Abstract / Summary
Abstract Background Port-site intercostal lung hernia (ILH) is an exceedingly rare complication following video-assisted thoracoscopic surgery (VATS), historically managed via urgent surgical reconstruction. The predisposing role of subclinical thoracic sarcopenia, the biomechanical limitations of passive lung reduction, and the feasibility of structured conservative management for acute incarcerated ILH remain poorly characterized. Case Presentation A 71-year-old Asian male with preoperatively documented thoracic muscle weakness and subclinical sarcopenia underwent uneventful VATS combined segmentectomy. Five hours following routine chest tube removal on postoperative day 4, a violent paroxysm of coughing triggered an acute intercostal lung hernia with extensive subcutaneous emphysema. An intentional atmospheric pneumothorax maneuver aimed at inducing passive lung retraction paradoxically failed due to an acute "collar effect"—a constricting ring formed by rapid parenchymal edema and reactive intercostal spasm. In the absence of parenchymal ischemia or strangulation, urgent re-exploration was avoided in favor of a structured non-operative protocol: focal bolster counter-pressure, continuous low-pressure pleural water-seal venting, aggressive intrathoracic pressure suppression, and serial dynamic computed tomography (CT) tracking. The incarcerated parenchyma progressively decompressed, achieving complete spontaneous reduction by postoperative day 12 and full anatomical restoration by postoperative day 16 without recurrence. Conclusions Subclinical thoracic sarcopenia and post-drain removal cough dynamics can precipitate port-site lung herniation. Incarcerated lung tissue may resist passive pneumothorax collapse due to the intercostal collar effect. A structured, pressure-regulated conservative regimen provides a safe, lung-preserving alternative to redo surgery in carefully selected patients without strangulation.