ReviewVideo-assisted thoracic surgery: state of the art in trauma care
Introduction
Video-assisted thoracic surgery (VATS) has become a standard diagnostic and therapeutic modality in thoracic surgery. Its broadening indications are largely attributable to improvements in and familiarity with instrumentation and techniques. A body of literature has accumulated to support its use in trauma patients. Twenty-five percent of mortality in trauma patients is related to injuries sustained within the thoracic cage. A proportion of these deaths are attributable to immediate exsanguination or cardiac tamponade. However, a greater burden of mortality is accrued from pulmonary contusion, ARDS or ventilator-associated pneumonia or the systemic inflammatory response syndrome from empyema or mediastinitis.18
Patients with chest trauma fall into four general categories. Firstly, those who die at the scene or undergo resuscitative thoracotomy in the trauma or operating room due to immediately fatal injuries, such as cardiac tamponade or exsanguinating haemorrhage. Secondly, those patients who require urgent thoracotomy for potentially fatal injuries. These patients generally come to thoracotomy after initial resuscitation and diagnostic work-up, for on-going haemorrhage arising from non-aortic great vessel, lung parenchymal or chest wall injuries. Also, in this category are patients with aortic, oesophageal or tracheo-bronchial injuries. The third group is managed initially with resuscitation and tube thoracostomy; these patients comprise 80–85% of all chest-injured patients.18 However, on-going haemorrhage, retained haemothorax, persistent pneumothorax, and empyema will necessitate thoracotomy in 20–30% of these initially non-operatively treated patients.2 Delayed operative intervention is also required for missed injuries of the diaphragm, oesophagus and contained vascular injuries. The fourth category is a subset of the third, and includes patients requiring surgery for complications of haemo- or pneumothoraces or missed injuries.
In chest trauma overall, the need for acute operative intervention is relatively infrequent and tube thoracostomy is the most common therapy. It is used to evacuate the pleural space of air, blood, or other fluid and allow for re-expansion of the lung. However, it is ineffective if these conditions become complicated. Thoracotomy accrues significantly greater morbidity than thoracoscopy and may be less desirable in the subacute setting of a multiply-injured trauma victim.
History, physical examination and plain chest X-ray are the essential diagnostic tools in chest trauma. Computed tomography, aortography, contrast and endoscopic oesophageal studies and bronchoscopy are also diagnostically important and used selectively. Together these investigations are reliable for great vessel, lung, oesophageal, tracheo-bronchial and bony injures, but they are unreliable for diaphragmatic injuries and to delineate the source of haemothorax. Video-thoracoscopy is an adjunctive diagnostic tool, which may also provide surgical therapy. It is less invasive and potentially as effective as thoracotomy, and is useful in trauma for selected indications with an acceptable conversion rate.11
Section snippets
Residual haemothorax
After rib fractures, haemothorax is the second most common complication of chest trauma. It can be treated effectively by the timely and precise placement of a chest tube. However, 18–30% of such patients will develop retained or clotted haemothorax, and up to 40% of these patients will require thoracotomy for non-resolving, complicated intrapleural collections.7., 8., 15. According to one review, 4% of all patients with traumatic haemothoraces will eventually require thoracotomy for
Contraindications and complications
Clear indications for thoracotomy, laparotomy or sternotomy are contraindications to thoracoscopy. These patients should have an open procedure without delay. This allows wide exposure, rapid assessment of all injuries, expedient packing and aggressive but precise control of bleeding. Haemodynamic instability arising from the chest, or massive haemothorax (1.5 l initially or 200 cm3/h for several hours) should prompt thoracotomy. Haemodynamically unstable patients with a penetrating injury in the
Surgical technique
VATS should be performed in the operating room under general anaesthesia. Double lumen intubation or single lumen intubation with bronchial blocker is essential to ensure that the ispislateral lung is collapsed. The position of the endotracheal tube should be confirmed bronchoscopically.
The patient is positioned in the full lateral decubitus position, using a bean bag for support of the torso. The higher arm should be flexed 90° at the shoulder and supported on an arm-rest. The lower arm is
Conclusions
VATS is widely used in elective thoracic surgery, however, despite favourable results for selected indications, it has not gained wide acceptance among trauma surgeons. Many trauma surgeons are general surgery trained with additional training in trauma and critical care. Many of us lack formal training and experience in thoracic procedures. Trauma surgeons should be familiar with the potential risks, benefits, indications and contraindications of VATS. It should be stressed that surgeons
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