A rare complication of video-assisted thoracoscopic surgery: lung herniation retrospective case series of three patients and review of the literature

Introduction
Lung herniation is defined as a protrusion of the lung parenchyma with its pleura through the intercostal space. It is a rare condition and usually occurs after thoracic trauma and surgical interventions. A few cases of lung herniations have been reported after video-assisted thoracoscopic surgery (VATS) but only two cases have been reported after VATS lobectomy.

Aim
The VATS procedure has become the dominant method of lung cancer surgery, but there is no case series about the complications of lung herniation in the literature. We aim to define some risk factors and possible ways of prevention of lung herniation after VATS resection.

Material and methods
This study retrospectively analyses 650 (550 anatomic, 100 non-anatomic sublobar resections) patients who underwent lung resections for lung cancer in our department between 2012 and 2018. We detected lung herniation in 3 patients after VATS resection.

Results
Asymptomatic lung hernias may be managed by close observation but because of the risk of incarceration of the pulmonary parenchyma, surgery is often necessary. The main steps of treatment involve: identification of the hernia, freeing of all adhesions, reduction of the lung tissue back into the thoracic cavity and repairing the defect of the chest wall.

Conclusions
By this retrospective case series, we defined some patient-related and surgeon-related risk factors and some basic recommendations for prevention of this complication.