Grubnik V.V., Baydan V.V., Severgin V.E., Grubnik V.Yu., ROLE OF VIDEO- THORACOSCOPY IN CLOSED CHEST TRAUMAS

Aim: To study the effectiveness of video thoracoscopy (VTS) in complicated closed chest traumas Methods: From 2006 to 2009, a total of 612 patients with complicated chest traumas have been treated. Along with the complicated closed chest traumas included the damage of the rib cage with the muscles and the inner organs.

Methods: The age varied from 17 to 86 years. Among them 411 (67.2%) were male and 201 (45.8%) female.

Ratio from male to female

Methods: 280 (45.8%) patients were hospitalized within 24 hours from the time of injury and other 332 (54.2%) patients were transferred from the department of general surgery with different complicated traumas and coagulated hemothorax to the specialized department of thoracic surgery within 72 hours or more.

Hospitalization time after injury

According to the methods of treatment used, all the patients were divided into 2 groups. The first group included 127 (20.7%) patients, who were treated according to the traditional cure and diagnostic procedures. The second group consisted of 485 (79.3%) patients, who were treated with the methods of operative VTS.

Patients distributed according to type of operative treatment

 Out of 127 patients of the first group, the control group –  100 (78.8%) patients at admission underwent pleural effusion with chest drain.  48 (48.0%) patients had to be re-drained because of air leak and formation of residual space in the pleural cavity.

Types of operative manipulations used in the control group of patients №Type of operative manipulation Numbers% 1 Use of chest drain, active aspiration Additional chest drainage48 3 Thoracotomy, suturing the lungs damages and bleeding chest wall vessels, osteocentesis of rib Lung decortication, including suturing the diaphragm damage Laparotomy, splenectomy First surgical aid of wounds Laparocentesis Fixation of the frail chest32.4

Mortality in this group of patients was not registered. Postoperative complications were seen in 54 (42.5%) patients.

In 485 (79.3%) patients, the main (2-nd) group, were treated using methods of operative VTS.

Indications for VTS in complicated chest traumas 1 Pneumothorax 2 Haemothorax 3 Pneumohaemothorax 4 Multiple ribs fracture with their dislocation 5 Fragmented fractured ribs with frail chest 6 Coagulated hemothorax 7 Purulent coagulated haemothorax and post- traumatic empyema of pleura

Distribution of patients undergoing according to type of anesthesia Type of anesthesia No. Of patients% Local anesthesia General anesthesia with the use of artificial lung ventilation Total

Characteristics of operative interventions involving VTS №Types of operations No. Of Operations 1Electro-coagulation of chest wall vessels85 2Electro-coagulation of lung ruptures52 3 Removal of intra-parenchymal and sub-pleural hematomas 28 4YAG – laser coagulation of chest wall vessels50 5Endoscopic reposition of rib fragments with hemostasis59 6Removal of coagulated hemothorax73 7Suturing of ruptures of lungs36 8Endoscopic clipping or suturing chest wall vessels39 9Suturing diaphragm damages or ruptures6 10Removal of hemopericardium with suturing its damages2 11VATS, suturing of ruptures of lungs8 12Lung decortication with coagulated hemothorax, fibrous pleurisy and posttraumatic empyema of pleura 47

The operative manipulations used such as electrocoagulation, removal of coagulated hemothorax, lung decortication etc. are shown in the following video clips -

Removal of coagulated hemothorax

Electrocoagulation

Removal of sub-pleural hematoma & lung decortication

Applying endo-clips over blood vessels

Resection of ruptured part of lung

Results: Good and excellent clinical effects with stable aero-hemostasis, total lung expansion and removal of hemothorax was achieved in 467 (96.3%) patients of the main group (2-nd group). Use of the cure – diagnostic tactics on the basis of VTS allows lowering the number of thoracotomies in complicated closed chest traumas (from 10.2% to 1.2%).

Apart from that, at retrospective analysis of 13 cases of the control group, where wide thoracotomy was used, in 7 (53.8%) patients’ thoracotomy could have been avoided by using methods of operative VTS.

Character of complications after VTS Types of complications No. Of patients % Infection on thoracoportal incisions61.2 Unstable aerostasis40.8 Prolonged exudation20.4 Formation of residual cavity10.3 Total

Complications: Complications after VTS were seen in 2.7% patients in main (2-nd) group and 42.5% in control group

Comparing characteristics of postoperative complications in both groups Type of complication Main group (n=485) Control group (n=127) Effectiveness Residual cavity in pleural cavity124< 24 times. Suppuration of postoperative wounds 63< 2 times. Unstable aerostasis46< less. Encysted pleurisy210< 1.5 times. Posttraumatic pneumonia-5< 24 times. Lung abscess-1< 1 times. Suppuration of intermuscles hematoma -1< 1 times. Coagulated hematoma-4< 4 times. Total 13 (2.7%) 54 (42.5%) < 4.2 times.

Noticeable decrease in the related complications with accurate diagnostic and sophisticated corrections of intrathoracic traumas using VTS, advanced total removal of hemothorax, decrease in numbers of thoracotomies. Average time for the pleural drainage was 72 hours in main group and hospital stay was 7.7 days, whereas in the control group it was 96 hours and 15.4 days respectively.

Mortality was registered in 3 cases (0.6%) in main group and was not related with the consequences using VTS. Death in 1 patient was due to spleen rupture with massive hemorrhage and in other 2 cases the death cause was due to massive thromboembolisation of lung artery in severe chest traumas.

Conclusions: Wide use of VTS in complicated chest traumas avoids and decreases the numbers of wide traumatic thoracotomies by 2.2 times. In the first 24 hours after trauma, VTS is indicated in patients suffering from hemo- and pneumo-hemothorax with stable hemodynamic.

Contraindications for VTS during clsed chest traumas are – hemorrhagic shock, total hemothorax, injuries of heart and major vessels, injuries of trachea and major bronchi. Use of operative VTS technology lowers the numbers of postoperative complications by 4.2 times.