Section 3 Chest Trauma

#### **Chapter 4**

## The Role of Minimally Invasive Surgery in Management of Chest Trauma

*Tuba Apaydin*

#### **Abstract**

The role of minimal invasive surgery in management of chest trauma should not be underestimated. The amount of data for video-assisted thoracoscopic surgery (VATS) management in chest-trauma patient is rare. Nevertheless the on-going acceptance and use of VATS for major thoracic resections has led to advanced techniques for management of major bleedings in the elective-surgery-patient. VATS as a procedure for pleural space management in the non-critical, non-massive-transfusion patients can be of great assistance. Its value in persistent non-major-vessel-bleeding hemothorax in terms of pleural space debridement is unchallenged. In some cases VATS is considered to be related to lower ARDS-rates in comparison to open thoracotomy patients, whereby an obvious bias for the non-massive-injury-patients exist. Jin et al. could prove a significant advantage for stable thoracic trauma patients treated through VATS in a randomised trial vs. open thoracotomy.

**Keywords:** chest trauma, minimal invasive surgery, video-assisted thoracoscopic surgery

#### **1. Introduction**

Video-assisted thoracic surgery (VATS) has a standart role in diagnosis and therapy in thoracic surgery. It has gained a wider spectrum of indications with the improvement in technology and methods. Literature has reported data about its use. Injuries related to the thoracic cage constitutes 25% of mortality in trauma patients. Some of these deaths are ascribable to acute bleeding or cardiac tamponade. However, most of these are because of ARDS, pulmonary contusion, ventilatory associated pnemonia or systemic inflammatory syndrome from empyema or mediastinitis [1].

Patients with chest trauma can be classified in four groups. First group die in the incident or undergo resuscitative thoracotomy in the emergency or operating room due to emergent fatal injuries like cardiac tamponade or acute hemorrage. Secondly, those patients who require emergent thoracotomy for potentially fatal injuries. These patients come to thoracotomy for on-going haemorrage related to non-aortic great vessel, lung parenchymal or chest wall injuries. Also, aortic, oesophageal injuries are in this group. The third group is treated with resuscitation and tube thoracostomy, which is %85 of all chest injured patients. However, retained hemothorax, persistent pneumothorax, on-going haemorrage and empyema will necessitate thoracotomy in %20–30 of these initially non-operatively treated patients. Surgical

treatment is also needed for missed injuries of diaphragm, oesophagus and vascular injuries. The fourth group constitutes of patients requiring surgery for complications of hemo- or pneumothoraces or missed injuries [1].

In the past, most patients necessiating surgical treatment secondary to chest trauma was exposed to open thoracotomy, which was the most morbid of surgical incisions. This made way for open thoracotomy as a less invasive method to diagnose and treat thoracic injuries, originally reported by Branco in 1943. The implementation of VATS in trauma was originally reported in a series evaluating diaphragmatic injuries. Afterwards, numerous other indications have been reported [2].

Video-assisted thoracoscopic surgery has become a popular and acceptable method for diagnosis of intra-thoracic lesions since 1990s with the developments in surgical techniques. It is also used for treatment of retained pleural collections, it is a simple alternative to open thoracotomy. Although it's multiple advantages, timing of surgery and its effects on patients' results are not well elucidated. Multiple studies report that prognosis of patients is better with the earlier interventions in injured chest. However, there is so much differences for the optimal time for surgery in these studies [3].

In this chapter, we reported the role of VATS in the management of chest trauma describing characteristics of injury, indications for surgery, methods performed and results in terms of postoperative length of stay, morbidity and mortality [2].

#### **2. Indications of VATS in management of chest trauma**

Indications of VATS have been extended for management of diagnosis and treatment of chest trauma since 1990. This approach has multiple advantages as chest tube setting, minimally invasive surgery, less postoperative pain and chest exploration. Today, VATS is used for empyema, persistent pneumothorax, retained haemothorax, mediastinal and diaphragmatic exploration, pleuro-pericardial ruptures, surgery for thoracic duct injury and aspiration of symptomatic foreign bodies. [4].

Persistent pneumothorax is defined as persistent air leak and pneumothorax observed in radiology within 72 hours after chest tube setting. Nearly 23% of pneumothoraces will have a peristent air leak. Several studies reported the effectiveness of VATS in this indication [4–6]. Retained hemothorax is persistent effusion after chest tube insertion on radiographic tools. Retained hemothorax over 300 ml should be an indication for surgery due to its' complications like empyema or pneumonia [7, 8]. 40% of these undrained hemothoraces result in fibrothorax. VATS is also reported that it's useful in the removal of clotted hemothorax. However, procedures performed after 10th. day are hard due to the extensive pleural adhesions.

American Association for the Surgery of Trauma published a significant study related to surgical treatment of retained hemothorax in 328 patients with blunt chest trauma [7]. 33% patients were treated with VATS, 25% required more than two interventions and 5% required more than 3 interventions for complete healing. Thoracotomy for unsuccessful VATS was required in 20% patients. Meyer et al. compared VATS vs. second chest tube setting including 39 patients in each group. VATS diminished duration of chest drainage, duration of hospital stay and hospital costs. Additionally, the second chest tube setting resulted in surgical treatment in 40% patients. VATS should be chosen over second chest tube setting for management of retained hemothorax [9].

Cobanoglu et al. compared chest tube setting vs. VATS as the first intervention for treatment of blunt chest trauma, including 60 patients [10]. VATS decreased duration of hospital stay and the number of reoperations. In the chest tube group,

#### *The Role of Minimally Invasive Surgery in Management of Chest Trauma DOI: http://dx.doi.org/10.5772/intechopen.98439*

indications for reoperation were clotted hemothorax (23%), empyema (13%), fibrothorax (6%) and continuing bleeding over 100 ml/h (3%). Besides, Smith et al. reported to perform the surgery in 5 days while Vassiliu et al. preffered this duration as 3 days [11, 12]. Nevertheless, Fabrucci et al. reported this duration as the first 48 h for both persistent pneumothorax and retained haemothorax with continuing bleeding over 100 ml/h (**Table 1**) [13].

In haemodynamically stable patients, early VATS should be preferred for retained haemothoraces.

Lazdunski et al. stated that early videotoracoscopic surgery is ideal for management of posttraumatic empyema because it can successfully control the fibrinopurulent phase of empyema and removes the infected hemothorax before the progression of fibrotic phase. However, if the procedure is realised late, a dense fibrotic pleural peel may result with trapped lung at least orient the surgeon to thoracotomy [15].

Traumatic injury to the toracic duct is a rare complication of chest trauma. Videothoracoscopy is a safe and minimally invasive method for ligation of thoracic duct. Lazdunski et al. reported that VATS can be useful for posttraumatic chylothorax if they still exist after 10 days of proper medical therapy and tube thoracostomy [16].

Although most of the patients with chest trauma is treated with chest tube insertion, this conservative method is insufficient in the minority of patients.

Over the last several years, VATS after trauma has been used as the first surgical intervention in hemodynamically stable patients who necessiated urgent thoracic exploration within 24 h after the first presentation.


*RH: retained haemothorax; PP: persistent pneumothorax; BCT: blunt chest trauma.*

*a Eleven patients with persistent air leak were excluded from VATS: 4 due to injuries requiring further ICU stay, 3 due to pneumonia, 2 patients were too small for dual lumen intubation and 2 needed further operations. \*P < 0.05.*

#### **Table 1.** *Table of evidence for VATS.*

Goodman et al. reported that the use of post-trauma VATS is a safe and effective technique in acutely injured and proper trauma patients including 23 patients in their study [16].

Contraindications for VATS include: Hemodynamic instability, intolerance to lateral decubitus position or single-lung ventilation, suspected injuries to the heart or great vessels and severe adhesions due to prior thoracic interventions [16].

### **3. Conclusion**

Videothoracoscopy is a safe and beneficial diagnostic and therapeutic device as an acute approach to selected patients with chest trauma with no indication for emergent thoracotomy or sternotomy. It is also beneficial in the acute or the retarded approach for patients with blunt chest trauma for treatment of clotted hemothorax, persistent pneumothorax, thoracic empyema, chylothorax and diagnosis of diaphragmatic injuries. However, in cases of suspected pericardial injury, videothoracoscopy should not be considered.

### **Acknowledgements**

No contribution by any other author or no funding declared.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Tuba Apaydin Department of Thoracic Surgery, SBU Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Training and Research Hospital, Istanbul, Turkey

\*Address all correspondence to: tubaapaydn72@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*The Role of Minimally Invasive Surgery in Management of Chest Trauma DOI: http://dx.doi.org/10.5772/intechopen.98439*

#### **References**

[1] Ahmed N, Jones D. Video-assisted thoracic surgery: state of the art in trauma care. Injury. 2004;35(5):479-489. doi: 10.1016/S0020-1383(03)00289-4. PMID: 15081325.

[2] Manlulu AV, Lee TW, Thung KH, Wong R, Yim AP. Current indications and results of VATS in the evaluation and management of hemodynamically stable thoracic injuries. Eur J Cardiothorac Surg. 2004;25(6):1048- 1053. doi: 10.1016/j.ejcts.2004.02.017. PMID: 15145008.

[3] H.L. Lin, W.Y. Huang, C. Yang, *et al.* How early should VATS be performed for retained haemothorax in blunt chest trauma? Injury, 2014;45,1359-1364. doi: 10.1016/j.injury.2014.05.036

[4] de Lesquen H, Avaro JP, Gust L. et al. Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries). Interact Cardiovasc Thorac Surg, 2015;20(3):399-408. doi: 10.1093/icvts/ ivu397. PMID: 25476459.

[5] Carrillo EH, Schmacht DC, Gable DR, Spain DA, Richardson JD. Thoracoscopy in the management of posttraumatic persistent pneumothorax. J Am Coll Surg, 1998;186:636-639.

[6] Schermer CR, Matteson BD, Demarest GB III, Albrecht RM, Davis VH. A prospective evaluation of video-assisted thoracic surgery for persistent air leak due to trauma. Am J Surg, 1999;177:480-484.

[7] DuBose J, Inaba K, Okoye O et al. Development of posttraumatic empyema in patients with retained hemothorax: results of a prospective, observational AAST study. J Trauma Acute Care Surg, 2012;73:752-757.

[8] Karmy-Jones R, Holevar M, Sullivan RJ, Fleisig A, Jurkovich GJ. Residual hemothorax after chest tube placement correlates with increased risk of empyema following traumatic injury. Can Respir J, 2008;15(5):255-8. doi: 10.1155/2008/918951. PMID; PMCID.

[9] Meyer DM, Jessen ME, Wait MA, Estrera AS. Early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective, randomized trial. Ann Thorac Surg, 1997;64(5):1396-1400. doi: 10.1016/ S0003-4975(97)00899-0. PMID: 9386710.

[10] Cobanoğlu U, Sayir F, Mergan D. Should videothorascopic surgery be the first choice in isolated traumatic hemothorax? A prospective randomized controlled study. Ulus Travma Acil Cerrahi Derg, 2011; 17(2): 117-122. DOI: 10.5505/tjtes.2011.96777

[11] Smith JW, Franklin GA, Harbrecht BG, Richardson JD. Early VATS for blunt chest trauma: a management technique underutilized by acute care surgeons. J Trauma, 2011;71(1):102-105. doi:10.1097/ TA.0b013e3182223080. PMID: 21818019.

[12] Vassiliu P, Velmahos GC, Toutouzas KG. Timing, safety, and efficacy of thoracoscopic evacuation of undrained post-traumatic hemothorax, Am Surg. 2001;67(12):1165-1169. PMID: 11768822.

[13] Fabbrucci P, Nocentini L, Secci S. et al. Video-assisted thoracoscopy in the early diagnosis and management of post-traumatic pneumothorax and hemothorax. Surg Endosc. 2008;22(5):1227-1231. doi: 10.1007/ s00464-007-9594-0. PMID: 17943365.

[14] DuBose J, Inaba K, Demetriades D et al. AAST Retained Hemothorax Study Group. Management of post-traumatic retained hemothorax: a prospective,

observational, multicenter AAST study. J Trauma Acute Care Surg, 2012;72(1): 11-22. doi: 10.1097/TA.0b013e31824 2e368. PMID: 22310111.

[15] Lang-Lazdunski L, Mouroux J, Pons F. et al. Role of videothoracoscopy in chest trauma. Ann Thorac Surg, 1997;63(2):327-333. doi: 10.1016/ s0003-4975(96)00960-5. PMID: 9033295.

[16] Goodman M, Lewis J, Guitron J. et al. Video-assisted thoracoscopic surgery for acute thoracic trauma. J Emerg Trauma Shock, 2013;6(2):106- 109. doi:10.4103/0974-2700.110757.

#### **Chapter 5**

## Surgical Approach to Rib Fractures

*Turkan Dubus*

#### **Abstract**

Rib fractures due to thorax trauma are one of the issues that mostly concern thoracic surgeons. Treatment for rib fractures is usually conservative. However, in some cases, fractured rib can cause complicated situations and surgical repair is required. Very serious respiratory problems occur in multiple costa fractures. Therefore, many advantages of surgical stabilization of the thorax wall have been reported. Especially shortening mechanical ventilation, decreasing the duration of intensive care unit stay, is important in preventing complications. Operation indications; Persistent pain despite intercostal block, narcotic and nonsteroidal anti-inflammatory analgesics, It was determined upon the presence of leakage from the thorax tube, intrathoracic hematoma and flail chest deformity. Nowadays, nithinol plates and titanium plates are frequently used in surgeon fixation of the rib fractures.

**Keywords:** Trauma, rib, fracture, surgical fixation, plaque

#### **1. Introduction**

The ribs are rigid and flexible structures that make up the chest skeleton and are a set of twelve paired bones. Pain, tenderness, cracking sound with movement in the chest area in cases such as compression, falling, hitting, and beating due to external factors bring to mind the rib fracture. Simple bumps, severe coughing and even sneezing can cause rib fractures in the elderly, where bones are more fragile. It is important to follow up elderly patients with multiple rib fractures in the hospital to prevent complications such as atelectasis and similar complications that may occur in the late period. If the patients are young, uncomplicated rib fractures can be followed up on an outpatient basis. After Blunt trauma rib fractures of incidence is about 30 to 40% [1].

Multiple rib fractures cause severe respiratory problems such as severe pain, dyspnea, flail chest, and atelectasis. Patients need medical or surgical intervention must be made. While the cracks in the ribs caused by traumas are insignificant, rib fractures can lead to intrathoracic organ and vascular injuries. Due to traumas, 4–9. ribs are often affected. 1.-2. fractures in ribs, subclavian vessel and brachial plexus damage, presence of fractures in one or more of the first 3 ribs of the upper thorax, major vascular injuries such as aorta indicate that the trauma is very severe. The fracture point of the ribs is often on the midaxillary line. In fractures in the lower elevations (9th–12th ribs), intraabdominal organ injuries such as liver, spleen and kidney should be investigated. 10–11. ribs fractures are rare because the ribs are more flexible. As the number of rib fractures increases, the risk increases in direct proportion. Complications may vary depending on the localization of rib fractures. Pneumothorax and hemothorax may develop as a result of the sharp end

of the broken rib causing lung parenchymal damage, and after tube thoracostomy is applied, rib fractures should be intervened [2].

### **2. Clinical examination**

Pain is the most important symptom indicating rib fracture, and it usually increases with coughing, breathing, and movement. Broken rib ends can be felt with palpation at the time of coughing or deep breathing.

### **3. Diagnostic methods**

#### **3.1 X-ray**

It is useful in showing displaced rib fractures, hemothorax and pneumothorax. Almost 50% of rib fractures can be missed on chest radiography. Lateral rib fractures can be hidden by rib lines in the absence of significant separation. Lower rib fractures (10–12th) can be observed on thoracolombar radiographs. Although special radiographs in oblique and bone dose increase the diagnosis rate, it is unnecessary because the treatment will be made according to the clinical findings (**Figure 1**).

**Figure 1.** *PA Chest Radiography. Left multiple rib fractures, subcutaneous emphysema.*

**Figure 2.** *Computed tomography (CT). Left displaced rib fractures, subcutaneous emphysema and pneumothorax.*

#### **3.2 Computed tomography (CT)**

It is possible to detect rib fractures, soft tissue and vascular injuries that cannot be detected by x-ray (**Figure 2**).

#### **3.3 Magnetic resonance imaging (MR)**

It shows ridge circumference, soft tissue and organ damage. It is also effective in detecting thinner rib fractures.

#### **4. Treatment approaches**

#### **4.1 Medical treatment**

Most rib fractures, especially nondisplaced ones, heal spontaneously within about six weeks. In medical treatments, epidural catheter application, nonsteroidal anti-inflammatories, intravenous narcotic sedatives and transdermal narcotic agents can be used.

#### **4.2 Nerve blocks**

If the pain caused by rib fractures is severe and does not pass, intercostal nerve blockage (long-term anesthesia injection) can be applied.

#### **4.3 Surgical fixation**

It is an alternative method to prevent pain and complications due to rib fracture. Surgical intervention is the process of stabilizing the chest wall with rib fixations. Especially patients in intensive care, it plays an important role in reducing the duration of mechanical ventilation and the duration of stay in the intensive care unit,

the cost of hospitalization, and the prevention of complications such as infection and morbidity [1].

**The flail chest** is formed by fractures of at least 3 adjacent ribs in at least 2 different places. Close follow-up of these patients and combating pain and secretions are important. If hypoxia develops in the sail chest, endotracheal intubation and a mechanical ventilator are required in the intensive care unit. With open reduction, rib fixation reduces the morbidity of the patient, and the need for mechanical ventilators and pulmonary infections [3, 4].

The indication for fixation of ribs is usually performing thoracotomy for another reason and applying fixation in this session. The durability of the fixation method to be chosen in the fixation application of the patient is also important. Plate application is very difficult, especially in rib fractures that develop in the posterior. A strong fixation should be provided against breathing, cough and the impacts that may come from outside. Nondisplaced rib fracture ends spontaneously heal by merging with callus formation. However, if the union does not occur at the displaced rib fracture ends, it causes serious pain in the patient (**Table 1**) [4–6].

Cho et al. achieved a successful stabilization using the "bone graft and reconstruction plate" in a patient who had previously undergone stabilization with a kirschner wire but no callus occurred [7]. In a series where fixation is applied to the ribs with the help of an absorbable plate, The application helped the patients to leave the ventilator and even if the application was subjective, it was beneficial [8].


#### **Table 1.**

*Types of plates and properties used in the fixation of rib fractures.*

*Surgical Approach to Rib Fractures DOI: http://dx.doi.org/10.5772/intechopen.98594*

**Figure 3.** *a–c. Judet plates (toothed plates) and surgical fixation of ribs.*

**Figure 4.** *a and b. Locking plates (locking plates).*

**Figure 5.** *a and b. U-plates.*

**Figure 6.** *Bio-absorbable plates.*

**Figure 7.** *a and b. Intramedullary plates.*

**Figure 8.** *Chest Radiograpeouhy. Surgical fixation of right rib fractures.*

**Figure 9.** *Use of nithinol plate in rib fractures (Judet plates).*

Plaque application is more difficult, especially in rib fractures that develop posteriorly. Researchers who found that intramedullary fixation is both easier and safer in these cases also underlined that the rib splint is more advantageous than the kirschner wire [9]. It is also important that the material to be used in stabilizing the rib fractures does not cause problems in later imaging methods (**Figure 8**).

Balcı et al. preferred titanium plate for this purpose and found that the material did not interfere with the visualization in thoracic CT and MRI taken after the plate application [10].

Today, MRI compatible titanium and nithinol plates are more preferred in rib fracture fixations. Very successful results are obtained in the short and long term follow-up of the patients (**Figure 9**).

#### **5. Conclusion**

Surgical stabilization of rib fractures reduces the possible pulmonary complications of patients. It shortens the duration of hospital stay and the time to return to work, improves the quality of life of the patients by physiologically improving their breathing.

### **Author details**

#### Turkan Dubus

Department of Thoracic Surgery, University of Health Sciences, Istanbul Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey

\*Address all correspondence to: drturkandbs@yahoo.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

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[2] Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review. Eur J Trauma Emerg Surg. 2017- 43:163-168. DOI: 10.1007/ s00068-016-0721-2

[3] Negin Sedaghat N, Chiong C, Tjahjono R, Hsu J. Early Outcomes of Surgical Stabilisation of Traumatic Rib Fractures: Single-Center Review With a Real-World Evidence Perspective. Journal of Surgical Research, 2021-08- 01, Volume 264, Pages 222-229. DOI: 10.1016/j.jss.2021.02.026

[4] Beks R, Peek J, de Jong MB, Wessem KJP, Oner CF, Hietbrink F, Leenen LPH, Groenwold RHH, Houwert RM. Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2019 Aug;45(4):631-644. DOI: 10.1007/s00068-018-1020-x

[5] Zhang, D., Zhou, X., Yang, Y. et al. Minimally invasive surgery rib fracture fixation based on location and anatomical landmarks. Eur J Trauma Emerg Surg 2021. DOI: 10.1007/ s00068-021-01676-2

[6] Zhang Q, Song L, Ning S, Xie H, Li N, Wang Y. Recent advances in rib fracture fixation. Journal of Thoracic Disease, Vol 11, Suppl 8 May 2019. DOI: 10.21037/jtd.2019.04.99

[7] de Jonga MB, Houwert RM, van Heerdea S, de Steenwinkel M, F. Hietbrink F, Leenena LPH. Surgical treatment of rib fracture nonunion: A single center experience. Injury, 2018- 03-01, Volume 49, Issue 3, Pages 599- 603. DOI: 10.1016/j.injury.2018.01.004

[8] Dehghan N. Challenges in plate fixation of chest wall injuries. Injury, 2018-06-01, Volume 49, Pages S39-S43 . DOI: 10.1016/S0020-1383(18)30301-2

[9] Nirula R. Postoperative Complications After Rib Fracture Repair. Rib Fracture. Management, 2018, pp 159-163. https://doi. org/10.1007/978-3-319-91644-6\_14

[10] Agababaoglu I, Hasan Ersöz H. The benefits of early rib fixation for clinical outcomes of flail chest patients in intensive care unit. Turkish Journal of Thoracic and Cardiovascular Surgery 2020;28(2):331-339. DOI: 10.5606/ tgkdc.dergisi.2020.18439

Section 4
