an 18-year - old male patient presented with pneumothorax on postoperative day four after the minimally invasive repair of pectus carinatum .
the pectus carinatum repair was performed using the sandwich technique , which involves a 33.02-cm press - molded internal bar and a 30.48-cm press- molded external bar ( fig .
a small- bore central venous access catheter was inserted to relieve the pneumothorax in a less invasive manner .
a chest computed tomography scan indicated the presence of multiple bullae at the apex of the upper lobe of the right lung .
on postoperative day seven after the pectus repair , three days after the development of pneumothorax , we decided to remove the bullae through video - assisted thoracoscopic surgery ( vats ) because the lung collapse was persistent . under general anesthesia , using double - lumen endotracheal intubation with the patient in the left lateral decubitus position , a 10-mm thoracoscopic port was placed at the eighth intercostal space of the middle axillary line , below the pectus bar insertion level in order to avoid bar interruption .
a 2-cm working incision was made at the fourth intercostal space of the anterior axillary line and a 5-mm working port incision was made at the subscapular tip area of the posterior axillary line for a three - port vats approach .
vats exploration using a 30 thoracoscope ( karl storz endoscope ; karl storz , tuttlingen , germany ) revealed minimal hemothorax and multiple apical multiple bullae as indicated by the preoperative computed tomography scan .
a finding that we did not anticipate was that the middle lobe of the right lung was entrapped between the chest wall and the pectus bar .
adhesion was present around the pectus bar and the entrapped lung , but we did not observe air leakage at that moment ( fig .
the entrapped lung was separated from the adhesion and carefully pulled out of the pectus bar . however , a portion was injured , and it had to be resected with endostaplers ( tristapler ; covidien , norwalk , ct , usa ) .
an air leak test confirmed that both resected areas of the apex and the entrapped middle lobe were airtight .
bio - absorbable felt ( neoveil ; gunze , osaka , japan ) was used to cover the lesions , followed by glue injection on the resected lesions .
pectus deformity repair using pectus bars is a standard operation to correct pectus excavatum that has been widely performed since its development in 1998 by donald nuss .
pneumothorax is one of the early postoperative complications of this procedure , and is caused by an incidental lung injury or air that was retained during the surgical procedure . in order to prevent this early complication , we routinely insert hemovac catheters into the bilateral pleural cavities in cases of the parallel insertion of two bars , intrapleural procedures , such as suturing for the placement of hinge plates , or in adult cases
. however , primary spontaneous pneumothorax , caused by the rupture of subpleural blebs or bullae , may occasionally occur in combination with pectus repair .
in such instances , it is difficult to determine the etiology of the pneumothorax and the subsequent treatment strategy .
initially , pneumothorax can be conservatively managed by chest tube or catheter insertion , but prolonged air leakage or recurrent pneumothorax must be treated by thoracoscopic wedge resection .
lung entrapment by surgical hardware is sharply distinct from usual cases of trapped lung , in which a part of the lung is unexpandable due to pleural inflammation , the development of adhesion after a surgical procedure , such as coronary artery bypass surgery , or pleural diseases including empyema , hemothorax , tuberculosis , and pleuritic .
the entrapment of part of the lung can occur in pectus repair using pectus bars , and it may be difficult to recognize without surgical exploration .
our vats finding , although it was incidentally discovered during a surgical procedure for pneumothorax , clearly demonstrated that the lung was caught between the pectus bar and the chest wall in our patient . in our case
, a sizable portion of the parenchyma of the right middle lobe was caught between the pectus bar and the anterior chest wall , with adhesions formed around it .
the cause of pneumothorax was uncertain in this case because no definitively identifiable ruptured bullae were leaking air at the time of surgery .
although the air leak points in the entrapped lung were also uncertain , we thought that the damaged lung may have been leaking air , which may have been the cause of the pneumothorax .
our surgical approach , therefore , combined resecting all bullae that we encountered and relieving the lung entrapment , which was ultimately accompanied by the removal of some damaged lung tissue .
we report a case of spontaneous pneumothorax involving lung entrapment in a pectus bar and multiple bullae in the lung .
this case demonstrates that pectus repair may be complicated by lung entrapment in the pectus bar .
 we report a case of an entrapped lung after the pectus bar repair of a pectus deformity . 
 the entrapped lung was found incidentally during video - assisted thoracoscopic surgery ( vats ) for pneumothorax . based on vats exploration 
 , multiple bullae seemed to be the cause of the pneumothorax , but the entrapped lung was suspected to have been a cause of the air leakage . 
CASE REPORT
DISCUSSION