Delayed splenic rupture following video-assisted thoracoscopic left upper lobectomy: a case report and literature review.

Video-assisted thoracoscopic surgery (VATS) is the preferred surgical approach for early-stage lung cancer, though it can rarely cause life-threatening delayed splenic rupture (DSR). With an insidious latent course, DSR frequently eludes early diagnosis and may progress to fatal hemorrhagic shock. We herein describe a 70-year-old male with a prior subtotal gastrectomy who developed DSR on postoperative day 6 after VATS left upper lobectomy. The patient presented with acute hypotension and tachycardia without overt abdominal signs, was confirmed via bedside ultrasonography (US) and diagnostic peritoneal paracentesis (DPP), and recovered uneventfully after emergency splenectomy. A pooled analysis of nine cases revealed that VATS-related DSR predominantly complicates left-sided thoracic surgery, manifesting as hemodynamic instability and progressive hematological decline with subtle abdominal findings, which commonly leads to early misdiagnosis. Major etiologies include intraoperative transdiaphragmatic injury and postoperative diaphragmatic traction aggravated by abdominal adhesions. Contrast-enhanced computed tomography (CT) remains the diagnostic gold standard for stable patients, while bedside US and DPP enable prompt emergency diagnosis. Individualized management is tailored to hemodynamic status and splenic injury severity. Meticulous intraoperative technique, rigorous postoperative monitoring, and high clinical vigilance, particularly for patients with abdominal adhesions, are critical to prevent DSR, reduce diagnostic delay, and optimize surgical outcomes.