Chest trauma: Use of VATS in traumatic patients

In 1600 BC, in the Edwin Smith Surgical Papyrus, written in ancient Egypt probably by Imhotep, the builder of the Step Pyramid in Saqqara, thoracic traumas were documented.

Later in 400 BC, Hippocrates described hemoptysis after rib fracture, defining hemoptysis as a significant injury to the underlying lung, much more serious than a simple rib fracture.

Later, in 300 BC, Aristotle said: “The heart alone of all the viscera cannot withstand serious injury. When the heart is destroyed there is no aid that can be brought to the other organs which depend on it.”

And in 100 BC, Galen noted that when heart wounds were seen in gladiators, they were uniformly fatal.

So, what if we stop rewinding the tape and ask where are we now?

First of all, we must take a look at the epidemiology of chest trauma.

Traumatic death rate is 56 per 100,000 people, or 6% of all deaths.

This death rate has slowly risen in recent years, with the lowest point occurring in 2000, at 52 per 100,000.

Motor vehicle–related injuries, firearms, stabbings, assaults and falls account for more than half of these deaths (58%).

The male/female ratio for firearm-related deaths is 6.5:1

There are some important facts about chest trauma that we should not forget.

• It is a cause of death worldwide.

• ⅔ of patients have a chest trauma with another injury.

• Blunt chest trauma is the most common with a 90% incidence.

• 10% of patients require surgical intervention.

• It represents 25 % of all trauma fatalities.

• Chest trauma mortality is the second highest at about 25.2 % after head injury.

• Trauma is the leading cause of death in people under 45 worldwide.

• Deaths can be prevented by prompt diagnosis and treatment.

• Thoracic injuries account for 60% of all trauma presentations.

Looking at the pathophysiology, there are clearly mechanisms for early loss of life:

• Airway obstruction

• Loss of oxygenation and ventilation

• Exsanguination

• Cardiac failure

• Cardiac tamponade

Management of chest trauma must be initial resuscitation based on ATLS protocols following the ABCDE algorithm.

In the primary survey, the following should be discarded:

• Airway obstruction

• Tension pneumothorax

• Open pneumothorax

• Massive hemothorax

• Flail chest

• Cardiac tamponade

Certain pathologies should be ruled out in the secondary survey, as they are severe pathologies that threaten patients’ lives and should be treated as soon as possible.

These are:

• Pulmonary contusion

• Myocardial contusion

• Aortic disruption

• Traumatic diaphragmatic rupture

• Tracheobronchial disruption

• Esophageal disruption

In the Emergency room, when performing trauma life support, the clinical examination in the primary and secondary survey with anamnestic information on the mechanism of thoracic trauma will provide information on the potential severity of thoracic injury.

These tools are also used:

• Blood test

• X-Ray

• Chest tube

• FAST

• CT scan

Thoracic injuries (85%) are managed conservatively with analgesia, respiratory support and physiotherapy.

Given this information, the question arises: WHAT ABOUT THE OTHER 15%?

15% of patients with thoracic trauma require surgical intervention due to hemorrhage or to disruption of an intrathoracic organ requiring repair or reconstruction.

The indications for thoracic surgical intervention are:

• Blood loss ≥1,500 mL initially/>200 mL/hour over 2–4 hours.

• Endobronchial blood loss; massive contusion with significant impairment of mechanical ventilation.

• Tracheobronchial tree injury (air-leakage/ hemothorax).

• Injury of the heart or large vessels (blood loss/ pericardial tamponade).

So is there a place for minimally invasive surgery in the management of severely injured patients?

Reviewing the literature, in 1922 Jacobeaus performed the first clinical application of Thoracoscopy in the management of pleural adhesions, biopsy, drainage of empyemas, and treatment of pleural effusions.

Later, in 1946, Branco described its value in patients with hemothorax secondary to penetrating injuries.

In 1981, Jones published a series of 36 trauma patients with hemothoraces who underwent emergency thoracoscopy under local anesthesia.

Currently, thanks to the development of surgical techniques and the use of minimally invasive surgery, the indications for VATS in severely injured patients are:

• Penetrating injury with little blood loss in a stable patient.

• Persistent hemothorax.

• Empyema.

• Persistent air-leakage.

• Suspicion of diaphragmatic rupture.

On this basis, we have conducted a retrospective review of the literature on published articles on this subject.

In one article from 1997 in Annals of thoracic surgery, Dan. M. Meyer et al. described that early VATS for retained hemothoraces decreases the duration of tube drainage, the length of hospital stay and hospital cost.

Early intervention with VATS may be a more efficient and economical strategy for managing retained hemothoraces after trauma.

In 2005, the American Journal of Surgery published an article about thoracoscopy in acutely injured patients. This group carried out a strong research and documented the benefits of using VATS in the care of trauma patients in the Trauma Program at the University of Louisville Hospital.

This area of research on VATS was performed in the Center for Advanced Surgical Technology, in a combined program of Norton Hospital and the Department of Surgery of the University of Louisville.

The purpose of this review was to describe the current role of VATS in the diagnosis and treatment of some specific conditions associated with thoracic injuries. In this article they made the following recommendations:

• VATS has no role in the management of patients in unstable condition or in whom there are clear indications for open thoracotomy.

• This procedure is for retained collections and persistent post traumatic pneumothorax.

• VATS is used to document the integrity of the diaphragm in penetrating thoracoabdominal trauma.

Later, in 2007 in a paper in Annals of thoracic surgery a group at the Rambam medical center in Israel described:

For stable patients with chest trauma, video assisted thoracic surgery is feasible and safe.

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.

Later, a systematic review and meta-analysis of a comparison of video assisted thoracoscopic surgery with open thoracotomy for the management of chest trauma was published in the World Journal of Surgery in 2015.

This group highlights that in addition to smaller incision and less pain, perioperative outcomes such as effectiveness, postoperative complications, perioperative mortality, and duration of hospitalization for VATS seem to be superior to open thoracotomy in treating chest trauma.

However, caution should also be exercised in certain clinical scenarios.

With all this information based on an extensive review of the literature, we can deduce that VATS would be an effective diagnostic and therapeutic modality in chest trauma patients.

It can be applied to retained hemothorax, persistent pneumothorax, suspicious diaphragm injury and even coagulation of bleeder.

A review published last year in the Journal of Thoracic Diseases by the Charité Hospital group in Berlin showed:

• The standard approach for an emergency thoracotomy is anterolateral but VATS can be used for diagnostic and therapeutic indications in hemodynamically stable patients.

• VATS has a favorable postoperative course, a greater patient satisfaction rate and a superior long-term outcome compared to open surgery in hemodynamically stable patients with blunt and penetrating chest trauma.

In this literature review we found a 2018 article about patients with thoracic impalement injury and management in the emergency room.

They applied an algorithm which they highly recommend, in hemodynamically unstable patients and in the presence of great vessel injury, when performing an urgent open thoracotomy.

Finally, a 2019 review in the Journal of Thoracic Diseases on the pros and cons of the use of VATS in trauma patients concluded:

• VATS can provide greater visualisation of the intra-thoracic structures.

• It is therefore becoming increasingly used as a diagnostic tool to identify the extent of the injuries whilst also allowing for therapeutic intervention.

• These benefits translate into decreased rate of post-operative complications and a shorter length of inpatient stay.

Take home messages:

After this extensive review, we highlighted some important facts.

In cases of previous thoracic surgery, and pleurodesis or radiological signs of dense adhesions we prefer to avoid the minimal invasive surgery.

Depending on the extent of difficulty ventilating, VATS should be considered a relative contraindication

Tracheobronchial injury is a challenging emergency. In this condition, VATS should not be considered.

VATS can be applied to retained hemothorax, persistent pneumothorax, suspicious diaphragm injury and even coagulation of bleeder.

In addition to smaller incision and less pain, perioperative outcomes such as effectiveness, postoperative complications, perioperative mortality, and duration of hospitalization for VATS seem to be superior to open thoracotomy in treating chest trauma in hemodynamically stable patients.

Haemodynamically unstable patients should be resuscitated aggressively, and an open approach will allow rapid control of haemorrhage.