Role of video assisted thoracoscopy in the management of clotted hemothorax

ABSTRACT

To evaluate therapeutic value of videothoracoscopy in chest trauma patients with residual clotted hemothorax. Prospective study Sixty five patients included in the study were seen at the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, after careful assessment of their haemodynamic status and the extent of injuries. Out of these, 15 presented in our casualty, while 50 were referred to the Department from elsewhere. Inclusion criterion for the study was x-ray chest showing a retained haemothorax 72 hours after tube thoracostomy. They underwent therapeutic VATS on the next available operation day. One lung anaesthesia was used with collapse of the lung on the ipsilateral side. Two or three ports were used keeping the concept of triangulation in mind. The pleural cavity was washed with warm normal saline and one or two 36 Fr. thoracostomy tubes were inserted under vision. Sixty-five hemodynamically stable patients [54 males and 11 females] with chest trauma [blunt 46, penetrating 19] were examined and treated videothoracoscopically over a period of 3 years from November 2001 to October 2004. The indication in this group of patients was clotted hemothorax, which failed to evacuate with a conventional large bore [36 F] thoracostomy tube. Most [77%] of the patients underwent VATS in the first week after injury, while 23% patients had video assisted thoracoscopy [VATS] in the second week. The rate of conversion to thoracotomy was 7.7% [5 patients]. It was seen that in these 5 patients requiring thoracotomy, an increased time interval between injury and VATS was a significant factor in determining the outcome [p<0.005]. In all these patients the time interval was more than 7 days. Post VATS full lung expansion was achieved in 51 [78.5%] patients. The average duration of VATS was 70.16 minutes [minimum 60 minutes; max 100 minutes]. Most patients [90.8%] had the thoracostomy tube removed in the first week after surgery. In 6 patients the tube was kept for a longer duration. Therapeutic video assisted thoracoscopy is a safe and reliable operative technique for the evacuation of post traumatic clotted hemothorax in hemodynamically stable patients. VATS, if performed within the first 7 days of injury, obviates the need for later thoracotomy and decortication avoiding prolonged hospital stay and morbidity of an empyema thoracis