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D. VanDerPloeg et al.
spontaneous pneumothorax is one that occurs in the presence of underlying lung
pathology, most commonly COPD.The incidence of spontaneous pneumothoraces
in the United States is thought to exceed 20,000 patients per year [2]. There is a
large variability in the management of spontaneous pneumothoraces and a lack of
well-accepted, consensus guidelines. Initial management can include simple aspiration, tube thoracostomy, or oxygen supplementation to assist in pneumothorax reabsorption [7, 12]. In emergent situations or in the presence of tension physiology,
patient stabilization requires tube thoracostomy for drainage of pneumothorax and
re-expansion of the lung. A recent randomized controlled trial demonstrated noninferiority from a conservative approach that did not include immediate tube decompression [3] for the management of spontaneous pneumothoraces. It prevented the
need for 85% invasive procedures and led to a decreased length of hospital stay and
decreased adverse events. Finally, computed tomography (CT) is a vital component
of the diagnostic workup and should be used to evaluate for pulmonary blebs as they
are a major risk factor for recurrent pneumothorax.
Surgical evaluation for primary spontaneous pneumothorax is indicated in
patients with a recurrent pneumothorax, persistent air leak after tube thoracostomy
more than 4days, or at rst occurrence for patients with occupational risks or for
recurrent pneumothorax. A thoracoscopic approach is preferred in these patients as
it decreases hospital stay and postoperative pain, with similar recurrence rates when
compared to an open surgical approach. There are two main goals of thoracoscopic
management [12]. The rst involves resection of bullae/blebs or area of persistent
air leak with an endoscopic stapler. The second is to induce pleural scarring, or
pleurodesis, in order to decrease recurrence. The pleurodesis may be achieved by
either mechanical, chemical, or both methods. One commonly used technique is the
instillation of talcum powder into the pleural space to create a chemical pleurodesis.
However, with the recall of talcum powder, other sclerosing agents are used, such as
betadine, tetracycline, doxycycline, or gentamicin. Mechanical pleurodesis may be
performed by formal parietal pleurectomy or by disrupting the pleura with direct
contact with Bovie scratch pad or gauze. Although chemical pleurodesis may be
performed at bedside via chest tube, without the need for operative intervention, it
is often poorly tolerated by the patient due to pain, and sometimes this requires
conscious sedation.
Patient positioning is one of the important rst steps in any thoracoscopic operation. Lateral decubitus with appropriate padding and arm rests is the position of
choice for thoracoscopic pleurodesis. Additionally, the break of the operating room
table should be positioned at the level of the xiphoid process in order to open the rib
spaces to increase working space during the operation. Attention to port placement
is also important in order to allow for working space and maneuverability within the
chest. See Fig.1.
Below is the preferred technique for thoracoscopic pleurodesis and bleb resection at our institution. After conrmation of appropriate lung isolation with either
double-lumen endotracheal tube or endobronchial blocker, the authors favor entering the chest using the optical viewing technique (with an endoscope inserted into a
12mm port) in the anterior-axillary line at the fourth or fth intercostal space. The
Role ofMIS Approaches inThoracic Emergencies andTrauma
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Fig. 1 Patient positioning
in the right lateral
decubitus position with
circled X marking
proposed port sites
placement. Costal margin
(C), scapular tip (S),
midaxillary line (MA), and
posterior axillary line (PA)
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chest is entered at the planned site of the chest tube placement after the operation,
directing the scope toward the scapular tip. The open technique is also acceptable
for initial entry into the chest. This involves an incision at the upper border of the
fourth or fth intercostal space and using surgical energy to dissect through the
intercostal muscle until the pleural space is entered. This may be the preferred
approach as it is similar to that for chest tube insertion. An additional 12mm port,
to accommodate a stapler, is placed under direct visualization in the posterioraxillary line. Our nal 5mm port is placed in the eighth or ninth intercostal space
along the midaxillary line and under direct visualization. The pleural space is evaluated, and any blebs are resected with endoscopic stapler using medium staple height
loads (2.5–3.5mm). See Figs.2 and 3.
Sometimes there may be adhesions already present at the site of ruptured blebs.
Careful lysis of adhesions may be required to free the bleb off of the chest wall in
order to perform a resection. Next, attention is turned to performing the chemical
pleurodesis. The preferred sclerosing agent at our institution is betadine. See Fig.4.
It is used to coat the entire parietal and visceral pleural surfaces by instilling it into
the chest via red rubber catheter and Toomey syringe or via suction irrigator.
Once all the pleural surfaces are covered, the lung is then reinated under direct
visualization in order to assess for air leaks. Once satised with the pleurodesis, a
chest tube is introduced through the anterior axillary port site and directed posterior
and apically. The chest tube is placed to continuous suction at 20cm H2O for 48h
to ensure pleural apposition.
A mechanical pleurodesis, using a Bovie scratch pad, requires the open technique for the anterior axillary site in order to use a working port rather than performing the pleurodesis via ports. The rest of the ports are placed per the above technique
under direct visualization. To perform the mechanical pleurodesis, a Bovie scratch
pad is folded in half and clasped with an empty ringed forceps. This is then used to
scratch the parietal pleura in order to induce scarring.
Recurrent pneumothorax still remains an area of concern, even after thoracoscopic bleb resection and pleurodesis. Recurrence after surgery is cited to occur in
between 5 and 19% of patients [1]. There have been a number of studies done to
identify risk factors for recurrence. Smoking increases the risk of recurrence by up
to four times when compared to nonsmokers [4]. One retrospective study identied
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Figs. 2 and 3 Thoracoscopic
stapled blebectomy after
identifying source of air leak
by submerging lung in saline
(top) and resected blebectomy
specimen (bottom)
D. VanDerPloeg et al.
risk factors for recurrence that included age <20, inability to identify bleb on preoperative CT imaging, and history of ipsilateral pneumothorax [1]. Another retrospective study identied female gender and prolonged air leak as risk factors for
recurrence after thoracoscopic surgery [9].
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Fig. 4 Betadine
pleurodesis being used to
cover the pleural spaces
via suction irrigator.
Betadine was injected into
a bag of saline and
connected to irrigator port
and used to coat the pleural
space
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3 Role 2: Pericardial Window forPericardial Effusion
A pericardial window can be done using thoracoscopy. This technique is preferred
for loculated, posterior effusions, or recurrent effusions as echocardiogram-guided
pericardial drain or pericardiocentesis are best for addressing more anterior effusions. One main advantage is that it offers access to different areas of the pericardium that can be difcult to access with a subxiphoid approach. The thoracoscopic
technique is also advocated for evaluation for pericardial injury in the setting of
penetrating chest trauma. In select patients, it is a safe and effective approach to rule
out injury to the heart for patients with penetrating trauma. However, a thoracoscopic approach should not be used in hemodynamically unstable patients or
patients with clear tamponade physiology as median sternotomy needs to be used in
these patients for immediate decompression.
Retrospective studies have been done that demonstrate comparable morbidity
and mortality between a thoracoscopic and a classical open subxiphoid approach.
Both techniques are effective at addressing and draining pericardial effusions. One
advantage of a thoracoscopic approach is the added potential to address concomitant pleural or pulmonary issues at the time of pericardial window [8].
Techniques to perform thoracoscopic pericardial drainage often utilize a leftsided approach as it allows access to most areas of the pericardium. A right-sided
approach may be indicated for a loculated right-sided effusion, but this can often
still be addressed via left-sided drainage. The surgical approach requires single- lung
ventilation and often requires slightly lower port placement compared to the previously described lung parenchymal procedure to allow better manipulation of the
pericardium. Three ports are usually sufcient for performing the procedure with a
camera port, grasping instrument, and working instrument. The camera port is
placed in the eighth or ninth intercostal space in the midaxillary line. The port for
the grasper is along the posterior axillary line, and the working instrument is along
the anterior axillary line. The working instrument is typically a laparoscopic scissors or energy device that are used to incise the pericardium. The grasping instrument is used to grab the pericardium and elevate it away from the heart to prevent
injury when incising the pericardium. The scissors are used to incise the
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D. VanDerPloeg et al.
pericardium and then remove a square 2cm portion of the pericardium. This can be
sent for pathological analysis but also ensures a communication between the pericardial and pleural spaces. This communication allows for both rapid and continued
drainage of the pericardial effusion.
A thoracoscopic technique is sufcient to treat pericardial effusions. It allows for
treatment of concomitant pleural or pulmonary issues at the same time. It does
require entry into two anatomical spaces but often provides better visualization
when compared to the classical subxiphoid, preperitoneal approach. It allows for
the same pathological and cytological uid analyses. Studies have been done that
demonstrate safety and efcacy of a thoracoscopic approach, even in the setting of
early echocardiographic signs of pericardial tamponade.
4 Role 3: Retained Hemothorax
A retained hemothorax is a complication often seen after thoracic trauma. It is
dened as hemothorax persisting after tube thoracostomy as demonstrated on chest
radiograph or chest CT.See Figs.5 and 6. Some practice patterns advocate for the
Figs. 5 and 6 CT scan
demonstrating retained
hemothorax after chest
tube placement (top).
Thoracoscopic
visualization of early
moderate volume retained
hemothorax (bottom)
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placement of an additional chest tubes after a persistent hemothorax is identied on
imaging. A retained hemothorax is an important diagnostic distinction as it may
occur in up to one third of trauma patients that initially present with hemothorax [5].
Additionally, it is a risk factor for increased morbidity such as empyema or a brothorax, also known as a trapped lung. It leads to such complications due to the
remodeling of retained blood products in the pleural space that can serve as a nidus
for infection or scarring. Surgical intervention becomes a point of discussion to
decrease these risks when imaging reveals a retained hemothorax. When utilized
appropriately, early thoracoscopic evacuation can lead to decrease length of hospital
stay, decreased length of chest tube duration, and decreased hospital cost [13]. One
additional benet of intervention is the ability to address causes of retained hemothoraces, such as lung lacerations or chest wall injury, that would have been otherwise untreated if undergoing tube thoracostomy alone. Therefore, early thoracoscopic
evacuation is an important tool in the acute care surgeon’s armamentarium for the
management of thoracic trauma.
Tissue plasminogen activator (tPA) and DNase is described for the treatment of
empyema and parapneumonic effusions. While intrapleural lytics have demonstrated some efcacy for treating empyemas, there is hesitancy to use these agents
in the acute setting of traumatic hemothorax due to the risk of rebleeding. A large
randomized control trial demonstrated improved pleural effusions at 7 days,
decreased hospital stay, decreased surgical referral, and no increase in adverse
events for pleural infections [16]. There have been a lack of prospective randomized controlled trials to evaluate thoracoscopic evacuation versus tPA for retained
hemothoraces. There have been some retrospective studies evaluating thoracoscopic evacuation compared to streptokinase that demonstrated the superiority of
surgery [14]. Additionally, a large majority of trauma patients have multisystem
injuries that often prohibit thrombolytic use in this population. There is also a lack
of trials done to determine appropriate dosing for intrapleural thrombolytics and
DNase. Although some studies have advocated that intrapleural thrombolytics and
DNase is safe in the trauma population, it is often associated with an increased
hospital stay and cost that could potentially be avoided with early thoracoscopic
evacuation [5, 13].
Operative intervention requires similar positioning in the lateral decubitus position. Here, a 12mm port is placed in the midaxillary line at the fourth or fth intercostal space. An additional 5mm port is placed along the anterior axillary line in the
sixth or seventh intercostal space to allow direct evacuation of the retained hemothorax most commonly located along the diaphragm at the base of the lung. A suction irrigator system is used to evacuate the retained hemothorax, and the pleural
space is irrigated until clear. If necessary to achieve adequate hemostasis or evacuation of hemothorax, an additional port may be placed along the posterior axillary
line. Evaluation of the entire pleural space is performed in order to identify and treat
any reversible cause of retained hemothorax such as pulmonary laceration or chest
wall bleeding. This may require upsizing the anterior axillary port to 12mm in order
to accommodate an endoscopic stapler. Once the hemothorax is completely evacuated, a posterior and apical chest tube can be placed under direct visualization via
previously placed port incision to allow for improved drainage postoperatively. A
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24–28 French chest tube is used as there is no better drainage with a larger bore
chest tube [10]. Additionally, the option to place a right-angled chest tube can be
utilized if increased basilar drainage along the diaphragm is desired.
An area of ongoing, particular interest is whether a retained hemothorax can be
prevented with sterile pleural irrigation at time of initial chest tube placement [11].
Current multicenter trials are underway to examine whether sterile pleural irrigation
with normal saline or sterile water is effective at preventing retained hemothorax.
The hypothesis behind pleural irrigation is that it breaks down the clotted blood
within the hemothorax, allowing for better evacuation and avoidance of need for
surgical evacuation.
D. VanDerPloeg et al.
5 Role 4: Diaphragm Evaluation forThoracoabdominal
Penetrating Trauma
Thoracoabdominal penetrating trauma is an important injury pattern to consider
thoracoscopic intervention. It is dened as an injury that occurs within the zone
delineated between the nipple, costal margin, and scapula. Organs with the chest
and abdomen are at risk of injury, including peritoneal and retroperitoneal structures
as well as the diaphragm. There is high incidence of diaphragmatic injury in thoracoabdominal wounds, up to approximately 20% [15]. Radiographic studies are very
poor at the evaluation of the diaphragm and have a wide range of sensitivity from 8
to 63% [18]. One reason is that the diaphragm laceration may be very small in penetrating trauma. A retrospective single institution study compared the newer 256slice CT scanners to the older 64-slice scanners to evaluate whether the newer
scanners improved the diagnostic capabilities [18]. The study failed to diagnose
traumatic diaphragm injuries in over 40% of patients. The study also found that CT
scanners result in a higher incidence of false negatives, conrming that intraoperative analysis should still be the gold standard. Thus, a high level of suspicion is
warranted and should drive the surgeon to operatively evaluate patients with thoracoabdominal penetrating trauma for a diaphragmatic injury.
Although many institutions prefer laparoscopy to evaluate for a diaphragmatic
injury, thoracoscopic evaluation is an important alternative approach. One advantage of a thoracoscopic approach is in the setting of other thoracic injuries, most
commonly a pneumothorax or hemothorax that requires chest tube placement. In
this situation, two thoracoscopic ports should be placed, one in the midaxillary line
and one in the anterior axillary line. This can also be done with the patient in the
supine position for conversion to exploratory laparotomy or laparoscopy if thoracoscopic exploration mandates further abdominal exploration. It allows for the insertion of an endoscope through a port for visual inspection of the pleural space and
diaphragm. It also allows for directed and more complete drainage of the pleural
space and chest tube placement under direct vision. There are studies that compare
thoracoscopy to exploratory laparotomy for the identication of diaphragmatic
Role ofMIS Approaches inThoracic Emergencies andTrauma
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injuries [17, 19]. They demonstrate that thoracoscopy is a safe and reliable method
for the evaluation of diaphragmatic injuries in the setting of thoracoabdominal
trauma. There has, however, not been a comparison of a thoracoscopic to a laparoscopic approach for the diagnosis of diaphragmatic injury. With the lack of randomized control trials or direct comparison, the recommendation is to use the approach
that the operating trauma surgeon is the most comfortable performing or would best
evaluate the concern for other injuries. Some patients may require both approaches.
Some institutions advocate for the use of a thoracoscope in the emergency
department to determine the need for further surgical evaluation and intervention.
Following bedside tube thoracostomy, a thoracoscope is introduced under sterile
conditions to survey the pleural space. This technique is promoted as a novel minimally invasive technique to evaluate the pleural space for diaphragm injury or ongoing bleeding that will require operative intervention [6]. It removes the requirement
for general anesthesia as it can be performed under local anesthesia and conscious
sedation. The technique is also thought to allow for better determination of the need
for chest exploration for a hemothorax. It allows for immediate evacuation of hemothorax and removes the need to wait for repeated chest X-rays. Most of the reports
describing this technique are small cohorts, and they demonstrated no increased
morbidity and a trend of decreased nontherapeutic operations. In order to validate
this technique, prospective clinical trials are needed to compare it to the classically
accepted diagnostic laparoscopic or thoracoscopic evaluation of thoracoabdominal
penetrating trauma.
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6 Role 5: Foreign Body Removal
Foreign bodies may enter the pleural space as a result of penetrating trauma or iatrogenic injury. Provided the patient is clinically stable, these objects may be readily
retrieved via thoracoscopic exploration. Depending upon the nature of the foreign
body and associated injury, additional chest wall debridement and/or reconstruction
may be necessary on an individual basis. Additionally, standard thoracoscopic port
sites may need to be enlarged to facilitate safe object retrieval.
7 Conclusions
VATS can be very helpful for a variety of acute pathologies including trauma. It
requires single-lung ventilation, proper positioning, and hemodynamic stability.
Acute patients who are unstable should undergo a thoracotomy if chest pathology is
suspected. The minimally invasive approach to the chest has several advantages
including decreased postoperative pain, decreased length of hospital stay, earlier
recovery of pulmonary function, and decreased narcotic requirements, decreased
incidence of postoperative complications, and lower overall cost. With increasing
popularity and training in minimally invasive techniques, VATS is a great tool for
the modern trauma and acute care surgeon.
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D. VanDerPloeg et al.
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