Role of VATS in chest trauma
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 .
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 chylo-thoraces.(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 fiber-optic bronchoscopy. Pulse oximetry, electrocadio-graphy, 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), broncho-pleural 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 intra-pleural 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.), 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 %).
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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