Lung adenocarcinoma surgery complicated by postoperative chest wall hernia

What happened, in summary

This 71-year-old man underwent 3-port video-assisted thoracoscopic surgery for lung adenocarcinoma. The operation was a left lower lobectomy with lymph node dissection, and it required extensive adhesiolysis because of scar tissue inside the chest. The main utility incision was a 4 cm cut in the anterior fourth intercostal space. The incision was closed in layers, including the chest wall muscles, but the ribs were not reapproximated with a pericostal stitch. Soon after surgery, chest X-rays showed a residual pleural air space that persisted after the chest drain was removed. One week later, coughing caused intermittent swelling at the incision site, with reducible air under the skin. The skin was soft and not tender, and there were no inflammatory signs. Doctors initially chose conservative monitoring because he was still early in the postoperative period. One month later, the cough-related swelling persisted, and imaging still showed a residual pleural space. The findings confirmed a postoperative chest wall hernia rather than a fluid collection or infection. He then underwent surgical repair. Surgeons found a 5 cm hernia sac and absence of the intercostal and chest wall muscle layers at the defect. A Vicryl mesh was sutured into the intercostal defect, and the chest wall muscles were closed with interrupted sutures. He went home on postoperative day 3 after hernia repair. This follow-up focused on healing of the chest wall defect and the unusual relationship between residual pleural air space, coughing, and wound separation after lung surgery. At 6 months, the chest wall hernia had not recurred.