Video-assisted thoracic surgery in treatment of chest trauma

Early video-assisted thoracoscopic surgery (VATS) for non-emergent thoracic trauma remains underutilized in trauma accredited centers despite evidence of improved patient outcomes

PURPOSE

Thoracic injury is a major contributor to morbidity in trauma patients. There is limited data regarding practice patterns of video-assisted thoracoscopic surgery (VATS) across trauma-accredited hospitals in the United States. We hypothesized that early VATS remains underutilized affecting patient outcomes.

METHOD

We evaluated a cohort of patients who underwent non-urgent thoracic surgical intervention for trauma from the ACS-TQIP database in 2017 excluding patients who were discharged within 48-h or died within 72-h. We selected patients who underwent partial lung resection and decortication to assess the effect of early (day 2-5) versus late VATS. Univariate followed by multivariate regression analyses were utilized to evaluate the independent impact of timing.

RESULTS

Over 12 months, 997,970 patients were admitted to 850 trauma-accredited centers. Thoracic injury occurred in 23.5% of patients, 1% of whom had non-urgent thoracic procedures. A total of 406 patients underwent VATS for pulmonary decortication with/out partial resection, 39% were Early VATS (N = 159) compared to 61% late VATS (N = 247). Both groups had comparable demographics and comorbidities with exception of a higher ISS score in the late surgical group (17.9 ± 9.8 vs 14.9 ± 7.6, p < 0.01). The late VATS patients' group had higher rates of superficial site infection, unplanned intubation, and pneumonia. Early VATS was associated with shorter ICU stay and HLOS. Multivariate analysis confirmed the independent effect of surgical timing on postoperative complications and LOS. The conversion rate from VATS to thoracotomy was 1.9% in early group compared to 6.5%, p = 0.03. There was no difference in surgical pattern among participating facilities.

CONCLUSION

Despite established practice guidelines supporting early VATS for thoracic trauma management, there is underutilization with less than half of patients undergoing early VATS. Early VATS is associated with improved patient outcomes.

Factors Associated with Successful Video-Assisted Thoracoscopic Surgery and Thoracotomy in the Management of Traumatic Hemothorax

BACKGROUND

Few studies have identified factors associated with successful VATS or thoracotomy as the initial operative strategy among patients with traumatic hemothorax.

MATERIAL AND METHODS

We performed an exploratory analysis using the 2008 to 2017 TQP database. We identified all patients aged 18 to 89 years with traumatic hemothorax who were treated with tube thoracostomy alone in the first 24-hours of admission, followed by VATS or thoracotomy. Logistic regression was used to identify factors associated with successful VATS (no conversion or reoperation) or thoracotomy (no reoperation) as the initial operative strategy.

RESULTS

Among 2052 patients managed with initial VATS after chest tube drainage, 1710 (83%) were successful, while 263 (13%) were converted to thoracotomy and 79 (4%) required reoperation. On multivariable analysis, poor GCS (OR = 0.96 [95% CI = 0.94-0.99]), major injury (OR = 0.69 [95% CI = 0.53-0.90]), and diaphragmatic injury (OR = 0.42 [95% CI = 0.30-0.60]) were associated with lower odds of successful VATS, while rib fractures (OR=1.29 [95% CI=1.01-1.66]) were associated with higher odds of success of the initial operative plan. Among 3486 patients initially managed with thoracotomy after drainage with tube thoracostomy, 3118 (89.4%) were successful, while 11% (n = 368) required reoperation. Multivariable analysis revealed that major injury (OR = 0.68 [95% CI = 0.50-0.92]), blunt mechanism (OR = 0.63 [95% CI = 0.50-0.78]), and diaphragmatic injury (OR = 0.67, 95% CI = 0.53-0.84]) were associated with lower odds of successful thoracotomy as the initial operative plan.

CONCLUSIONS

More severe injuries and diaphragmatic injuries have lower odds of successful of VATS or thoracotomy as the initial operative management strategy among patients with traumatic hemothorax. Rib fractures may be associated with higher odds of success of VATS as the initial management strategy.

Simultaneous pneumothorax and pneumoperitoneum as a late consequence of traumatic injury of the diaphragm: Multimodality imaging approach with surgical correlation and treatment

Simultaneous occurrence of pneumothorax and pneumoperitoneum is a rare event, usually related to traumas or surgical procedures involving the diaphragm.

However, clinicians should be aware of the possible onset of these two clinical conditions even in patients without a recent clinical history that can clearly explain them.

Cross-sectional imaging techniques are of great importance, providing crucial information about the patient's clinical status and guiding the following patient management.

This work describes a unique case of a sudden occurrence of simultaneous pneumothorax and pneumoperitoneum in a previous asymptomatic man with a solely clinical history of minor trauma during childhood, evaluated through a multimodality imaging approach and treated with video-assisted thoracoscopy surgery.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

Thoracic irrigation prevents retained hemothorax: A prospective propensity scored analysis

BACKGROUND

Thoracic trauma resulting in hemothorax (HTx) is typically managed with thoracostomy tube (TT) placement; however, up to 20% of patients develop retained HTx which may necessitate further intervention for definitive management. Although optimal management of retained HTx has been extensively researched, little is known about prevention of this complication. We hypothesized that thoracic irrigation at the time of TT placement would significantly decrease the rate of retained HTx necessitating secondary intervention.

METHODS

A prospective, comparative study of patients with traumatic HTx who underwent bedside TT placement was conducted. The control group consisted of patients who underwent standard TT placement, whereas the irrigation group underwent standard TT placement with immediate irrigation using 1 L of warmed sterile 0.9% saline. Patients who underwent emergency thoracotomy, those with TTs removed within 24 hours, or those who died within 30 days of discharge were excluded. The primary end point was secondary intervention defined by additional TT placement or operative management for retained HTx. A propensity-matched analysis was performed with scores estimated using a logistic regression model based on age, sex, mechanism of injury, Abbreviated Injury Scale chest score, and TT size.

RESULTS

In over a 30-month period, a total of 296 patients underwent TT placement for the management of traumatic HTx. Patients were predominantly male (79.6%) at a median age of 40 years and were evenly split between blunt (48.8%) and penetrating (51.2%) mechanisms. Sixty (20%) patients underwent thoracic irrigation at time of initial TT placement. The secondary intervention rate was significantly lower within the study group (5.6% vs. 21.8%; OR, 0.16; p < 0.001). No significant differences in TT duration, ventilator days, or length of stay were noted between the irrigation and control cohort.

CONCLUSION

Thoracic irrigation at the time of initial TT placement for traumatic HTx significantly reduced the need for secondary intervention for retained HTx.

LEVEL OF EVIDENCE

Therapeutic Study, Level III.

Thoracostomy tube function not trajectory dictates reintervention

BACKGROUND

Hemothorax and/or pneumothorax can be managed successfully managed with tube thoracostomy (TT) in the majority of cases. Improperly placed tubes are common with rates near 30%. This study aimed to determine whether TT trajectory affects the rate of secondary intervention.

METHODS

A retrospective review of all adult trauma patients undergoing TT placement over a 4-y period was performed. TT trajectory was classified as ideal, nonideal, or kinked-based on anterior-posterior chest x-ray. TTs with sentinel port outside the thoracic cavity were excluded. The primary outcome was any secondary intervention.

RESULTS

Four-hundred eighty-six patients and a total of 547 hemithoraces underwent placement and met inclusion criteria. The majority of patients were male (76%), with a median age of 41 y, and majority suffered blunt trauma ideal trajectory was identified in 429 (78.4%). Kinked TTs were noted in 33 (6%) hemothoraces with a 45.5% replacement rate. Review with staff demonstrates inherent bias to replace kinked TTs. The overall secondary intervention rate was 27.8%. Kinked TTs were removed from final analysis due to treatment bias. Subsequent analysis demonstrated no significant difference between ideal and nonideal trajectories (25.1% versus 34.1%, P = 0.09).

CONCLUSIONS

Intrathoracic trajectory of nonkinked TTs with the sentinel port within the thoracic cavity does not affect secondary intervention rates, including the rate of surgical intervention.

Case study: Idiopathic hemothorax in a patient with status asthmaticus

INTRODUCTION

Idiopathic spontaneous hemothorax has been rarely described in the literature.

CASE STUDY

A case of status asthmaticus and spontaneous hemothorax is described in a 29-year-old female of African descent who presented to the emergency room after 2 days of severe cough productive of yellow sputum, otalgia, sore throat, subjective fevers, chills, headache, progressive wheezing, chest tightness and dyspnea. She had a history of 7 years of asthma and was non-adherent with her controller asthma medications. Prophylactic subcutaneous administration of enoxaparin 40 milligrams was initiated upon hospitalization. The patient initially had a normal chest radiograph but subsequently developed a large, left hemothorax that required tube thoracostomy placement followed by video-assisted thoracoscopic surgery (VATS).

RESULTS

The patient was transferred to the Intensive Care Unit (ICU) and tube thoracostomy resulted in evacuation of 1,400 milliliters of blood-like fluid, which had a pleural fluid hematocrit greater than 50% of the serum hematocrit. A contrast-enhanced computed tomography (CT) scan of the chest did not reveal any source for the bleeding and a technetium bone scan of the chest was normal. The patient required transfusion of 5 units of packed red blood cells. She was then taken to the operating room for VATS because of continued chest tube drainage (3,200 milliliters of fluid over a 48-hour period).

CONCLUSION

The etiology of the hemothorax was unknown despite surgical exploration but was felt to be secondary to cough and bronchospasm associated with status asthmaticus.

Thoracic irrigation prevents retained hemothorax: a pilot study

BACKGROUND

Upward of 20% of patients undergoing thoracostomy tube (TT) placement develop retained hemothorax (HTx) requiring secondary intervention. The aim of this study was to define the rate of secondary intervention in patients undergoing prophylactic thoracic irrigation.

METHODS

A prospective observational trial of 20 patients who underwent thoracic irrigation at the time of TT placement was conducted. Patients with HTx identified on chest x-ray were included. After standard placement of a 36-French TT, the HTx was evacuated using a sterile suction catheter advanced within the TT. Warmed sterile saline was instilled into the chest through the TT followed by suction catheter evacuation. The TT was connected to the sterile drainage atrium and suction applied. TTs were managed in accordance with our standard division protocol.

RESULTS

The population was predominantly (70%) male at median age 35 years, median ISS 13, with 55% suffering penetrating trauma. Thirteen (65%) patients underwent TT placement within 6 h of trauma with the remainder within 24 h. Nineteen patients received the full 1000-mL irrigation. The majority demonstrated significant improvement on postprocedure chest x-ray. The secondary intervention rate was 5%. A single patient required VATS on post-trauma day zero for retained HTx. Median TT duration was 5 d with median length of stay of 7 d. No adverse events related to the pleural lavage were noted.

CONCLUSIONS

Thoracic irrigation at the time of TT placement for traumatic HTx may decrease the rate of retained HTx.

Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries)

This review aims to answer the most common questions in routine surgical practice during the first 48 h of blunt chest trauma (BCT) management. Two authors identified relevant manuscripts published since January 1994 to January 2014. Using preferred reporting items for systematic reviews and meta-analyses statement, they focused on the surgical management of BCT, excluded both child and vascular injuries and selected 80 studies. Tension pneumothorax should be promptly diagnosed and treated by needle decompression closely followed with chest tube insertion (Grade D). All traumatic pneumothoraces are considered for chest tube insertion. However, observation is possible for selected patients with small unilateral pneumothoraces without respiratory disease or need for positive pressure ventilation (Grade C). Symptomatic traumatic haemothoraces or haemothoraces >500 ml should be treated by chest tube insertion (Grade D). Occult pneumothoraces and occult haemothoraces are managed by observation with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B). No sign of life at the initial assessment and cardiopulmonary resuscitation duration >10 min are considered as contraindications of Emergency Department Thoracotomy (Grade C). Damage Control Thoracotomy is performed for either massive air leakage or refractive shock or ongoing bleeding enhanced by chest tube output >1500 ml initially or >200 ml/h for 3 h (Grade D). In the case of haemodynamically stable patients, early video-assisted thoracic surgery is performed for retained haemothoraces (Grade B). Fixation of flail chest can be considered if mechanical ventilation for 48 h is probably required (Grade B). Fixation of sternal fractures is performed for displaced fractures with overlap or comminution, intractable pain or respiratory insufficiency (Grade D). Lung herniation, traumatic diaphragmatic rupture and pericardial rupture are life-threatening situations requiring prompt diagnosis and surgical advice. (Grades C and D). Tracheobronchial repair is mandatory in cases of tracheal tear >2 cm, oesophageal prolapse, mediastinitis or massive air leakage (Grade C). These evidence-based surgical indications for BCT management should support protocols for chest trauma management.

How early should VATS be performed for retained haemothorax in blunt chest trauma?

BACKGROUND

Blunt chest injury is not uncommon in trauma patients. Haemothorax and pneumothorax may occur in these patients, and some of them will develop retained pleural collections. Video-assisted thoracoscopic surgery (VATS) has become an appropriate method for treating these complications, but the optimal timing for performing the surgery and its effects on outcome are not clearly understood.

MATERIALS AND METHODS

In this study, a total of 136 patients who received VATS for the management of retained haemothorax from January 2003 to December 2011 were retrospectively enrolled. All patients had blunt chest injuries and 90% had associated injuries in more than two sites. The time from trauma to operation was recorded and the patients were divided into three groups: 2-3 days (Group 1), 4-6 days (Group 2), and 7 or more days (Group 3). Clinical outcomes such as the length of stay (LOS) at the hospital and intensive care unit (ICU), and duration of ventilator and chest tube use were all recorded and compared between groups.

RESULTS

The mean duration from trauma to operation was 5.9 days. All demographic characteristics showed no statistical differences between groups. Compared with other groups, Group 3 had higher rates of positive microbial cultures in pleural collections and sputum, longer duration of chest tube insertion and ventilator use. Lengths of hospital and ICU stay in Groups 1 and 2 showed no statistical difference, but were longer in Group 3. The frequency of repeated VATS was lower in Group 1 but without statistically significant difference.

DISCUSSION

This study indicated that an early VATS intervention would decrease chest infection. It also reduced the duration of ventilator dependency. The clinical outcomes were significantly better for patients receiving VATS within 3 days under intensive care. In this study, we suggested that VATS might be delayed by associated injuries, but should not exceed 6 days after trauma.

Use of a trauma service clinical pathway to improve patient outcomes for retained traumatic hemothorax

INTRODUCTION

Early evacuation of retained hemothorax (RHTX) has been shown to improve clinical outcomes. In 2006, our trauma surgery service instituted a clinical pathway for management of RHTX that was designed to decrease time to operation and improve patient outcomes. We report our experience with early evacuation of posttraumatic RHTX after instituting a service-wide clinical pathway.

METHODS

From 2006 to 2007, 29 operations were performed by the trauma surgery service for RHTX. Using the clinical pathway, if patients had a persistent effusion on hospital day 2, the patient underwent thoracoscopic (VATS) evacuation of the hemothorax. A case control cohort (24 patients) was generated from 2003 to 2005 of operations for retained hemothorax before implementation of this pathway.

RESULTS

The mean age was 33.2 years. There was no difference in ISS between groups (p = 0.14). The study group had significantly decreased time to operating room (3.0 +/- 0.33 days vs. 9.9 +/- 2.0 days, P = 0.002) and shorter hospital stays (10.8 +/- 0.8 days vs. 30.5 +/- 5.8 days, P = 0.003). All 29 study patients had their hemothorax evacuated by VATS, whereas 14 of 29 control patients had evacuation attempted by VATS (P = 0.0003). There were no differences in complications or reoperation between groups. Total hospital charges for the study group were $46,471 in the study group compared with $126,221 in the control group (P = 0.03).

CONCLUSIONS

Implementation of a clinical pathway for early evacuation of retained hemothorax can significantly improve patient outcomes and decrease hospital costs. Furthermore, trauma surgeons are capable of safely performing thoracic surgery for evacuation of retained hemothorax.

Best timing for thoracoscopic evacuation of retained post-traumatic hemothorax

OBJECTIVE

To determine the best timing for thoracoscopic drainage of clotted hemothorax in order to ensure safe and effective results and to identify risk factors associated with drainage failure.

MATERIALS AND METHODS

Cohort retrospective study of 139 consecutive patients who underwent thoracoscopic retained hemothorax drainage between April 1997 and May 2005.

RESULTS

The procedure was successful in 102 patients (73.4%), in whom complete evacuation was achieved, with no accumulation of fluid in the pleural cavity requiring reintervention. Conversion to thoracotomy was required in 22 patients (15.8%) because of the inability to attain adequate drainage of clots and collections and lung re-expansion. Fifteen patients (10.8%) required reintervention as a result of fluid accumulation in the pleural cavity and lung collapse, and thoracotomy was performed in all those cases. The best results were obtained when thoracoscopic drainage was performed before the fifth day. There were 33 major post-operative complications including 20 cases of empyema of which 10 required thoracotomy, and 13 bronchopleural leaks, four of which required open surgery. There were no fatal outcomes in the study group.

CONCLUSIONS

Videothoracoscopy must be considered the procedure of choice for the treatment of retained post-traumatic hemothorax. It is a safe and effective procedure allowing the successful treatment of up to 73.4% of patients. Best results are obtained when drainage is performed within the first five days after trauma.

Video-Assisted Thoracoscopic Surgery in the Treatment of Chest Trauma: Long-Term Benefit

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has gained an increasing importance as a diagnostic and therapeutic tool in chest trauma. Several studies have demonstrated its feasibility and safety, but only a few addressed the long-term benefit of VATS. The aim of this study was to evaluate the short-term and long-term benefits of VATS in chest trauma, with emphasis on the patient's point of view.

METHODS

Medical records of patients with chest trauma during a 10-year period were reviewed. The study included 77 patients (37 patients in the VATS group and 40 in the thoracotomy group). Forty-four patients who underwent operative treatment during the study period were excluded from the study. Hospital charts and a telephone questionnaire were used to evaluate the outcome.

RESULTS

No deaths occurred in either group. Clotted hemothorax was the most common finding. The incidence of wound and pulmonary complication were higher in the thoracotomy group. Patients in the thoracotomy group needed significantly higher doses of narcotic analgesia. Average time to resume normal activity was shorter in the VATS group. More than 2 years after discharge, the rate of return to a normal lifestyle was 81% in the VATS group and 60% of the thoracotomy group. Patients in the VATS group were generally more satisfied with their health status and surgical scars.

CONCLUSIONS

The results of this study show that for stable patients with chest trauma, video assisted thoracic surgery is feasible and safe. Moreover, it is tolerated better than open thoracotomy, has a favorable postoperative course, a superior long-term outcome, and greater patient satisfaction.

Video-assisted thoracic surgery--the past, present status and the future

Video-assisted thoracic surgery (VATS) has developed very rapidly in these two decades, and has replaced conventional open thoracotomy as a standard procedure for some simple thoracic operations as well as an option or a complementary procedure for some other more complex operations. In this paper we will review its development history, the present status and the future perspectives.

[Thoracic kidney: congenital or traumatic origin?]

The discovery of a thoracic kidney in adult patients can lead to three diagnoses, yielding different prognoses and treatment. It can either mean traumatic or congenital diaphragmatic hernia, or a congenital ectopic kidney. Intrathoracic herniation of the left kidney trough a left diaphragmatic rupture is an exceptional discovery. We report the case of a 44 year-old man who met with a car accident 20 years ago, and presented abdominal pain. CT-scan showed an intrathoracic herniation of the left kidney trough a left posterior diaphragmatic rupture. Laparoscopic approach in lateral position showed a traumatic hernia of the left costo-diaphragmatic hiatus only containing the left kidney and its pedicle. After reduction of herniated left kidney into the abdomen, the hiatus was closed by non-resorbable prosthetic mesh. Postoperative course was uneventful.

Thoracoscopic evacuation of retained posttraumatic hemothorax

BACKGROUND

Residual posttraumatic hemothoraces occur in 1% to 20% of patients managed with tube thoracostomy. Video-assisted thoracoscopic surgery (VATS) has emerged as an alternative to thoracotomy to evacuate these retained collections. This report reviews a recent trauma unit experience with thoracoscopic evacuation of hemothoraces.

METHODS

The records of all trauma patients undergoing surgical intervention for retained hemothoraces over the 30-month period January 2001 to June 2003 were reviewed.

RESULTS

The study included 46 patients. All sustained penetrating injuries, 40 with stab and 6 with gunshot wounds. Twenty-two, 17, and 7 patients each had one, two and three attempts at drainage with tube thoracostomy, respectively. In 37 patients (80%), retained infected/uninfected pleural fluid was successfully evacuated thoracoscopically. VATS failed in 9 (20%) patients and the procedure was converted to open thoracotomy. Dense adhesions were present in all 9 of these patients. The mean time interval between injury and thoracoscopy and thoracotomy, was 13.3 days (range 3-46 days) and 14.5 days (range 11-24 days), respectively. The mean volume of pleural fluid evacuated thoracoscopically was 650 mL. The failure of VATS evacuation correlated with the empyema rate. The median postoperative stay was 5 days for both groups.

CONCLUSIONS

Video-assisted thoracoscopic surgery is an accurate, safe, and reliable operative therapy for retained posttraumatic pleural collections, even in patients presenting later than the conventionally accepted 3- to 5-day window from the time of injury.

Video-assisted thoracic surgery: state of the art in trauma care

The majority of chest-injured patients are managed with resuscitation and placement of chest tubes. Further interventions are required for complications or missed injuries. Video-assisted thoracic surgery (VATS) has become standard in elective surgery. Our purpose was to review the use of VATS in trauma. The literature and our experience support the use of VATS for specific indications. These indications are: (1) management of retained haemothorax; (2) management of persistent pneumothorax; (3) evaluation of the diaphragm in penetrating thoraco-abdominal injuries and management; (4) management of infected pleural space collections; and (5) diagnosis and management of on-going bleeding in haemodynamically stable patients. VATS for specific indications in trauma is associated with improved outcomes and decreased length of stay. VATS provides diagnostic and therapeutic benefit and should be included in the trauma surgeon's clinical armamentarium.

Lateral approach to laparoscopic repair of left diaphragmatic ruptures

Video-assisted repairs of traumatic diaphragmatic ruptures have been described where thoracoscopy or laparoscopy in the supine position were used. This study aims to validate a new lateral laparoscopic approach for left diaphragmatic repairs. Six consecutive patients were operated on for left diaphragmatic rupture using a lateral approach (Gagner's position). A series of 362 consecutive patients presenting with abdominal or thoracic trauma with or without diaphragmatic rupture over a 2-year period were reviewed retrospectively. Contraindications for immediate or delayed lateral laparoscopic approach were studied. The lateral approach provided complete visibility of the subdiaphragmatic space, easy reduction of herniated organs, easy thoracic inspection and cleaning, the use of low peritoneal pressure, full range of instrumental motion, and rapid diaphragmatic repair. No operative mortality or morbidity was noted. Altogether, 14% to 50% of the patients with diaphragmatic ruptures were candidates for immediate lateral laparoscopic repair. Associated spleen injury in 50% of the cases was the main contraindication. The lateral laparoscopic approach provides better exposure of the diaphragm on the left side and facilitates the diaphragmatic repair especially with a large herniation. Immediate repair is possible in selected cases (14-50%). There is no contraindication in case of delayed diagnosis.

[Treatment of diaphragmatic ruptures by laparoscopic approach in the lateral position]

STUDY AIM

The aim of this retrospective study was to assess the feasibility of the treatment of recent diaphragmatic ruptures through laparoscopic approach in lateral position in patients with stable hemodynamic condition.

PATIENTS AND METHOD

From 1994 to 1999, seven patients, 16 to 68 years old, were operated on for diaphragmatic rupture after a 6 hours to 15 days delay. Diaphragmatic rupture was located on the left side in 6 patients, on the right side in 1. Diagnosis was confirmed by CT-scan with reconstructions; there was no associated visceral injury. Patients were operated on by laparoscopic approach in lateral position, herniated viscera reintegrated by moderate pulling and diaphragmatic rupture repaired with non resorbable continuous suture.

RESULTS

Stomach was the usual herniated viscera (n = 6); hemothorax was less than 300 cL; diaphragmatic rupture was 8 to 12 cm long. Duration of surgery was no more than 120 minutes. The seven patients after a two months to two years delay had normal chest X-rays.

CONCLUSION

The laparoscopic approach in lateral position provides good visibility of the diaphragmatic lesions, easy reduction of herniated organs, complete thorax exploration and cleaning, and easy diaphragmatic repair. This technique is only feasible in patients with stable hemodynamic conditions and does not provide a complete abdominal exploration.

Changing indications for thoracotomy in blunt chest trauma after the advent of videothoracoscopy

BACKGROUND

The advent of videothoracoscopy may restrict the indications for thoracotomy in blunt chest trauma.

METHODS

We retrospectively compared two groups of patients with blunt chest trauma observed in consecutive periods, before and after the advent of videothoracoscopy, 989 patients from 1989 to 1993 and 908 patients from 1994 to 1998.

RESULTS

During the first period, 38 thoracotomies were performed; but in 8 instances (21%), no major injuries were found. In the second period, 36 videothoracoscopies were performed to repair the lung (n = 5) or diaphragm (n = 5), to evacuate clots (n = 4), pericardial effusion (n = 3), and empyema (n = 2). Six procedures were converted and 11 findings were negative for lesions. Only nine intentional thoracotomies were performed, and significant lesions were found in each case.

CONCLUSION

Videothoracoscopy has reduced the number of thoracotomies performed. Thoracotomy can be limited to massive bleeding with hemodynamic instability, major air leak, radiologic evidence of mediastinal enlargement or diaphragmatic rupture, or major anterolateral flail chest.