Reinforcement Mesh Repair for Persistent Pleural Leakage Following VATS Lobectomy: A Case Report and Clinical Insights

Reinforcement Mesh Repair for Persistent Pleural Leakage Following VATS Lobectomy: A Case Report and Clinical Insights | 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 Reinforcement Mesh Repair for Persistent Pleural Leakage Following VATS Lobectomy: A Case Report and Clinical Insights Marco Lizwan, Cynthia Ming Li Chia This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7929416/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Early chest drain removal and discharge are standard in enhanced-recovery protocols after video-assisted thoracoscopic surgery (VATS) lobectomy, but rare wound complications may arise. A 71-year-old man underwent uneventful 3-port right VATS lower lobectomy, with chest drain removal on postoperative day 2. Two weeks later, serous fluid leaked through the access wound. Conservative management with antibiotics and re-suturing failed. VATS re-exploration revealed pleural adhesions and 300 mL effusion without lung herniation. A gentamicin-soaked Prolene® mesh was anchored to reinforce the intercostal defect. The patient healed uneventfully with no recurrence. Persistent pleural leakage through a VATS access wound is rare but merits consideration. When conservative measures fail and structural weakness is suspected, mesh reinforcement offers a durable repair option. VATS lobectomy pleural leakage Prolene® mesh pleural effusion surgical reinforcement Figures Figure 1 Figure 2 Introduction Video-assisted thoracoscopic surgery (VATS) is widely adopted in thoracic surgery because it reduces postoperative pain, shortens hospital stays, and promotes faster recovery (1). Enhanced recovery protocols often advocate for early chest drain removal and discharge (2,3). However, very rarely, patients may present later with wound-related complications such as pleural fluid leakage through the access incision. Although the clinical appearance may mimic lung herniation, the underlying mechanism is distinct: instead of lung parenchyma protruding through intercostal defects, persistent leakage entails escape of pleural fluid via a focal weakness in thoracic wall closure. This report describes such a case following early drain removal, treated with mesh reinforcement, and discusses management considerations. Case Presentation A 71-year-old Eurasian male ex-smoker with comorbidities including hypertension, hyperlipidaemia, glaucoma, cervical spondylosis, previous spinal surgery, bilateral knee replacements and appendectomy, was referred for evaluation of a suspicious right lung nodule. Computed tomography (CT) of the thorax showed a right lower lobe nodule suspicious for malignancy (Fig. 1A-B). Positron Emission Tomography (PET)/CT scan revealed mild 18F-fluoro-2-deoxy-d-glucose (FDG) avidity and no evidence of metastasis (Fig. 1C). Brain magnetic resonance imaging (MRI) was negative for brain metastasis. The patient underwent a standard 3-port right VATS lower lobectomy with mediastinal lymph node dissection (4). Intraoperative air leak testing was negative and closure was uneventful. Patient was discharged well on post-operative day 2. Two weeks later, the patient presented to the emergency department with visible pleural fluid leaking from previous access wound (Fig. 2A). Clinical examination revealed no signs of lung herniation or wound dehiscence. Routine bloods were sent and C-reactive protein was 20 mg/L. CT thorax showed focal soft tissue thickening at the surgical site and a new small right pleural effusion (Fig. 1D), but no signs of lung herniation, pneumothorax or infection. Patient was empirically covered with PO Augmentin for possibility of early wound dehiscence from wound infection and the wound was also reinforced with two mattress sutures (Fig. 2B). Minimal leakage was noted after coughing and the patient was discharged. However, the patient re-presented the next day with persistent leakage. Given persistence despite conservative measures, the decision was made for VATS re-exploration. Intraoperatively, significant pleural adhesions were found, along with 300 mL of pleural effusion which was evacuated (Fig. 2C). No lung herniation or obvious air leak was observed. To prevent further leakage, Prolene® mesh soaked in gentamicin was anchored to the rib (Fig. 2D, Video 1), mimicking a lung herniation repair technique (5). Routine closure was then performed. This approach reinforced the thoracic wall defect, stabilised the wound, and provided local antimicrobial coverage to reduce the risk of postoperative infection. The surgical wound was closed routinely. Patient was reviewed in the clinic 1-week and 2-week post-VATS exploration. During the clinic visit, his wound was healing well (Fig. 2E) and his repeat chest X-ray (CXR) was unremarkable. Discussion This case illustrates a rare postoperative complication in which persistent pleural fluid leakage occurred through the VATS access incision after an otherwise uneventful lobectomy and early drain removal. Although VATS has significantly improved perioperative outcomes through smaller incisions, reduced pain, and shorter hospitalization, the widespread implementation of enhanced recovery after surgery (ERAS) protocols has also shifted postoperative practice toward early drain removal and same-week discharge (2,3). While this approach is safe and effective in the vast majority of patients, occasional delayed wound complications such as localized pleural leakage can arise. Awareness of such rare events is important to balance the benefits of accelerated recovery with patient safety. The mechanism underlying pleural fluid leakage through a VATS access wound likely involves multifactorial processes. Following lung resection, minor pleural fluid accumulation is common, particularly if postoperative exudation exceeds the absorptive capacity of the pleura. In cases where the intercostal closure is slightly weakened – due to surgical dissection, local tissue oedema, or mechanical stress – fluid may track externally through the tract of least resistance. Increased intrathoracic pressure from coughing or movement can then perpetuate this leakage (6). In this elderly patient with multiple comorbidities, delayed tissue remodelling and collagen cross-linking likely contributed to reduced wound tensile strength. The dynamic mechanical forces of respiration, particularly at lateral chest wall sites used for VATS access, may further stress the intercostal musculature and fascial closure, creating a small communicating tract. Although such micro-dehiscence may not be apparent intraoperatively, it can become clinically evident once pleural pressure differentials increase after discharge. It is essential to differentiate such cases from wound dehiscence, infection, or lung herniation. True lung herniation involves parenchymal protrusion beyond the thoracic wall, usually accompanied by palpable bulging or radiographic evidence of extra-thoracic lung tissue (7). In contrast, pleural leakage produces fluid seepage without tissue extrusion and may be associated with small serous collections on imaging rather than herniated parenchyma. Initial management should remain conservative, focusing on wound re-suturing, local compression, and empirical antibiotics if infection is suspected. Most small leaks resolve spontaneously as granulation tissue develops. However, persistent leakage despite conservative measures suggests a structural defect in the intercostal space or failure of the fascial seal, warranting surgical re-exploration. In this case, VATS re-exploration confirmed pleural adhesions and effusion but no herniation or air leak. Given the persistence of leakage despite bedside repair, reinforcement was required to ensure closure stability. Prolene® (polypropylene) mesh was chosen because it offers several distinct advantages: (i) mechanical strength to resist cyclical chest wall motion, (ii) resistance to infection due to its inert nature, and (iii) long-term durability in reconstructive applications (8,9). Anchoring the mesh to the adjacent rib effectively redistributed mechanical tension across a wider surface, preventing recurrence and promoting fibrous tissue incorporation for long-term stability. Alternative strategies, such as muscle flap advancement or multilayer fascial closure, may suffice in cases with limited leakage or robust local tissue. However, in an elderly patient with fragile musculature and prior wound stress, mesh reinforcement provides an added safety margin without significant additional morbidity. The adjunctive use of gentamicin irrigation and mesh soaking provided localized antimicrobial coverage, potentially reducing the risk of subclinical infection – a prudent step in the setting of prior leakage. Clinically, this case underscores the need for vigilance following early discharge under ERAS protocols, as patients may develop delayed wound-related complications. Judicious chest drain management remains crucial; while early removal reduces discomfort and hospital stay, drain duration should be individualized, especially in older patients or those with borderline output. Furthermore, this experience highlights the importance of tailoring management to each patient’s tissue characteristics and physiological context. Although most cases can be managed conservatively, prompt recognition of persistent pleural leakage and timely surgical intervention are vital to avoid chronic fistula formation or infection. Mesh reinforcement, in particular, offers a reliable option when conservative measures fail, ensuring durable thoracic wall integrity and preventing recurrence. Persistent pleural leakage is rare and likely underreported, as mild cases may resolve spontaneously or remain unrecognized. This report contributes to the limited literature on thoracic wall complications unrelated to air leaks or infection. Further studies could evaluate the incidence of such leaks in ERAS populations and compare the outcomes of mesh versus non-mesh approaches. Additionally, the potential role of bioabsorbable or biologic meshes warrants investigation, as these materials may offer equivalent support with improved tissue integration and reduced long-term stiffness. Conclusion Persistent pleural fluid leakage through a VATS access wound, though extremely rare, is a worthwhile consideration in postoperative surveillance. When conservative measures prove insufficient and local structural weakness is suspected, mesh reinforcement may provide a durable, safe solution. Declarations Data Availability Statement Additional data are available from the corresponding author on reasonable request. Acknowledgement We would like to thank all individuals who were involved in the care for our patient. Author Contributions ML wrote the manuscript. CMLC supervised the entire manuscript writing. All authors were involved in the patient’s care and have read and approved the final manuscripts. Fundings This research did not receive any grants from any funding agencies. Ethical Approval Written informed consent was obtained from patient to include the information in this manuscript. Institutional Review Board (IRB) approval was not required. Competing Interests The authors declare no competing interests. References Mehrotra M, D’Cruz JR, Bishop MA, Arthur ME. Video-Assisted Thoracoscopy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 Mar 11]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK532952/ Dinic VD, Stojanovic MD, Markovic D, Cvetanovic V, Vukovic AZ, Jankovic RJ. Enhanced Recovery in Thoracic Surgery: A Review. Front Med. 2018;5:14. Homma T, Saji H, Shimada Y, Tanabe K, Kojima K, Marushima H, et al. Early chest tube removal within 6 hours after thoracic surgery results in improved postoperative prognosis and no adverse effects. J Thorac Dis. 2024 May 31;16(5):3096–106. Hansen HJ, Petersen RH. Video-assisted thoracoscopic lobectomy using a standardized three-port anterior approach - The Copenhagen experience. Ann Cardiothorac Surg. 2012 May;1(1):70. Chiang TY, Yin MF, Yang SM, Chen KC. Thoracoscopic management of incarcerated lung herniation after blunt chest trauma: a case report and literature review. J Thorac Dis. 2017 Mar;9(3):E253. Kuehlmann B, Bonham CA, Zucal I, Prantl L, Gurtner GC. Mechanotransduction in Wound Healing and Fibrosis. J Clin Med. 2020 May 11;9(5):1423. Leivaditis V, Grapatsas K, Papatriantafyllou A, Koletsis EN, Charokopos N, Dahm M. Surgical Repair of Spontaneous Lung Herniation Induced by Vigorous Coughing: A Case Report and Literature Review. Cureus. 2023 Apr;15(4):e37325. Miller DL, Force SD, Pickens A, Fernandez FG, Luu T, Mansour KA. Chest Wall Reconstruction Using Biomaterials. Ann Thorac Surg. 2013 Mar 1;95(3):1050–6. Chiang TY, Yin MF, Yang SM, Chen KC. Thoracoscopic management of incarcerated lung herniation after blunt chest trauma: a case report and literature review. J Thorac Dis [Internet]. 2017 Mar [cited 2025 Oct 13];9(3). Available from: https://jtd.amegroups.org/article/view/12542 Additional Declarations No competing interests reported. Supplementary Files mesh.mp4 Video 1. Video-assisted thoracoscopic surgery (VATS) showing Prolene® mesh anchoring for unusual complication of persistent pleural leakage post-VATS lobectomy. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 25 Jan, 2026 Reviews received at journal 22 Jan, 2026 Reviewers agreed at journal 21 Jan, 2026 Reviewers invited by journal 20 Jan, 2026 Editor assigned by journal 25 Oct, 2025 Submission checks completed at journal 25 Oct, 2025 First submitted to journal 23 Oct, 2025 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-7929416","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":578410164,"identity":"28176670-ba9d-4ae1-bca5-f4e0a16b1afb","order_by":0,"name":"Marco Lizwan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYPACCx4w9YGBIcGASC0SYC2MM0jRAiaZeYjRott+9uGHDwwSMvIzkp89ts2xyTNnYH746AZDnV0DDi1mZ9KNJWcAHcY4I83cOHdbWrFlA5uxcQ7D4WScWg6ksQHdI8HDLJ1gJp277XDihgM8bNI5DAeScTnM7PwziBY26fRv0pYILXW4tdyA2sIjnWMmzYjQwmyHW8szZskZBhI8EvJvyiR7t6UlbjgM8ovB4QTcDktj/PChwsZevuf4Nomf22wSNxxvfvg4p6LOHpcWCECJC2aISGIDfj1YAAFbRsEoGAWjYAQBAG1ZSt2Tq4/cAAAAAElFTkSuQmCC","orcid":"","institution":"National Heart Centre Singapore","correspondingAuthor":true,"prefix":"","firstName":"Marco","middleName":"","lastName":"Lizwan","suffix":""},{"id":578410165,"identity":"2325d5d7-a5e4-48a7-b710-166d6480a1c8","order_by":1,"name":"Cynthia Ming Li Chia","email":"","orcid":"","institution":"National Heart Centre Singapore","correspondingAuthor":false,"prefix":"","firstName":"Cynthia","middleName":"Ming Li","lastName":"Chia","suffix":""}],"badges":[],"createdAt":"2025-10-23 07:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7929416/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7929416/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100883988,"identity":"1202e0a1-5fd3-43d9-9396-1700c5deb7f7","added_by":"auto","created_at":"2026-01-22 11:41:52","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":172622,"visible":true,"origin":"","legend":"\u003cp\u003e(A-B) CT thorax showed a spiculated sub-solid peri-bronchial nodule in the superior segment of the right lower lobe. (C) PET/CT scan showed a 2.2 cm right lower lobe nodule with mild FDG-avidity and no metastasis (D) CT thorax showed no definite rim-enhancing collection detected at the right chest wall with a new small right pleural effusion.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7929416/v1/9772074281539dd071d5d18d.jpg"},{"id":100883982,"identity":"0e9e7d76-71c0-42b4-92fd-7687c5095c68","added_by":"auto","created_at":"2026-01-22 11:41:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":88752,"visible":true,"origin":"","legend":"\u003cp\u003eClinical progression: (A) fluid leakage from previous VATS access wound, (B) temporary bedside wound reinforcement, (C) intraoperative findings of pleural adhesions and effusion without lung herniation, (D) and definitive repair with gentamicin-soaked Prolene®. (E) Follow-up revealed a well-healed wound with no further leakage.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7929416/v1/11ce99b890f1d828e7e3cf21.jpg"},{"id":100884193,"identity":"669c0768-6118-4a1a-8918-bc1156f7de33","added_by":"auto","created_at":"2026-01-22 11:42:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":560647,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7929416/v1/91a011dd-7af1-4bb8-b9e2-5e6c1be1f1c6.pdf"},{"id":100884014,"identity":"34eb470c-0d33-46e6-abad-bd8d73190fda","added_by":"auto","created_at":"2026-01-22 11:41:55","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":301920560,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo 1. \u003c/strong\u003eVideo-assisted thoracoscopic surgery (VATS) showing Prolene® mesh anchoring for unusual complication of persistent pleural leakage post-VATS lobectomy.\u003c/p\u003e","description":"","filename":"mesh.mp4","url":"https://assets-eu.researchsquare.com/files/rs-7929416/v1/29d1cb87623c5111348681af.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Reinforcement Mesh Repair for Persistent Pleural Leakage Following VATS Lobectomy: A Case Report and Clinical Insights","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVideo-assisted thoracoscopic surgery (VATS) is widely adopted in thoracic surgery because it reduces postoperative pain, shortens hospital stays, and promotes faster recovery (1). Enhanced recovery protocols often advocate for early chest drain removal and discharge (2,3). However, very rarely, patients may present later with wound-related complications such as pleural fluid leakage through the access incision.\u003c/p\u003e\n\u003cp\u003eAlthough the clinical appearance may mimic lung herniation, the underlying mechanism is distinct: instead of lung parenchyma protruding through intercostal defects, persistent leakage entails escape of pleural fluid via a focal weakness in thoracic wall closure. This report describes such a case following early drain removal, treated with mesh reinforcement, and discusses management considerations.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 71-year-old Eurasian male ex-smoker with comorbidities including hypertension, hyperlipidaemia, glaucoma, cervical spondylosis, previous spinal surgery, bilateral knee replacements and appendectomy, was referred for evaluation of a suspicious right lung nodule. Computed tomography (CT) of the thorax showed a right lower lobe nodule suspicious for malignancy (Fig. 1A-B). Positron Emission Tomography (PET)/CT scan revealed \u0026nbsp;mild 18F-fluoro-2-deoxy-d-glucose (FDG) avidity and no evidence of metastasis (Fig. 1C). Brain magnetic resonance imaging (MRI) was negative for brain metastasis.\u003c/p\u003e\n\u003cp\u003eThe patient underwent a standard 3-port right VATS lower lobectomy with mediastinal lymph node dissection (4). Intraoperative air leak testing was negative and closure was uneventful. Patient was discharged well on post-operative day 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo weeks later, the patient presented to the emergency department with visible pleural fluid leaking from previous access wound (Fig. 2A). Clinical examination revealed no signs of lung herniation or wound dehiscence. Routine bloods were sent and C-reactive protein was 20 mg/L. CT thorax showed focal soft tissue thickening at the surgical site and a new small right pleural effusion (Fig. 1D), but no signs of lung herniation, pneumothorax or infection. Patient was empirically covered with PO Augmentin for possibility of early wound dehiscence from wound infection and the wound was also reinforced with two mattress sutures (Fig. 2B). Minimal leakage was noted after coughing and the patient was discharged.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, the patient re-presented the next day with persistent leakage. Given persistence despite conservative measures, the decision was made for VATS re-exploration. Intraoperatively, significant pleural adhesions were found, along with 300 mL of pleural effusion which was evacuated (Fig. 2C). No lung herniation or obvious air leak was observed. To prevent further leakage, Prolene® mesh soaked in gentamicin was anchored to the rib (Fig. 2D, Video 1), mimicking a lung herniation repair technique (5). Routine closure was then performed. This approach reinforced the thoracic wall defect, stabilised the wound, and provided local antimicrobial coverage to reduce the risk of postoperative infection. The surgical wound was closed routinely.\u003c/p\u003e\n\u003cp\u003ePatient was reviewed in the clinic 1-week and 2-week post-VATS exploration. During the clinic visit, his wound was healing well (Fig. 2E) and his repeat chest X-ray (CXR) was unremarkable.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case illustrates a rare postoperative complication in which persistent pleural fluid leakage occurred through the VATS access incision after an otherwise uneventful lobectomy and early drain removal. Although VATS has significantly improved perioperative outcomes through smaller incisions, reduced pain, and shorter hospitalization, the widespread implementation of enhanced recovery after surgery (ERAS) protocols has also shifted postoperative practice toward early drain removal and same-week discharge\u0026nbsp;(2,3). While this approach is safe and effective in the vast majority of patients, occasional delayed wound complications such as localized pleural leakage can arise. Awareness of such rare events is important to balance the benefits of accelerated recovery with patient safety.\u003cbr\u003e\u0026nbsp;\u003cbr\u003eThe mechanism underlying pleural fluid leakage through a VATS access wound likely involves multifactorial processes. Following lung resection, minor pleural fluid accumulation is common, particularly if postoperative exudation exceeds the absorptive capacity of the pleura. In cases where the intercostal closure is slightly weakened – due to surgical dissection, local tissue oedema, or mechanical stress – fluid may track externally through the tract of least resistance. Increased intrathoracic pressure from coughing or movement can then perpetuate this leakage\u0026nbsp;(6). In this elderly patient with multiple comorbidities, delayed tissue remodelling and collagen cross-linking likely contributed to reduced wound tensile strength. The dynamic mechanical forces of respiration, particularly at lateral chest wall sites used for VATS access, may further stress the intercostal musculature and fascial closure, creating a small communicating tract. Although such micro-dehiscence may not be apparent intraoperatively, it can become clinically evident once pleural pressure differentials increase after discharge.\u003cbr\u003e\u0026nbsp;\u003cbr\u003eIt is essential to differentiate such cases from wound dehiscence, infection, or lung herniation. True lung herniation involves parenchymal protrusion beyond the thoracic wall, usually accompanied by palpable bulging or radiographic evidence of extra-thoracic lung tissue\u0026nbsp;(7). In contrast, pleural leakage produces fluid seepage without tissue extrusion and may be associated with small serous collections on imaging rather than herniated parenchyma. Initial management should remain conservative, focusing on wound re-suturing, local compression, and empirical antibiotics if infection is suspected. Most small leaks resolve spontaneously as granulation tissue develops. However, persistent leakage despite conservative measures suggests a structural defect in the intercostal space or failure of the fascial seal, warranting surgical re-exploration.\u003cbr\u003e\u0026nbsp;\u003cbr\u003eIn this case, VATS re-exploration confirmed pleural adhesions and effusion but no herniation or air leak. Given the persistence of leakage despite bedside repair, reinforcement was required to ensure closure stability. Prolene® (polypropylene) mesh was chosen because it offers several distinct advantages: (i) mechanical strength to resist cyclical chest wall motion, (ii) resistance to infection due to its inert nature, and (iii) long-term durability in reconstructive applications\u0026nbsp;(8,9). Anchoring the mesh to the adjacent rib effectively redistributed mechanical tension across a wider surface, preventing recurrence and promoting fibrous tissue incorporation for long-term stability. Alternative strategies, such as muscle flap advancement or multilayer fascial closure, may suffice in cases with limited leakage or robust local tissue. However, in an elderly patient with fragile musculature and prior wound stress, mesh reinforcement provides an added safety margin without significant additional morbidity. The adjunctive use of gentamicin irrigation and mesh soaking provided localized antimicrobial coverage, potentially reducing the risk of subclinical infection – a prudent step in the setting of prior leakage.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Clinically, this case underscores the need for vigilance following early discharge under ERAS protocols, as patients may develop delayed wound-related complications. Judicious chest drain management remains crucial; while early removal reduces discomfort and hospital stay, drain duration should be individualized, especially in older patients or those with borderline output. Furthermore, this experience highlights the importance of tailoring management to each patient’s tissue characteristics and physiological context. Although most cases can be managed conservatively, prompt recognition of persistent pleural leakage and timely surgical intervention are vital to avoid chronic fistula formation or infection. Mesh reinforcement, in particular, offers a reliable option when conservative measures fail, ensuring durable thoracic wall integrity and preventing recurrence.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Persistent pleural leakage is rare and likely underreported, as mild cases may resolve spontaneously or remain unrecognized. This report contributes to the limited literature on thoracic wall complications unrelated to air leaks or infection. Further studies could evaluate the incidence of such leaks in ERAS populations and compare the outcomes of mesh versus non-mesh approaches. Additionally, the potential role of bioabsorbable or biologic meshes warrants investigation, as these materials may offer equivalent support with improved tissue integration and reduced long-term stiffness.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePersistent pleural fluid leakage through a VATS access wound, though extremely rare, is a worthwhile consideration in postoperative surveillance. When conservative measures prove insufficient and local structural weakness is suspected, mesh reinforcement may provide a durable, safe solution.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdditional data are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all individuals who were involved in the care for our patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eML wrote the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCMLC supervised the entire manuscript writing.\u003c/p\u003e\n\u003cp\u003eAll authors were involved in the patient’s care and have read and approved the final manuscripts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFundings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any grants from any funding agencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from patient to include the information in this manuscript. Institutional Review Board (IRB) approval was not required.\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"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMehrotra M, D\u0026rsquo;Cruz JR, Bishop MA, Arthur ME. Video-Assisted Thoracoscopy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 Mar 11]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK532952/\u003c/li\u003e\n\u003cli\u003eDinic VD, Stojanovic MD, Markovic D, Cvetanovic V, Vukovic AZ, Jankovic RJ. Enhanced Recovery in Thoracic Surgery: A Review. Front Med. 2018;5:14. \u003c/li\u003e\n\u003cli\u003eHomma T, Saji H, Shimada Y, Tanabe K, Kojima K, Marushima H, et al. Early chest tube removal within 6 hours after thoracic surgery results in improved postoperative prognosis and no adverse effects. J Thorac Dis. 2024 May 31;16(5):3096\u0026ndash;106. \u003c/li\u003e\n\u003cli\u003eHansen HJ, Petersen RH. Video-assisted thoracoscopic lobectomy using a standardized three-port anterior approach - The Copenhagen experience. Ann Cardiothorac Surg. 2012 May;1(1):70. \u003c/li\u003e\n\u003cli\u003eChiang TY, Yin MF, Yang SM, Chen KC. Thoracoscopic management of incarcerated lung herniation after blunt chest trauma: a case report and literature review. J Thorac Dis. 2017 Mar;9(3):E253. \u003c/li\u003e\n\u003cli\u003eKuehlmann B, Bonham CA, Zucal I, Prantl L, Gurtner GC. Mechanotransduction in Wound Healing and Fibrosis. J Clin Med. 2020 May 11;9(5):1423. \u003c/li\u003e\n\u003cli\u003eLeivaditis V, Grapatsas K, Papatriantafyllou A, Koletsis EN, Charokopos N, Dahm M. Surgical Repair of Spontaneous Lung Herniation Induced by Vigorous Coughing: A Case Report and Literature Review. Cureus. 2023 Apr;15(4):e37325. \u003c/li\u003e\n\u003cli\u003eMiller DL, Force SD, Pickens A, Fernandez FG, Luu T, Mansour KA. Chest Wall Reconstruction Using Biomaterials. Ann Thorac Surg. 2013 Mar 1;95(3):1050\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eChiang TY, Yin MF, Yang SM, Chen KC. Thoracoscopic management of incarcerated lung herniation after blunt chest trauma: a case report and literature review. J Thorac Dis [Internet]. 2017 Mar [cited 2025 Oct 13];9(3). Available from: https://jtd.amegroups.org/article/view/12542\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"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":"VATS lobectomy, pleural leakage, Prolene® mesh, pleural effusion, surgical reinforcement","lastPublishedDoi":"10.21203/rs.3.rs-7929416/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7929416/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Early chest drain removal and discharge are standard in enhanced-recovery protocols after video-assisted thoracoscopic surgery (VATS) lobectomy, but rare wound complications may arise. A 71-year-old man underwent uneventful 3-port right VATS lower lobectomy, with chest drain removal on postoperative day 2. Two weeks later, serous fluid leaked through the access wound. Conservative management with antibiotics and re-suturing failed. VATS re-exploration revealed pleural adhesions and 300 mL effusion without lung herniation. A gentamicin-soaked Prolene® mesh was anchored to reinforce the intercostal defect. The patient healed uneventfully with no recurrence. Persistent pleural leakage through a VATS access wound is rare but merits consideration. When conservative measures fail and structural weakness is suspected, mesh reinforcement offers a durable repair option.","manuscriptTitle":"Reinforcement Mesh Repair for Persistent Pleural Leakage Following VATS Lobectomy: A Case Report and Clinical Insights","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 11:39:40","doi":"10.21203/rs.3.rs-7929416/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-25T09:06:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-22T07:59:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244436653953112983015769487901972817418","date":"2026-01-22T00:44:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-20T15:20:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-25T04:37:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-25T04:36:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-10-23T07:09:40+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":"6434a561-e62d-46af-acc6-5cfc85323f7d","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T16:24:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-22 11:39:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7929416","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7929416","identity":"rs-7929416","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}