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Ann Thorac Surg 1997;63:327
© 1997 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Role of Videothoracoscopy in Chest Trauma

Department of General and Thoracic Surgery, Hôpital d'Instruction des Armées Percy, Clamart; Department of General and Thoracic Surgery, Hôpital Pasteur, Nice; Department of Thoracic Surgery, Hôpital Central, Nancy; and Department of Thoracic and Vascular Surgery, Hôpital Avicenne, Bobigny, France

Accepted for publication August 28, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. The aim of this study was to evaluate videothoracoscopic procedures in the setting of chest trauma.

Methods. We retrospectively analyzed our experience of videothoracoscopy in patients with either blunt trauma or penetrating thoracic injuries.

Results. Forty-three procedures involving 42 patients were performed between July 1990 and April 1996. Indications for videothoracoscopy included suspected diaphragmatic injury (14 patients), clotted hemothorax (12), continued hemothorax (6), persistent pneumothorax (5), intrathoracic foreign body (4), posttraumatic chylothorax (1), and posttraumatic empyema (1 patient). Ten patients (24%) required conversion to thoracotomy. Two patients suffered postoperative pneumonia. There was one perioperative death. Mean hospital stay was 17 days; 21 days for patients with blunt trauma and 13 days for patients with penetrating injuries. There was no procedure-related complication. Videothoracoscopy allowed precocious discharge of patients suffering penetrating injuries and allowed faster recovery in the majority of patients suffering severe blunt trauma.

Conclusions. Videothoracoscopy appears to be a safe, accurate, and useful approach in selected patients with chest trauma. It is ideal for the assessment of diaphragmatic injuries, for control of chest wall bleeding, for early removal of clotted hemothorax, for treatment of empyema, for treatment of chylothorax, for treatment of persistent pneumothorax, and for removal of intrathoracic foreign body. However, we do not recommend the use of this technique in the setting of suspected great vessel or cardiac injury.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Although the majority of chest trauma does not require major operations and tube thoracostomy remains the basis of treatment, any patients who would have required thoracotomy a few years ago may actually benefit from less invasive surgical techniques to perform diagnostic or therapeutic procedures. Rapid improvements in endoscopic surgical technique and instrumentation expanded the indications of videothoracoscopy in the diagnosis and treatment of diseases of the chest, but its use remains controversial in the trauma setting. Recent publications suggested the interest of videothoracoscopy for the diagnosis or treatment of traumatic diaphragmatic injuries, clotted hemothoraces, or continued hemothoraces in hemodynamically stable patients [1–4].

Four French surgeons, all members of the Thorax Group, decided to evaluate videothoracoscopy in various surgical procedures performed in the setting of chest trauma. We retrospectively analyzed our experience from July 1990 to April 1996 to confirm the usefulness of videothoracoscopy and to determine indications for its use in patients with blunt chest trauma or penetratingthoracic injuries. Our analysis forms the content of this article.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Patients admitted for chest trauma who underwent videothoracoscopic evaluation or treatment in our four hospitals from July 1990 to April 1996 were enrolled in the study. Patients were divided into seven groups as described in Table 1. Continued bleeding was defined as ongoing blood loss greater than 1,500 mL/24 Patients with exsanguinating hemorrhage, with bleeding greater than 200 mL/h for 2 to 4 hours, with systolic arterial pressure less than 90 mm Hg, or those with hemodynamic instability were not considered for videothoracoscopic evaluation and underwent immediate thoracotomy. Clotted hemothorax was defined as residual clot estimated to be greater than 500 mL, which occupied at least one-third of the hemithorax (chest computed tomographic scan estimation) and could not be evacuated by nonoperative methods including thoracocentesis, tube thoracostomy, and pleural irrigation. Diaphragmatic injuries were systematically suspected in patients with blunt trauma and abnormal chest roentgenograms or equivocal computed tomographic scan, and in patients with penetrating wounds in proximity to the diaphragm. Proximity to the diaphragm was considered as a penetrating wound located at the level or below the fourth intercostal space anteriorly, sixth intercostal space laterally, and eight intercostal space posteriorly. Patients requiring emergent celiotomy were not considered for immediate videothoracoscopic evaluation. In addition, patients with other suspected injuries were not considered for immediate videothoracoscopy, which included: hemodynamic instability or systolic arterial pressure less than 90 mm Hg; suspected great vessels/cardiac wound; suspected great vessels/cardiac blunt injury; widened mediastinum (more than 8 cm); suspected tracheobronchial wound/rupture; continued bleeding more than 200 mL/hour; initial drainage more than 1,500 mL; and inability to tolerate one-lung ventilation or lateral decubitus position.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
A total of 43 procedures were performed from July 1990 to April 1996. Twenty-two procedures involved the right side, and 21 the left side. There were 34 men and 8 women in our study population. The mean age was 37 ± 15 years (range, 17 to 75 years). The mechanisms of trauma and indications for operation are reported in Tables 1 and 2. The mean delay between chest trauma and videothoracoscopy was 14 days (range, 0 to 212 days), being 22.7 days for blunt trauma and 5.7 days for penetrating trauma (1 patient was excluded in this group). Thirty-three percent of patients were operated on within the first 24 hours, and in this subgroup 85.7% suffered penetrating thoracic injuries. The mean hospital stay was 17 days (range, 4 to 103 days); 21 days for patients with blunt trauma and 13 days for patients with penetrating trauma. Fifteen patients had a preoperative chest computed tomographic scan and 26 had preoperative tube thoracostomy for either pneumothorax or hemothorax, or both. Four patients underwent previous celiotomy for intraabdominal bleeding before videothoracoscopic procedure was performed. Ten patients required conversion to thoracotomy for achievement of thoracic duct suture repair (1 patient), for repair of large diaphragmatic defect (7), for adequate decortication (1), and for systematic pericardial exploration (1 patient). There was no procedure-related complication. There was one perioperative death 36 hours after removal of an intrapericardial bullet, and 2 patients suffered postoperative pneumonia.

One patient underwent videothoracoscopy for posttraumatic empyema. He sustained a trunk gunshot wound and had undergone emergency celiotomy for intraabdominal bleeding (spleen and colon injuries). At celiotomy, a left hemidiaphragm defect was found and sutured. Four days later the patient developed a typical empyema in the left hemithorax. He was successfully managed by a videothoracoscopic approach, which consisted in evacuation and aspiration of all infected pleural fluid, removal of fibrinous material, and high-pressure irrigation of the pleural cavity. Chest tubes were removed 6 days later and the patient was discharged home a few days after.

Fourteen patients underwent videothoracoscopic approach for suspected diaphragmatic injury (Table 3). After entering the thoracic cavity, blood clots, if present, were carefully removed. The mediastinum, pericardium, chest wall, lung, and diaphragm were carefully inspected. In 7 patients no diaphragmatic injury was found and two chest tubes were placed under direct vision through the previous trocar sites. Two patients with penetrating injuries to the diaphragm required conversion to a 5-cm minithoracotomy for optimal exposure and repair. Four patients with blunt diaphragmatic injuries required conversion to thoracotomy because of extensive defect, disinsertion of the hemidiaphragm, or herniation of abdominal organs. In these patients, the thorax was entered through a posterolateral thoracotomy and the diaphragm was repaired using standard techniques. One additional patient with an unsuspected blunt diaphragmatic injury underwent the same procedure (Table 4).

Four patients underwent videothoracoscopic removal of symptomatic intrathoracic foreign bodies (Table 5). In those patients, videothoracoscopy allowed complete inspection of the chest cavity and precise evaluation of the projectile path. The only death in our study occurred after videothoracoscopic removal of an intrapericardial bullet. The patient probably died of acute ventricular arrhythmia at the 36th hour. One patient in this group underwent a contralateral procedure for removal of clotted hemothorax during the same anesthesia.

One patient underwent videothoracoscopic procedure for evaluation of recurrent right chylothorax. He suffered blunt chest trauma 5 weeks before, and was unresponsive to appropriate tube thoracostomy, medical regimen, and repeated thoracocentesis. At operation, the surgeon discovered a transection of the thoracic duct just above the aortic hiatus. The operation was converted to a 5-cm minithoracotomy for optimal exposure and the surgeon performed a suture repair of the thoracic duct. The patient had an uneventful postoperative course and was discharged home 10 days later. Five years after, he is still asymptomatic.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Although videothoracoscopic techniques have gained wide acceptance for the treatment of many thoracic diseases their use remains controversial in the trauma setting, and few surgeons reported their positive experience with such techniques in patients with either blunt trauma or penetrating thoracic injuries [1–7]. The present study was undertaken to confirm the role of diagnostic or therapeutic videothoracoscopic procedures in the management of patients with chest trauma, and to confirm or suggest contraindications to videothoracoscopy in this setting.

Diaphragm
The diagnosis of diaphragmatic injury resulting from penetrating thoracic or thoracoabdominal trauma may be difficult to establish. Thus, commonly used diagnostic modalities including chest radiography, computed tomography, and diagnostic peritoneal lavage remain inadequate for the reliable diagnosis of diaphragmatic injuries, missing approximately 30% of injuries [8–10]. Most of these injuries are diagnosed at exploratory celiotomy or thoracotomy. However, minimal defect or posterior injury can be missed at celiotomy if both hemidiaphragms are not carefully inspected [8, 9]. Moreover, indications for surgical intervention in asymptomatic patients with penetrating thoracoabdominal injuries still remain controversial because of a 30% rate of negative celiotomies [3]. In addition, in spite of favorable reports, laparoscopy may be inadequate and potentially dangerous in patients with diaphragmatic injuries [11]. Unlike laparoscopy with pneumoperitoneum, videothoracoscopy obviates the risk of tension pneumothorax as insufflation is not required, and it allows an excellent visualization of all parts of the diaphragm. For these reasons, some researchers advocated the systematic use of videothoracoscopy in selected patients with penetrating thoracoabdominal trauma [1–3]. In our experience, we found a similar usefulness for videothoracoscopy in identifying (7 patients) or excluding (7 patients) diaphragmatic injuries, and therefore, in avoiding 50% of unnecessary celiotomies or thoracotomies. As reported by other investigators, only small diaphragmatic lacerations (1 to 3 cm) resulting from penetrating injury can be repaired using endoscopic techniques [1, 3]. Larger defects required conversion to a minithoracotomy for optimal exposure and repair in two of our patients. Diaphragmatic ruptures resulting from blunt trauma always required conversion to thoracotomy in our experience, as in others' [2].

Clotted Hemothorax
The development of posttraumatic clotted hemothorax still remains a difficult problem for the thoracic surgeon. Despite adequate tube thoracostomy, a small percentage of patients will have development of a residual hemothorax that will not be reabsorbed spontaneously, and will even cause respiratory embarrassment, become infected, or evolve to fibrothorax, and finally require decortication [6, 12]. Considering these complications, recent articles emphasized the beneficial role of videothoracoscopy in early removal of clotted hemothorax [1, 4]. However, it was stated that procedures performed after the 10th day were relatively harder, and those performed later often required conversion to thoracotomy because of extensive pleural adhesions and presence of a dense fibrous peel requiring decortication [1, 4]. In our experience, 10 patients were operated on after a 10-day period, and all procedures except for one could be achieved using exclusively videothoracoscopic techniques, with no patient requiring secondary thoracotomy for decortication or empyema. We found videothoracoscopy to be particularly useful in the delayed management of patients with blunt chest trauma. Those patients usually suffer multiple life-threatening injuries and may require several orthopedic, neurosurgical, or abdominal surgical procedures before considering a residual hemothorax. Those patients are referred after the acute period, but still remain "fragile" patients. A minimally invasive videothoracoscopic procedure that permits early recovery and provides less postoperative pulmonary dysfunction seems more appropriate than a classic thoracotomy in this indication.

Posttraumatic Empyema
In our experience, only 1 patient was treated for posttraumatic empyema. As Landreneau and colleagues stated [4], we estimate that the early videothoracoscopic approach is ideal for the management of posttraumatic empyema because it can effectively assist in controlling the fibrinopurulent phase of empyema and in removing infected hemothorax before it progresses to the fibrotic phase and definitive pleural sequelae. However, if the procedure is performed late, recognition of a dense fibrotic pleural peel associated with a trapped lung should lead the surgeon to convert to thoracotomy to adequately decorticate the lung.

Chylothorax
Traumatic injury to the thoracic duct is a rarely reported complication in the setting of chest trauma [13]. Although various surgical approaches have been described for more than 40 years [14], videothoracoscopy appears now as a reliable and minimally invasive approach for ligation or suture repair of the thoracic duct. We actually consider that all cases of posttraumatic chylothorax may benefit from videothoracoscopic procedures if they persist after a 10-day period of appropriate medical management and tube thoracostomy. In case of poor exposure or technical difficulty, the surgeon may convert to a minithoracotomy, as in our case, to achieve optimal repair.

Continued Bleeding
The majority of patients with chest trauma are presently successfully managed by insertion of a chest tube and expectant monitoring of the drainage and vital signs. However, this conservative approach delays definitive treatment in the minority of patients finally requiring operation [15–17]. In addition, some patients may rapidly exsanguinate after apparent stabilization of bleeding before treatment can be instituted [18]. For these reasons, some surgeons advocated systematic use of thoracoscopy, and more recently of videothoracoscopy, in the management of selected patients with traumatic hemothorax and continued bleeding [1, 6]. In our 6-year experience of video-assisted thoracic surgery, we often achieved hemostasis of bleeding chest wall vessel by monopolar diathermy or surgical endoscopically applied clips. However, in patients with initial important bleeding and secondary stabilization, especially when there was arterial bleeding, we recommend great prudence because removing a clot may release a dramatic hemorrhage that is almost impossible to control under videothoracoscopy because of lack of visualization. In these cases, immediate conversion to thoracotomy should be performed to achieve hemostasis under direct vision. Likewise, if a major vessel injury is diagnosed at videothoracoscopy, immediate conversion should be performed. Although few patients have been enrolled in our study, we estimate that early videothoracoscopic approach may advantageously decrease the hospital stay by allowing direct aspiration of hemothorax, and by allowing direct hemostasis of bleeding vessels or pulmonary parenchyma. Thus, by reducing the risk of posttraumatic clotted hemothorax and empyema and by permitting a rapid and direct assessment of the thoracic cavity, videothoracoscopy appears now as an interesting diagnostic and therapeutic tool in selected patients with continued bleeding. Recently, Uribe and colleagues [3] proposed the use of this technique to rule out pericardial or cardiac injuries in patients with penetrating trauma. In addition, they advocated the use of videothoracoscopy for evaluation of patients with suspected mediastinal injuries including those with transthoracic gunshot wounds. Actually, and in the absence of conclusive data demonstrating benefit, we do not believe this attitude to be safe. According to our experience, we often prefer subxiphoid pericardial window, median sternotomy, or thoracotomy for the management of such patients.

Pneumothorax
Pneumothorax is extremely frequent both in blunt and penetrating trauma and tube thoracostomy remains the mainstay of treatment [19]. Air leaks usually resolve in a few days. However, air leaks may persist in patients requiring mechanical ventilation and particularly high-level positive end-expiratory pressure, as in patients with large lung laceration, or in patients as ours with broken rib fragment penetrating the pulmonary parenchyma. In those patients, videothoracoscopy allows a direct stapling of the air leak zone and aspiration of associated hemothorax significantly accelerating patient's recovery. In our experience, this was always a simple procedure requiring approximately 20 to 30 minutes to be performed.

Intrathoracic Foreign Body
An other aspect of the usefulness of videothoracoscopy in the setting of chest trauma is the possibility to remove intrathoracic foreign bodies expeditiously in a less invasive way than thoracotomy. However, we still estimate, as other investigators do, that asymptomatic patients with intrathoracic foreign bodies including bullets in proximity to a major vessel should not be operated on [20]. The efficacy and rapidity of a videothoracoscopic procedure should not be an argument to operate on asymptomatic patients.

According to our present experience, we consider videothoracoscopy as a very useful adjunct in our current practice for the management of selected patients with chest trauma. However, we agree that our study can only suggest the beneficial use of this technique because it suffers from three major limitations: (1) we report on a small number of patients including acute and chronic cases, (2) this is not a prospective study comparing videothoracoscopy and thoracotomy in the trauma setting, and (3) all procedures were performed exclusively by senior thoracic surgeons who have extensive experience of videothoracoscopy and chest trauma. As a result, there were no iatrogenic injuries or increased morbidity from the learning curve associated with the use of video-assisted thoracic surgery.

In conclusion, videothoracoscopy is a safe, accurate, and useful diagnostic and therapeutic tool in the acute management of selected patients with penetrating chest trauma and no indication for emergent thoracotomy or sternotomy. It is also useful in the acute or delayed management of patients with blunt trauma for removal of clotted hemothorax, for treatment of thoracic empyema, for treatment of persistent pneumothorax, for treatment of recurrent or continued chylothorax, and for diagnosis of diaphragmatic injuries. However, we do not recommend use of videothoracoscopy in the setting of suspected cardiac or pericardial injury.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Jancovici, Service de Chirurgie Générale et Thoracique, Hôpital d'Instruction des Armées Percy, 101 ave Henri Barbusse, BP 406, 92141 Clamart Cedex, France.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jerôme Mouroux Francois Pons Gilles Grosdidier Jacques Azorin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lang-Lazdunski, L. Articles by Jancovici, R. Search for Related Content PubMed PubMed Citation Articles by Lang-Lazdunski, L. Articles by Jancovici, R.