The role of diagnostic VATS in penetrating thoracic injuries

BACKGROUND: Penetrating chest injuries account for 1–13% of thoracic trauma hospital admissions and most of these are managed with a conservative approach. Nevertheless, 18–30% of cases managed only with tube thoracostomy have residual clotted blood, considered the major risk factor for the development of fibrothorax and empyema. In addition, 4–23% of chest injury patients present persistent pneumothorax and 15–59% present an injury to the diaphragm, which is missed in 30% of cases. In order to make a correct diagnosis, reduce the number of missed injuries, chronic sequelae and late mortality we propose performing surgical exploration of all patients with a penetrating injury of the pleural cavity. METHODS: 1270 patients who sustained thoracic trauma were admitted to our hospital between 1994 and 2004. Of these, 16 patients had penetrating injuries: thirteen were surgically explored by means of Video Assisted Thoracic Surgery (VATS), and 3 with thoracotomy due to hemodynamic instability or suspected lesion of the heart or great vessels. RESULTS: In the 13 patients who underwent VATS, 5 injuries to the diaphragm, 3 lesions to an intercostal artery, and 1 lesion to the diaphragmatic artery were detected. In 12 of these patients a laceration of the pulmonary parenchyma was also present. A conversion to thoracotomy was necessary due to a broad laceration of the diaphragm and due to hemostasis of an intercostal artery. In all but one case, which was later converted, diagnostic imaging missed the diagnosis of laceration of the diaphragm. There was no intra- or postoperative mortality, and average hospital stay was five days. CONCLUSION: VATS is a safe and effective way to diagnose and manage penetrating thoracic injuries, and its extensive use leads to a reduction in the number of missed, potentially fatal lesions as well as in chronic sequelae.