ROLE OF VATS IN CHEST TRAUMA
-Mamdouh El-Sharawy
-Mahmoud Abd-Rabo
-Ayman Gabal
-Mohammad Khairy*
-Nezar El-Nahaal
-Khalid Abdel-Bary
-Magdy Mobasher
-Adel Ragheb***
-Tarek Nosier**
Background: Thoracotomy is a major operation and associated risk of
morbidity and mortality. Because the morbidity from VATS is much
lower, it can implemented with a lower degree of suspicion and this
allow earlier direct inspection of intra-thoracic organs in cases of
chest trauma.
Methods: Medical records of patients with chest trauma during a 4
years period (2004- 2007) were reviewed. All patients in need for
exploration with VATS for both diagnostic and therapeutic
management were studied.
Results: Out of 784 of chest trauma admission to our hospital, 29
patients (3.82%) underwent VATS . there were 24 men and 5 women
with mean age 22.7+19.6 years. Penetrating injuries were responsible
for 7 patients (24.1 %) and 22 patients (75.9%) had blunt chest
trauma. VATS revealed injury of the diaphragm in (5 pts.), injury to
the intercostals vessels (9 pts.), lung injuries or tears or parenchymal
laceration (11 pts.), broncho-pleural fistula (2 pts.) and clotted
haemothorax (4 pts.). VATS was successful for treating 17 patients
(58.6 %) and conversion to thoracotomy for 12 patients ( 41.4 %).
Conclusion: Direct evaluation of thoracic cavity by VATS in early
period , may have reduced the incidence of complication after chest
trauma. VATS also prevent extensive surgery and its complication,
and reduces the morbidity to minimum .
T
Request Dr. Mamdouh El-Sharawy
Dept. of Cardiothoracic Surgery,
Zagazig, Banha*, Cairo** Univ.
and National Heart Institute***
horacic injuries are among the most severe forms of
trauma and also a leading cause of morbidity and
mortality (Ambrogi, 2002). In the vast majority of
traumatized patients, the traumatic force is applied to
and through the chest wall, making trauma to the ribs and
sternum the most common of all thoracic injuries and therefore a
subject of considerable importance (Ben-Nun et al, 2007).
Thoracic trauma represents a major diagnostic and
therapeutic challenge to surgeons. Accurate assessment and
treatment require detailed knowledge of the protean
manifestations resulting from thoracic injuries. The trauma is
known to be a leading cause of death in the first four decade of
life (Cetindag et al, 2007).
The majority of chest trauma does not require major
operations and tube thoracostomy remains the basis of the
treatment. Rapid improvements in endoscopic surgical technique
and instrumentation expanded the indications of
video-thoracoscopy both diagnosis and treatment
of chest traumas (Manlulu et al, 2008).
Although the indications for video-assisted
thoracic surgery (VATS) have expanded rapidly,
especially in the areas of therapeutic and operative
procedures, its role in the definite surgical
treatment of chest trauma is not clear. (Dah-Wei
1997) . With the advent and increasing expertise in
video assisted thoracic surgery, this modality has
become an attractive alternative in the
management of patients with thoracic injury.
(Reddy, 2008)
Video-assisted thoracic surgery (VATS) has
been used in thoracic trauma for treatment of
retained haemothorax, persistent pneumothorax,
the diagnosis of diaphragmatic injuries after
penetrating trauma, posttraumatic empyema,
management of ongoing bleeding, retrieval of
foreign bodies, and for traumatic chylothoraces.(Shinji et al, 2008).
PATIENTS AND METHOD
Medical records of patients with chest
trauma during a 4-year period (2004-2007 ) at
Buridah King Fahad Specialist Hospital, K.S.A. ,
were reviewed. The study included 29 patients
subjected to VATS for diagnosis and management
. Hospital charts were used to evaluate the
outcome
Most therapeutic procedures are performed
in the operating room, with the patient under
general anesthesia. Induction is achieved with
barbiturates of sedative hypnotics, and general
anesthesia is maintained with propofol, isoflurane,
narcotics, or neuromuscular blocking agents.
Selective single-lung ventilation is achieved by
double-lumen endo-tracheal intubation. The
position of the tube is checked by flexible fiberoptic bronchoscopy. Pulse oximetry, electrocadiography, blood pressure and end tidal CO2 are
monitored continuously.
The patient is placed in the lateral decubitus
position, with the dependent lung ventilated.
Complete collapse of the nondependent lung away
from the chest wall allows thorough inspection of
the pleural cavity, provides access to mediastinal
structures, and mobilizes the lung. If the lung is
insufficiently collapsed, it may help to compress
the lung parenchyma with large grasping forceps,
perform bronchoscopic suction, or insufflate air
into the pleural cavity. Opening the pleural
cannula to the atmosphere avoids tension
physiology.
A 2 cm incision is made over the seventh
intercostal space at mid-axillary line. The chest is
entered carefully through a stab incision. Digital
palpation determined the presence of adhesions,
and bleedings from the wound are checked
meticulously. If none are present a 11mm trocar is
inserted through which the thoracoscope is
introduced. The entire thoracic cavity was then
carefully explored by means of projected images
on the video monitor.
Depending on the site of lesion and the
type of operation, one or two additional stab
incisions (2cm) are made to allow for the
introduction of instruments into the chest. The
procedures are usually carried out with three
incisions in a triangular configuration on the chest.
At the end of the procedure a chest tube is placed
through the seventh intercostal incision. All
incisions are inspected from within the chest for
bleeding before the procedure is completed and
should be carefully closed. This is followed by
gentle inflation of the lung, and closure of the skin
incisions in layers
Postoperative pain, which may be
exacerbated if the ribs are subjected to significant
pressure during the procedure, can be controlled
by applying local anesthesia to the incision sites.
Postoperative chest wall discomfort related to
indwelling chest tubes can be alleviated with
patient-controlled administration of intravenous
morphine for the first 24 hours, followed by oral
analgesics.
RESULTS
Our hospital admission for chest trauma in this
4 years period were 784 patients . VATS was
done for 29 patients (3.82% )as diagnostic and
therapeutic management of these chest trauma
patients . There were 24 male and 5 female with a
mean age 22.7 ± 19.6 years. All patients were
haemo-dynamically stable
Seven patients (24.1%) had Penetrating
injuries (5 stab in quarrel, 1 fall on sharp object
and 1 had gunshot).22 patients (75.9%) had blunt
chest trauma (15 road traffic accident, 5 fall from
height and 2 assault).the chest trauma was14(48.3)
in the right side and 16(55.2%) in the left side
(one patient-3.4%- had bilateral chest trauma ).
The result of VATS was injury to the
diaphragm (5 patient ),injury to the inter costal
vessels (9 patients), lung injury or tear or
parenchymal laceration (11patients), bronchopleural fistula (2 patients). And clotted
haemothorax (4 patients) .
In hemo- dynamically stable patient with
slow-rate persistent bleeding (100-150 ml/hour),
VATS is useful to find out the localization, and
they can be often controlled with diathermy,
endoclips or endosutures.
Conversion was done in 12 patients. this
was necessary due to laceration of the diaphragm
or failed heamostasis of an intercostals vessel.
VATS had been used for control of ongoing intrapleural bleeding in 3 patients (10.3 %), early
removal of clotted haemothorax in 4 patients
(13.8%), evaluation and repair of diaphragmatic
injuries in 2patients ( 6.9 %), and suturing for
lacerated lung parenchyma in 7patients ( 24.1 %).
The average of intercostals tube stay was 2
to 7 days (mean 3.7±1.9 days), in both cases of
VATS or which converted to thoracotomy. The
incidence of wound and pulmonary complication
after VATS was 6.9% (2 patients).There was no
intra-or postoperative mortality and average
hospital stay was 5 days.
The
contraindication
of
VATS
were
hemodynamic instability and indications for
emergencies thoracotomy.
DISCUSSION
Thoracic traumas continue to be one of the
most common reasons for patients to seek
emergency medical care. Many of the significant
advances in the management of thoracic trauma
are linked to technology, diagnostics and system
developments.
VATS has gained an increasing importance
diagnostic and therapeutic tool in chest trauma
(Ben-Bun et al , 2007 ).
Out of 784 of chest trauma admission to our
hospital, 29 patients (3.82%) underwent VATS .
there were 24 men and 5 women with mean age
22.7
19.6 years. Penetrating injuries were
responsible for 7 patients (24.1 %) and 22 patients
(75.9%) had blunt chest trauma. VATS revealed
injury of the diaphragm in (5 pts.), injury to the
intercostals vessels (9 pts.), lung injuries or tears
or parenchymal laceration (11 pts.), bronchopleural fistula (2 pts.) and clotted haemothorax (4
pts.). VATS was successful for treating 17
patients (58.6 %) and conversion to thoracotomy
for 12 patients ( 41.4 %).
Our results go hand in hand with the result of
Paci and his colleague 2006 who had 16 patients
with penetrating chest trauma out of 1270 of their
chest trauma patients, 13 were explored by VATS
(5 diaphragmatic injuries, 3 intercostals artery,
one diaphragmatic artery injury, and 12 laceration
of pulmonary parenchyma ) and 3 patients had
urgent thoracotomy . also our results came with
the results of Cansever, 2005 who had 103 cases
with isolated haemothorax between 1995 and
2003 with the mean age of his patients was 39.4
years. Left side affected at 41 cases, right side at
16 cases and bilateral at 2 cases. Although he had
51.4% penetrating, 47.5% blunt and .9
%iatrogenic traumas with resultant hemothoraces.
they performed tube thoracostomy in 99 cases and
one case required an urgent thoracotomy.
Conservative approach was sufficient for 82
patients (81%) and 21 patients operated and 6 of
them thoracoscopy was performed
Ben-Nun et al (2007) study the average time
to resume normal activity was shorter in the group
VATS. 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.
For stable patients with chest trauma , VATS is
feasible and safe . Moreover, it is tolerated better
than open thoracotomy , has smooth post
operative course , a superior long term outcome
and greater patients satisfaction.
Emergency VATS removes both the
uncertainly and waiting period before definitive
treatment by allowing direct inspection of the
intra-thoracic organs and chest wall. VATS also
proved to be a definite therapy for many of the
patients who continued to bleed after volume
resuscitation.
VATS allows complete visualization of the
diaphragm, thoracic cavity, mediastinum and
pericardium. VATS facilitates identification and
evaluation of residual haemothorax and empyema.
Repair of diaphragmatic injuries are easy with
thorascopic approach (Szenthkereszty et al,
2007).
Direct evaluation of thoracic cavity by
VATS in early period, may have reduced the
incidence of complications after haemothorax.
VATS also prevents extensive surgery and its
complications and reduces the morbidity to
minimum due to minimally invasive nature of this
procedure (Khammash and Rebee, 2006 and
Fabbracci et al, 2007).
We thus believe that surgical exploration
must be performed whenever there is suspicion
that a penetrating chest injury has penetrated the
chest cavity in order to thoroughly examine the
pleural cavity, identify the source of bleeding and
possible injuries to the pulmonary parenchyma,
the diaphragm, and to remove foreign bodies. In
addition, the complete evacuation of blood clots
and the placement of drainage under direct vision
are associated with a reduction of related
complications, chronic sequelae and length of
hospital stay. To this end we believe that VATS
can be employed as a substitute for thoracotomy
whenever the patient's hemodynamic conditions
permit it. Finally, VATS has an accuracy of
almost 100% in diagnosing injuries to the
diaphragm. Generally speaking, the rate of missed
diagnosis using VATS for chest trauma is 0.8%,
with a 2% rate of procedure-related complications;
that for conversion is 14–31%(Manlulu et al ,2004
and Paci et al 2006 ) Our findings are in line with
those reported in published studies.
The main contraindication to VATS in
trauma is patients who require emergency
treatment because of hemodynamic instability; in
these patients a thoracotomy or sternotomy should
be used (Cetindag et al 2007).
CONCLUSION
In hemo-dynamically stable patients with
thoracic injuries, VATS provides an accurate
assessment of intra-thoracic organ injury and can
be utilized to definitively and effectively manage
injuries sustained as a result of blunt or
penetrating thoracic
trauma. VATS should be
used with caution in patients sustaining severe and
life threatening intra-abdominal injuries.
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Cardiothoracic Surg 2004, 25:1048-1053.
Paci M., Ferrari G., Annessi V., Salvatore
de Franco, Guasti G, and Sgarb G. The role of
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Shinji S., Shiro Y., Shuich S., Osamu K.,
Tsutomu H., Nobuhide K., Keigo T., Nobuo
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‫الملخص العربي‬
‫دور المنظار الصدرى فى االصابات الصدرية‬
‫مقدمةةة ان عمليةةا اق ةةص اق ةةتبر عمعيةةب عمليةةا خيةةبر ضاع متةةونب امالةةوع وع ا ةةبا ن‬
‫اقم وب اق تبر يعيح ق و بؤيةا جزةءاا اق ةتب مةن اقةتاتا قةضا كنةا يمخةن افةعتتام ك ةو ع‬
‫ا ويوع اق تبيا قعقييم اع تيص علك ا ويوع‪.‬‬
‫خطة البحث عةم مبازمةا ا ةويوع اق ةتبيا علة مةتر ‪ 4‬فة ااع يةين ‪ 2007 – 2004‬اعةم‬
‫تبافا اق و ع اقع افعتتم كينو اقم وب اق تبر يغبض اقع تيص ااقمالج قنضه اق و ع‪.‬‬
‫عةم عمةا م ةوب ةتبر قمةتت ‪29‬‬
‫النتائج من يين ‪ 784‬وقا ا ويا تبيا جتتلع قلمفع‬
‫مةةةبيض ‪ 24 )%3,82‬بزةةةا ا ‪ 5‬فةةةوا ايلةةةط معافةةةن جعمةةةوب م ‪ 22,7‬فةةة ا اخةةةون عةةةتت‬
‫ا ةةةويوع اق ةةةتب اق وكةةةض ‪ )%24,1 7‬ةةةو ع اا ةةةويوع اقخوقةةةا ‪ )%75,9 22‬وقةةةا‪ .‬عةةةم‬
‫ع ةةتيص ا ةةويا اق زةةوج اق ةةوزء كة ‪ 5‬ةةو ع اا ةةويا ا اعيةةا اقتمايةةا يةةين اقالةةلا كة ‪9‬‬
‫و ع اا ويوع اعنعخوع يوقبئا ك ‪ 11‬مبيض ا تاث و اب يللابر مي ك ‪ 2‬وقةا‬
‫اعزمةةد تما يللةةابر مةةعزلن كة ‪ 4‬ةةو ع‪ .‬ا ةةت افةةعتتم اقم ةةوب اق ةةتبر كة عةةالج ‪ 17‬وقةةا‬
‫‪ )%58,6‬اعم عما ص تبر ك ‪ 12‬مبيض ‪.)%41,4‬‬
‫الخالصةةة يفةةعتلص مةةن ةةضا اقي ةةث جن افةةعتتام اقم ةةوب اق ةةتبر ي ةةاب ميخةةب كة عقيةةيم‬
‫و ع اق ويوع اق تبيا يمخن جن يقلا اق وزا اق ازباا عمليةا ةص ةتبر ايوقعةوق يز ي ةو‬
‫اقمالوع وع اقع يمخن جن ع تث عيزا علك اقزبا ا‪.‬‬