This case report describes a rare case of an acquired anterior thoracic lung herniation in a 63-year-old female that developed four years after video-assisted thoracic surgery (VATS) for lung cancer resection and adjuvant radiation for breast cancer. The 8 cm x 10 cm chest wall defect was reconstructed with mesh and reinforced with a latissimus dorsi flap. The authors believe the herniation was caused by intercostal muscle denervation from the distant VATS and soft tissue damage from radiation. The patient had complete resolution of symptoms after surgical repair. The case demonstrates that lung herniation can occur remotely from VATS incision sites due to potential nerve or muscle injury during the procedure.

1. 1
Acquired Anterior Thoracic Lung Herniation and Repair: A Rare Case and Discussion
Alyssa C. Fazi1
, Meghan L. Davis1
, Susan Kurian1
, W. Thomas McClellan, M.D.2
1. West Virginia University School of Medicine, Morgantown, W.Va
2. Plastic and Reconstructive Surgery, West Virginia University, Morgantown, W.Va
Corresponding Author Information:
Dr. W. Thomas McClellan, M.D.
West Virginia University, Division of Plastic and Reconstructive Surgery
1085 Van Voorhis Road, Suite 350
Morgantown, W.Va 26505
wtmcclellan@gmail.com

2. 2
Acquired anterior thoracic lung herniation and repair: a rare case and discussion.
Alyssa Fazi, Meghan Davis, Susan Kurian
West Virginia University School of Medicine, Morgantown, W.Va
W. Thomas McClellan M.D.
Plastic and Reconstructive Surgery, West Virginia University, Morgantown, W.Va
SUMMARY: We report a case of acquired anterior thoracic lung herniation in a 63-year-old female. This painful
herniation developed four years after uncomplicated video-assisted thoracic surgery for lung cancer resection
and adjuvant radiation for concomitant breast cancer. The herniation site was remote from all prior incisions,
and demonstrated intercostal muscle denervation and radiation fibrosis. The 8 cm x 10 cm chest wall defect
was reconstructed with inlay PROCEED mesh and reinforced with a pedicled latissimus dorsi flap. Five months
postoperatively the patient had complete resolution of symptoms, no evidence of herniation, and a stable
wound.
INTRODUCTION: Traumatic lung herniation is a rare condition that may result from blunt force or as a
complication of video-assisted thoracic surgery (VATS). There is evidence that small incisions from
thoracoscopic procedures have a higher risk for lung herniation than incisions from larger, more invasive
thoracic surgeries1
. This increase in risk is possibly due to the nature of incision closure, which is often less
precise in VATS2,3
. To our knowledge, there have been no reported cases of acquired lung herniation at sites
distant from VATS incisions when thoracoscopic damage is suspected. Intercostal nerve injury is a likely
etiology of remote herniation and has previously been implicated in post-thoracotomy pain syndrome4
.
Most lung hernias are asymptomatic2
. However,
symptomatic patients may present with bulging through the
chest wall, which becomes more apparent upon coughing
or Valsalva. Symptomatic lung hernias are associated with
pain and shortness of breath5
. Computed tomography (CT)
scans are best used to demonstrate features of a lung
herniation. CT scans can both clearly identify hernia
dimensions and highlight defects in the thoracic wall and
pleural space. Traditional x-rays are insufficient to confirm
a diagnosis because lung herniation and thoracic wall
defects will not be apparent unless they are at an exact
tangent to the x-ray plane6
.
CASE PRESENTATION: We present a rare case of
acquired lung herniation through the right anterior
intercostal space in a 63-year-old female. The patient
presented with a six-month history of worsening right chest
pain exacerbated by coughing, Valsalva, and associated
dyspnea. There was a visible 10 cm protrusion of lung and
pleural tissue in the third intercostal space at the
midclavicular line (Fig. 1).
Fig. 1. Appearance of chest bulging upon deep breathing,
coughing, or Valsalva.

3. 3
The patient is a former smoker with COPD
who underwent a lumpectomy and adjuvant
radiation for stage 1 breast cancer, four
years prior. During radiation treatment, a
VATS right upper lobectomy was performed
to remove a primary bronchoalveolar
carcinoma. The lung herniation was remote
to previous incision sites from both the
lumpectomy and VATS procedures.
A chest CT scan demonstrated herniation of
lung tissue through the anterior third
intercostal space. No evidence of recurrent
malignancy was identified. All other
radiographic and laboratory values were
normal.
Repair focused on reduction of the lung
components, identification of the complete
defect, creation of a stable hernia repair,
and coverage with well-vascularized overlay
tissue. The right pectoralis major muscle was
reflected to expose the 10 cm defect in the
third intercostal space. No identifiable
intercostal muscle or tissue existed between
the two rib segments from the sternocostal
junction to the midclavicular line (Fig. 2).
Adherent pleura was dissected, the full
scope of the defect was delineated, and a
chest tube was placed. PROCEED mesh
was used as an inlay and secured with
cerclage sutures to surrounding ribs (Fig. 3).
The pectoralis major muscle was repaired
over the mesh and an ipsilateral pedicled
latissimus flap was inset over the defect field
for well-vascularized soft tissue
reinforcement. (Fig. 4).
The patient was discharged on postoperative
day 4 with a viable flap and no signs of
infection or pneumothorax. She had
aggressive physical therapy postoperatively
and retained full range of motion and
strength. At six months, she had no pain or
bulging in the right chest upon cough or
Valsalva.
Fig. 2. Initial appearance of the defect in the third intercostal space. No
intercostal muscle was identified in this position. Pectoralis major muscle
has been reflected.
Fig. 3. Inlay PROCEED Mesh repair of the defect, positioned with cerclage
around the ribs with PDS.

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DISCUSSION: Lung hernias are
subdivided into congenital and acquired
cases. Congenital lung hernias account
for 18% of cases and involve
developmental chest wall defects.
Acquired lung hernias can be further
classified as traumatic, spontaneous, or
pathologic. Traumatic events include
surgical procedures and blunt force.
Spontaneous lung hernias can be
triggered by chronic coughing, COPD,
forceful Valsalva, chronic steroid use, or
heavy lifting3
. Pathological events leading
to lung herniation may be inflammatory or
neoplastic in nature7
.
Lung hernias are also classified by
location. Seventy percent are thoracic,
while the remainder are cervical and
diaphragmatic8
. The anterior chest wall is
inherently prone to lung herniation
because only a single layer of intercostal
muscle exists parasternally3,9
. Lateral and
posterior lung herniations are rarely problematic due to the greater support provided by side and back
muscles6,10
.
We believe the lung herniation presented here was likely caused by a combination of events including
denervation of muscle in the third intercostal space, resulting from distant VATS, and soft tissue damage from
radiation. Fibrosis of muscles after radiation compromises blood supply and innervation, which possibly
contributed to the defect. Muscles themselves can also become weakened and easily fatigued following
radiation11
.
There are multiple points during VATS procedures at which injury may occur. The incision may be made with
less care, leading to muscle or fascial injury, costal cartilage damage, or muscle denervation. There may also
be damage from excessive cauterization or poor dissection2,3
. However, this case of lung herniation after
uncomplicated VATS demonstrates a chest wall defect that was both temporally and spatially remote from the
incision site.
The large and worsening defect in this patient required surgical repair. Although smaller defects in the chest
wall can be approached with mesh and rib suturing alone, lung hernias due to missing ribs or extensive trauma
may require the support and blood supply associated with muscle flaps2
. A latissimus dorsi muscle flap was
used to reinforce the large inlay mesh repair and provide a reliable source of vascularized tissue to the
radiated field. Pedicled muscle flaps are well-tolerated by patients in other procedures. In this case, it resulted
in both long-term reduction of the hernia and regaining of strength and range of motion.
CONCLUSION: Many procedures using thoracoscopy can also be performed in a more invasive manner, but
patients often elect the use of VATS over an open procedure with hopes of a better cosmetic result. While
thoracoscopy involves a small incision, less cost, and a shorter hospital stay, lung herniation through the
Fig. 4. A pedicled latissimus dorsi myocutaneous flap was positioned over the
mesh repair and pectoralis muscle for reinforcement of the thoracic defect.

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incision site is a distinct possibility. The risks and consequences of lung herniation must be weighed against
the benefits of thoracoscopy. With the growing use of VATS, iatrogenic nerve or muscle injury may soon
become a common cause of traumatic lung herniation. Greater understanding of lung herniation etiology and
implementation of better thoracoscopic techniques that minimize such complications are both warranted.
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