Indications and Patient Selection

The first diagnostic and therapeutic application of thoracoscopy for the management of thoracic pathologies such as pleural effusions, pleural adhesions, empyemas, and thoracic malignancy, was recorded by Jacobeaus at the University of Stockholm in 1922.⁷ Thoracoscopy for the treatment of traumatic injuries was first described in 1946 by Branco for the management of hemothorax in penetrating chest injuries.⁸ In the last decade, the advent of minimally invasive access to the thoracic cavity combined with video-assisted technology and selective lung ventilation has revolutionized the diagnosis and the treatment of thoracic injuries with improved use and outcomes.^9,10

Patient selection is very important for the application of VATS in thoracoabdominal trauma. The current indications are both diagnostic and therapeutic and include mainly the evaluation of a structural injury (the diaphragm, the pericardium, lung parenchyma, the thoracic duct, etc.) or the drainage of a pleural collection and repair of any structural damage. Aside from the usual bleeding disorders, the main contraindications of VATS include an unstable patient, or a patient with underlying lung and cardiac pathologies that preclude the use of single lung ventilation. Table 1 lists the current indications and contraindications for the use of VATS.

Table 1 Indications and Contraindications of VATS in Trauma

Diaphragmatic Injuries

The incidence of blunt diaphragmatic injuries have been reported as low as 0.8% and as high as 7%.^11,12 Blunt trauma accounts for 10%–30% of traumatic diaphragmatic ruptures (TDR) in North American series from urban trauma centers.¹³ The incidence of diaphragmatic injuries has been reported to be as high as 67% in penetrating thoracoabdominal trauma.¹⁴

Diaphragmatic injuries are particularly difficult to diagnose with the use of radiographic imaging such as chest x-ray or CT and can be missed in up to 30% of patients.^14,15 Together with laparoscopy, thoracoscopy has become the diagnostic tool of choice for diaphragmatic injuries when compared with other nonoperative modalities.^16,17 Thoracoscopy is particularly useful when laparoscopy may not be optimal or feasible. It is useful for evaluation of right-sided diaphragmatic injuries and of posterior wounds from the posterior axillary line to the spine.¹⁸ It is also useful for avoidance of abdominal procedures, particularly in patients with previous laparotomies and expected presence of extensive adhesions.

The therapeutic role of VATS in the treatment of diaphragmatic injuries is well documented.^14,19 In a report of 24 patients who underwent VATS for thoracic injuries, 9 of 10 patients were successfully diagnosed with diaphragmatic injuries. VATS was used for repair of the diaphragm in four patients.¹⁹ Martinez et al.¹⁴ evaluated 52 patients with penetrating thoracoabdominal trauma admitted to the General Hospital for Accidents in Guatemala City. VATS was used to diagnose 35 patients with diaphragmatic injuries. All 35 diaphragmatic injuries were successfully repaired thoracoscopically. Even though successful thoracoscopic repair of diaphragm injuries is reported as feasible, safe, and expeditious, currently no long-term outcome results are available.

In areas where other abdominal injuries are suspected, a laparoscopic or open surgical approach is preferable depending on the available surgical expertise. A combined thoracic and abdominal cavitary endoscopy can also be useful. Figure 1 shows the thoracoscopic evaluation of a right diaphragm injury from an impaled object in the chest of a patient evaluated in our trauma center. This was followed by the thoracoscopic repair of the diaphragm after the laparoscopic confirmation of a nonbleeding liver laceration, and no other associated abdominal injuries. In all cases where a diaphragm injury is found, an exploratory laparoscopy or laparotomy is mandatory to rule out associated intra-abdominal injuries.

Figure 1 This 48-year-old construction worker was impaled with a 4×4 wooden object. (A) Large 5-cm, full-thickness diaphragm injury was noted with underlying liver laceration. (B) Diaphragm was repaired thoracoscopically.

Retained Thoracic Collection

The evacuation of a retained hemothorax is one of the main indications for VATS. Inadequate evacuation of blood from the pleural space and prolonged thoracostomy tube drainage put the patient at risk for developing empyema and fibrothorax with prolonged hospital stays and increasing costs.^9,20 The incidence of a retained hemothorax and empyema post–tube thoracostomy placement ranges from 4% to 20% and from 4% to 10%, respectively.^{8,9,19,21–23} A prospective randomized study of 39 patients with thoracic trauma and retained hemothoraces from Parkland Memorial Hospital showed that early evacuation with VATS compared with conventional therapy of a secondary chest tube placement lead to a significantly shorter duration of tube drainage (2.5 days), shorter hospital stay (2.7 days), and reduced hospital costs ($6000).⁹ These advantages of VATS were attributed to rapid and complete evacuation of the pleural space, optimal video-assisted positioning of the thoracostomy tubes, and identification and treatment of the sources of the bleeding and of other associated intrathoracic injuries.

It is important to note that these advantages rest on the early use (day 4–7 postinjury) of VATS for the evacuation of the hemothorax. In a study by Heniford et al.,²⁰ 19 of 25 patients (76%) with retained hemothorax were successfully treated with VATS. Failure of VATS correlated with time interval from injury to operation, and with the type of fluid collection (hemothorax vs. empyema). The mean time between admission and operation for the successful versus unsuccessful thoracoscopic drainage was 4.5 days and 14.5 days, respectively.²⁰

The application of VATS for traumatic empyema is dependent on the phase of the empyema. For the acute/exudative empyema occurring between 1 and 5 days, VATS is uniformly effective. The success rate for the transitional/fibrinopurulent stage (day 6–14) is around 75%–85%, with a sharp drop to around 50% in the organized/chronic phase (>2 weeks).^24,25 The presence of a thick fibrin peel with entrapped lung requires mature surgical judgment for early conversion to open thoracotomy and avoidance of the risk of further pulmonary parenchymal injury or the creation of a bronchopleural fistula.

Persistent Hemorrhage

Video-assisted thoracoscopic surgery is also useful for patients with persistent but slow hemorrhage and no hemodynamic instability. Unstable patients with suspected thoracic bleed require open thoracotomy. Smith et al.²⁶ performed VATS on five hemodynamically stable patients for persistent hemorrhage from intercostal vessels. In three patients, the bleeding was successfully controlled with diathermy. Other techniques for hemorrhage control, including endoclips or argon beam coagulators, can be used.¹⁵ Intracorporeal suture placement around the rib was used successfully in our center for control of a persistent intercostal bleed not amenable to endoclip placement. The success rate for the thoracoscopic control of a nonhemodynamically compromising hemorrhage is around 80% with a thoracotomy conversion rate of 15%–20%.^24,27

Persistent Pneumothorax

The incidence of persistent air leak and lung re-expansion 72 hours post–thoracostomy tube placement ranges from 4% to 23%.^27,28 Conservative management with continuous pleural suction leads to prolonged chest tube drainage, prolonged hospital length of stay (LOS), and increased hospital costs.²⁸ VATS has been shown to be safe and effective in the treatment of persistent pneumothorax with decreased number of chest tube days, hospital LOS, and cost.^9,28,29 In our trauma center, endo-GIA staplers are routinely employed to staple off the affected lung parenchyma. Recently the use of a topical synthetic nonreactive surgical sealant (Coseal by Baxter, Freemont, CA) for the creation of an elastic watertight seal has also been reported.¹⁷ Chemical pleurodesis or pleural scarification by electrocoagulation remains a viable option especially in recurrences post-VATS. Carillo et al.²⁸ reported the successful use of VATS in 10 of 11 patients with persistent pneumothorax post-traumatic injuries. The 11th patient was successfully treated with chemical pleurodesis. The inflammatory reaction that occurs with chemical pleurodesis, however, is often associated with increased pleural edema, drainage, and postoperative pain.¹⁵ Prior to committing a patient to VATS, it is important to aggressively evaluate the cause of the air leak and rule out a malfunctioning or a malpositioned chest tube, the presence of a foreign body, or a deeply penetrating rib fragment. The patient should be evaluated thoroughly with chest CT and bronchoscopy to evaluate the tracheobronchial tree, the distal parenchyma, and the pleural cavity.

Other Indications/Application

Other indications for use of VATS in chest trauma include diagnosis of bronchopleural fistulas, removal of retained foreign bodies, ligation of injured thoracic duct, drainage of chylothorax, and assessment of cardiac and mediastinal structure.^10,15 Although pericardioscopy for suspected penetrating cardiac injury has been reported as feasible and safe in the hemodynamically stable patient, it remains very controversial, with potential for iatrogenic life-threatening injuries.³⁰ In a stable patient, the gold standard approach for suspected cardiac injury remains the use of echocardiography or subxyphoid pericardial window followed by immediate sternotomy or left thoracotomy for evacuation of hemopericardium and repair of cardiac injury.