Abstract
- The majority of traumatic hemothoraces can be managed successfully with a chest tube placement.
- Retained hemothorax is defined as residual pleural blood >300–500 mL after initial thoracostomy tube evacuation.
- The gold standard for diagnosing retained hemothorax is a noncontrast CT scan of the chest. A chest X-ray is not reliable in the accurate diagnosis of retained hemothorax.
- VATS is usually contraindicated in patients with previous thoracic operations and in patients with respiratory failure or significant contralateral lung injury, such as contusion, atelectasis, or pneumonia, because single-lung ventilation may not be tolerated.
- Ideally, VATS should be done within the first 3–5 days. Early VATS (within 72 hours of admission) for evacuation of retained hemothorax reduces hospital length of stay, number of procedures, and cost. VATS is more difficult and less effective if performed more than 7–10 days after the injury, due to clot organization and dense adhesions.
General Principles
The majority of traumatic hemothoraces can be managed successfully with a chest tube placement.
Retained hemothorax is defined as residual pleural blood >300–500 mL after initial thoracostomy tube evacuation.
The gold standard for diagnosing retained hemothorax is a noncontrast CT scan of the chest. A chest X-ray is not reliable in the accurate diagnosis of retained hemothorax.
VATS is usually contraindicated in patients with previous thoracic operations and in patients with respiratory failure or significant contralateral lung injury, such as contusion, atelectasis, or pneumonia, because single-lung ventilation may not be tolerated.
Ideally, VATS should be done within the first 3–5 days. Early VATS (within 72 hours of admission) for evacuation of retained hemothorax reduces hospital length of stay, number of procedures, and cost. VATS is more difficult and less effective if performed more than 7–10 days after the injury, due to clot organization and dense adhesions.
Patient Preparation and Positioning
After intubation with a double-lumen endotracheal tube, the patient is placed in lateral decubitus position (operative thorax up) on a vacuum bean bag. The hips are secured to the table with wide adhesive tape.
If there is no spinal injury, the operating room table should be flexed at the hips to increase the separation of the ribs, and reduce the risk of trauma to the intercostal nerves and chronic postoperative pain.
The dependent arm is extended on the operating table for ease of access for anesthesia. The superior arm is extended and flexed at the elbow and secured on an arm board. The elbow should extend cephalad to rest above the shoulder so as to not interfere with the surgeon.
The lower leg is bent and the upper leg left straight, with a pillow between the knees. All bony prominences and axilla (brachial plexus) should be well padded to prevent neuropraxia to the brachial plexus and peroneal nerves (most common nerve injuries).
In the lateral decubitus position, the external landmarks to note for port insertion planning include: the tip of the scapula and mid and anterior axillary lines.
