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

Thoracoscopy in chest trauma: an update

The role of thoracoscopy in the management of patients with chest injuries is constantly being redefined as more reports on its use continue to emerge in the literature. As of today video-thoracoscopy has been used mainly as a diagnostic tool for certain occult injuries, such as of the diaphragm, as well as a minimally invasive management option in specific therapeutic situations including early evacuation of retained thoracic collections. It has the potential to replace open surgery in the management of more than 50% of civilian and military thoracic injuries previously considered candidates for open surgical management with all the benefits of minimally invasive surgery. In addition, it is a promising tool for earlier detection of missed injuries in patients otherwise managed nonoperatively. The procedure-related complication rate is low and there are only few contraindications for thoracoscopy, mainly haemodynamic instability and obliterated pleural space caused by previous infections or surgical interventions. However, the scientific evaluation of the global impact of thoracoscopy in the management of thoracic injuries is currently limited to descriptive series, some of them using historical controls, and a few non-randomized prospective studies. Until more well-designed, prospective, randomized studies emerge which compare thoracoscopy to standard management protocols in defined patient populations with thoracic injuries using relevant end points, the potential benefit of thoracoscopy in chest trauma remains unvalidated and its value is limited to isolated patients depending on individual surgeon’s preferences and skills.

Pulmonary trauma

Pulmonary trauma is common and devastating and is associated with significant morbidity and mortality. The present review highlights recent literature and case reports in this area. Topics of particular significance or interest include mechanisms of injury, potentially fatal intrathoracic vascular injuries, anesthetic management, fluid management (crystalloids as well as hemoglobin-based oxygen-carrying solutions), pain management of severe chest trauma, surgical management, and novel methods of diagnosis.

The Wider Scope of Video-Assisted Thoracoscopic Surgery

In the past, rudimentary devices were used to look closely into the chest; currently, advanced video technology, computers, and high-tech electronics are being used to perform many surgical procedures that formerly required a large, open incision. The goal of video-assisted thoracoscopic surgery (VATS) is the same as for comparable open procedures, but it is accomplished with less pain, less patient morbidity, and a shorter hospital stay. In addition to evaluating and treating thoracic injuries, VATS has demonstrated effectiveness in detecting and managing many other conditions, such as pleural disease, interstitial lung disease, and thoracic malignancies.

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.

Missed diaphragm rupture following blunt trauma

Traumatic rupture of the diaphragm resulting from blunt trauma remains a challenging clinical entity. Diagnosis remains difficult and is often delayed. A prompt diagnosis requires a high index of suspicion. We describe two patients with ruptured diaphragms in whom the diagnosis was made at different stages of their illness. The diaphragmatic injury reflects the magnitude of their associated injuries and probably contributes to the overall mortality.

Blunt thoraco-abdominal injury

Recent advances in blunt thoraco-abdominal trauma management include improvements in imaging, particularly in trauma bay ultrasound. Indications for non-operative management have expanded for solid organ and aortic injury. The physiology of abdominal compartment syndrome continues to be defined, with resulting improvements in care.