haverich, Lung herniation: a rare complication in minimally invasive cardiothoracic surgery, European Journal of Cardio-thoracic Surgery 33 (2008) 774\u0026mdash;776.\u003c/li\u003e\n\u003cli\u003eWaqar S, Vaughan P, Edwards JG. Late presentation of a traumatic lung hernia. Ann Thorac Surg. 2010;90(5):1715.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pulmonary hernia, Uniportal video-assisted thoracoscopic surgery, Manual reinsertion","lastPublishedDoi":"10.21203/rs.3.rs-5324898/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5324898/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntercostal pulmonary hernia is an uncommon condition characterized by the protrusion of lung parenchyma through a compromised or defective chest wall into the thoracic cavity. The etiologies of pulmonary hernia can be categorized as traumatic, post-thoracotomy, and spontaneous occurrences. Treatment modalities for pulmonary hernia are classified into conservative management and surgical intervention. 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