J Med Sci 2003;23(2):113-118 Jeng-Yuan Wu, et al.

http://jms.ndmctsgh.edu.tw/2302113.pdf
Copyright 2003 JMS

Video-Assisted Thoracoscopic Surgery

for Early Evacuation of Traumatic Clotted Hemothoraces
Jeng-Yuan Wu1*, Shou-Shan Chen1, Shao-Yu Jen1, and Shih-Chun Lee2
1
Division of Thoracic Surgery, Department of Surgery, Armed Forces Taichung General Hospital, Taichung,
2
Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital,
National Defense Medical Center, Taipei, Taiwan, Republic of China

Background: Traumatic hemothorax without early adequate evacuation of intrathoracic blood often results in
prolonged hospitalization and severe complications such as empyema and fibrothorax. The efficacy of video-assisted
thoracoscopic surgery (VATS) applied on this disease entity was studied. Methods: Chest trauma patients who
developed retained clotted hemothoraces after initial management with chest intubation were prospectively randomized
to treatment with either traditional posterolateral thoracotomy (group 1, n=9) or video-assisted thoracoscopic surgery
(group 2, n=9). In group 1 patients, the goal of operative procedure was to evacuate blood clots, with the thoracotomy
wound being less extensive as possible. Duration of chest tube drainage, total amount of tube drainage, hospital stay
and estimated costs of both groups were studied. Results: Patients in group 2 had shorter duration of postoperative tube
drainage (3.44
0.68 versus 5.67
1.53 days; p<0.001), shorter hospital days after the procedure (4.56
1.06 versus
9.11
2.64 days; p<0.001), and shorter total hospital stay (8.56
1.83 versus 15.22
3.58 days; p<0.001) compared
to group 1 patients. Hospital costs were also less in group 2 (NT$ 51,556
16,561 versus 78,656
14,105; p<0.001).
There were no mortalities in either group of patients. No conversion to thoracotomy procedure was needed in group 2
patients. Conclusion: VATS performed early on patients who failed the initial chest intubation to treat traumatic
retained clotted hemothoraces significantly decreases the expected time of tube drainage, the length of hospital stay,
and total hospital cost. Thoracotomy itself, relatively time wasting and labor consuming, could be reserved as a second
choice in case there are contraindications to VATS procedure.
Key words: chest trauma, clotted hemothorax, video-assisted thoracic surgery (VATS)

INTRODUCTION ing complications, such as empyema thoracis and fibro-

In the modern speed-pursuing era, there are increasing
number of cases of trauma death being reported annually,
of those more than one fourth are attributable to thoracic
injuries. Hemothorax, often resulting from thoracic trauma
and presenting with fracture of ribs initially, is a unique
disease entity that might be life-threatening in the begin-
ning or later evolve to chronic sequelae. Various inappro-
priate treatment modalities done inadequately to remove
the blood contained in the pleural space after thoracic
trauma often lead to prolonged hospitalization and endur-
Received: September 11, 2002; Revised: November 26,
2002; Accepted: December 4, 2002.
*
Corresponding author: Jeng-Yuan Wu, Division of Thoracic
Surgery, Department of Surgery, Armed Force Taichung
General Hospital, 348, Chung-San Road Section 2, Tai-Ping
County, Taichung, Taiwan, Republic of China. Tel: +886-
4-23925948; Fax: +886-4-24225791; e-mail:
wujames15@hotmail.com
thorax etc1-3. Traditionally, chest tube placement is the first
step for pleural drainage in the management of hemody-
namically stable patients with traumatic hemothorax. If the
thoracostomy tube fails to clean blood clots, the next step
would be inserting additional tubes or performing early
thoracotomy4. However, an additional thoracostomy tube
placement usually could not solve the underlying problem
of clotted hemothorax, even if it is handled by an experi-
enced thoracic surgeon, thus inevitably leading to a pro-
longed hospital course. Early thoracotomy serves as an
alternative and indeed effectively offers such benefits as
good exposure of the operative field, complete evacuation
of the retained intrapleural blood clots and concomitant
dealing with associated pathology. Nevertheless, this inva-
sive procedure usually associates with potential morbidity
and protracted course of functional recovery5. Currently
video-assisted thoracoscopic surgery (VATS) has ensued
to be another choice in the scope of treatment options for
traumatic hemothoraces. Its less invasiveness and faster
implementation than that of thoracotomy per se may allow

113
VATS for clotted hemothoraces
Fig. 1 Standard VATS procedure
employs 3-port app-roach.
early complete evacuation of pleural blood clots under
direct vision, thereby reducing or preventing pleural space
complications. With much smaller surgical wounds of
VATS, which usually needs only 3-port incisions, it fea-
tures on comparably favorable outcome and early func-
tional recovery of the patients5,6. The objective of our study
is to compare the results of exploratory thoracotomy and
VATS in treating clotted hemothoraces after chest trauma
in order to identify an efficient and cost-effective way to
improve quality of care and clinical outcomes of the
patients.
MATERIALS AND METHODS
From January 1999 to June 2002, 62 patients with
various amount of traumatic hemothoraces were admitted
to Armed Force Taichung General Hospital. Fifty-five
patients received chest intubation and 18 of them incurring
clotted hemothoraces were prospectively randomized into
this study. The inclusion criteria were having stable vital
signs at admission and prior to surgical intervention, no
significant associated intraabdominal or other organ
injuries, and undergoing no therapeutic modalities other
than tube thoracostomy. Forty-four patients were excluded
from the study either because of minimal hemothorax
treated conservatively or if they were hemodynamically
unstable, had greater than 1,000 ml of immediate blood
drainage during initial tube thoracostomy, or had ongoing
hemorrhage via chest tube of more than 200 ml per hour for
more than 4 hours consecutively. Patients with previous
thoracotomy on the side of injury were also excluded. All
patients had been treated with placement of a straight 32Fr
chest tube because of various size or extent of hemothoax
or hemopneumothorax originating from chest trauma.
Patients chest film taken within 72 hours of initial evalu-
ation and insertion of the thoracostomy tube still showing
residual clotted hemothorax or hemopneumothorax were
involved in the study. Chest X-ray findings that revealed
only minimal blunting of costophrenic angle, simple pneu-
114
Table 1 Characteristics of patients in both groups
Variables Group 1 Group 2
(n=9) (n=9)
Age range (mean) 16-58 (31.2) 20-47 (33.9)
Gender
Male 7 8
Female 2 1
Mechanism of injury
Penetrating 3 2
Blunt 6 7
Associated injuries
Non 4 5
Neurologic 1 1
Pulmonary 3 2
Orthopedic 1 1
mothorax alone, subcutaneous emphysema, or chest wall
hematoma etc. were not included in this study.
Patients whose clinical presentations and roengeno-
graphic results met the above criteria were randomly
assigned to each of the two treatment groups with informed
consent. In group 1, limited posterolateral thoracotomy via
the fifth intercostal space was performed, with possible
extension guided by the extent of injury for complete
removal of the retained blood clots. Group 2 patients were
managed with the VATS procedure. Characteristics of
patients in each group are shown in Table 1. VATS tech-
niques were carried out under general anesthesia after
introduction of double-lumen endotracheal tubes. It pro-
ceeded with a 0 degree thoracoscope viewing through the
thoracostomy site and the other two 10-mm ports made
over the fourth intercostal space along the anterior and
posterior axillary line individually (Fig. 1). Ports were
made to meet the possibility of conversion to thoracotomy.
Following evacuation of the retained blood clots, expan-
sion of the compressed lung and irrigation of the pleural
cavity, one or two 32 Fr. chest tubes were introduced for
both VATS and thoracotomy procedures. All the patients
were extubated before leaving the operating room with no
respiratory compromise. The time for removal of chest
tubes was defined as daily drainage amount less than 100
cc and no air leakage was observed. Data analysis included
the variables of duration of thoracostomy tube drainage
postoperatively, total amount of tube drainage yielded
from daily recording on patients charts, hospital stay after
performing thoracotomy and VATS procedures, overall
length of hospitalization, and estimated hospital costs of
both groups. Estimated hospital costs included all pre-
operative, intraoperative, and postoperative medical
expenses. Statistical analysis was performed using a Mann-
Whitney U test and differences were considered signifi-
cant if p value was less than 0.05.

Table 2 Comparison of outcome indicators between two
groups
Variables Group 1 Group 2
(n=9) (n=9)
Duration of tube 5.67
1.53 3.44
0.68
drainage (days)
Total amount of 830
384.39 780
297.92
tube drainage (ml)
Hospital days after 9.11
2.64 4.56
1.06
the procedures
Total hospital days 15.22
3.58 8.56
1.83
Estimated costs (NT$) 78,656
14,105 51,556
16,561
Results are presented as mean
standard deviation.
*p<0.05 by Mann-Whitney U test.
RESULTS
There were 18 qualified patients included in this study,
15 men and 3 women, with ages ranging from 16 years to
58 years (mean: 32.6 years). The type of thoracic injury
was penetrating in 5 patients and blunt in 13 patients. All
penetrating injuries were by knife or other sharp objects.
Blunt injuries were due to motor vehicle accidents in 10
patients and falling down incidents in 3 patients. Most
blunt injuries of these 13 patients resulted in fracture of
more than one rib. The operative findings in both groups
disclosed much in common with blood clots accumulation
in the pleural cavity that left the originally placed chest
tube largely malfunctioned for drainage. No specific lung
parenchymal pathology was noticed except that partial
collapse of the lung due to blood clots appeared in most of
the cases (Fig. 2). The operating time showed no signifi-
cant difference between both groups (104.44
28.01 in
group 1 versus 94.44
26.03 minutes in group 2, p=0.16).
Patients initially randomized to VATS (group 2) had a
significantly shorter duration of chest tube drainage (3.44

0.68 versus 5.67
1.53 days, p<0.001), and hospital
days after the operation (4.56
1.06 versus 9.11
2.64
days; p<0.001) than group 1 patients (Table 2). Total
hospitalization was still shorter in group 2 patients (8.56

1.83 versus 15.22
3.58 days; p< 0.001). Estimated hos-
pital costs were significantly lower in group 2 when com-
pared with group 1 patients (NT$ 51,556
16,561 versus
78,656
14,105; p<0.001). With regard to the total amount
of chest tube drainage during hospitalization (830
384 in
group 1 versus 780
298 ml in group 2, p=0.45) and
postoperative degree of wound pain, which was mostly
alleviated by prescribing regular oral analgesics, no sig-
Jeng-Yuan Wu, et al.
p Value

0.001*
0.449

0.001*

0.001*
Fig. 2 Partial collapse of the right lower lobe (black arrowhead)
0.001* results from accumulation of intrapleural blood clots
(white arrowhead).
nificant differences were noted between the two groups.
In VATS group, no patient needed intraoperative con-
version to thoracotomy during the procedure. No mortality
was found in both groups during the study period. Postop-
erative morbidities were minor. Segmental atelectasis in 1
patient and residual pneumothoraces in 2 patients after
removal of chest tubes developed only in group 1 patients.
They all recovered well without further interven-tion.
During the 4 to 36 months follow-up period, no residual
blood clots, empyema or eventual fibrothorax formation
was identified in any of the patients.
DISCUSSION
Our study demonstrated that video-assisted thoraco-
scopic surgery could be safer and more effective than
conventional thoracotomy in the management of acute
traumatic clotted hemothoraces. Also, improved drainage
can be accomplished by endoscopically guided thoracos-
tomy tube placement or by simultaneously detecting and
resolving the various causes of incomplete drainage of the
hemothorax. In fact, after the advent of VATS in 1990 by
Levi and associates to treat pneumothorax5,6, there was
progressive refinement in technique in later years. Several
publications subsequently confirmed the feasibility of this
procedure with low recurrence rate, satisfactory cosmetic
result, early functional recovery and a much lower inci-
dence of postoperative neuralgia7-9. The use of thoracos-
copy in the management of the trauma patients can be
traced back to 1946, when Branco10 used thoracoscopy to
aid in the diagnosis and treatment of patients with penetrat-
ing injury to the chest. He located and coagulated bleeding
vessels in 5 patients, eliminating the need for conventional
thoracotomy. Later studies11-13 have reported the use of the
115
VATS for clotted hemothoraces
thoracoscope to assess patients after penetrating thoracic
trauma, significantly reducing the risk and need for per-
forming thoracotomy. However, not until the introduction
of modern laparoscopy into the trauma setting14-16 did
thoracic surgeons begin to reassess the thoracoscopy for
traumatic applications17. Recent reports have supported
the feasibility of VATS for diagnostic procedures. Ochsner
and associates18 used thoracoscopy to evaluate and verify
14 patients of initially obscured diaphragmatic injuries.
They found that VATS was able to evacuate retained
hemothoraces and provide excellent visualization of in-
trathoracic structures, as well as detecting any associated
injuries in an earlier stage and reducing subsequent
complications. Later in a similar study, Uribe and col-
leagues19 prospectively evaluated 28 patients with tho-
racoabdominal penetrating trauma by VATS. Although
this study focused on the utility of VATS for identification
of diaphragmatic injury, they also noted VATS was useful
for evacuation of blood clots from the pleural space. Our
study showed comparable results in a prospective clinical
trial specifically involving both the thoracotomy and VATS
procedures and illustrated that the latter could practically
be applied to thoracic trauma patients for both diagnostic
and therapeutic purposes.
Early experiences with VATS in the management of
traumatic hemothoraces have been reported in many other
studies. Smith and associates20 assessed 24 consecutive
patients with chest trauma by way of thoracoscopy for
clotted hemothorax. In 8 of 9 patients successful evacua-
tion of blood was performed. Five patients were treated for
ongoing hemorrhage, with 3 of 5 safely managed by
thoracoscope using diathermy without additional pro-
cedures. Landreneau and colleagues21 used VATS in 23
patients with retained hemothoraces from various causes
and recommended VATS early in the management of
patients with retained hemothoraces to avoid the problems
of secondary infection within the intrathoracic clot or late
formation of fibrothorax. A recent experience with VATS
for management of retained hemothorax was reported by
Heniford and associates22. In their series of 25 patients, 19
patients (76%) were successfully treated with VATS. Four
patients (16%) were converted to open thoracotomy, and 2
(8%) required additional procedures to drain fluid col-
lections. Thoracoscopic intervention within 5 days of chest
injury was considered to have higher success rate when
compared to delayed treatment after average 2 weeks
following chest trauma, the latter usually incurring formi-
dable complications or prolonged hospitalization. Empy-
ema did not develop in cases operated within 7 days of
injury. These authors recommended VATS as the initial
116
treatment for trauma patients with residual intrathoracic
blood collections. In our group 2 patients, VATS was
successfully performed on all 9 patients with no convert to
thoracotomy or any other complications. We agreed that
failure to achieve acceptable result using thoracoscopy
correlated with the time interval from injury to operation
and the type of collection such as infected hemothorax or
empyema.
In our experiences, we suggest that early repeat chest
roentgenogram within 72 hours of the initial management
after chest tube insertion will help sorting out who need
further surgical interventions. Case selections based on
hemodynamical stability and positive abnormal findings
with retained blood clots in our 18 patients would get the
best result. In hemodynamically unstable patients present-
ing with ongoing hemorrhage after tube thoracostomy, we
strongly recommend immediate open thoracotomy to stop
bleeding.
We believe that in cases with retained hemothoraces
after chest trauma, the goals of acute management include
early rapid removal of residual blood clot without awaiting
hematoma formation, simultaneous identification of the
sources of bleeding, and treatment of other associated
intrathoracic injuries. The present study demonstrated that
the VATS procedure can accomplish these goals in acute
trauma setting and significantly improve outcomes of the
patients in terms of reduced duration of tube drainage,
reduced time of hospital stay after the procedure and
overall hospitalization and less cost of hospitalization
comparing with open thoracotomy procedure. Although
VATS took less operating time than that of thoracotomy in
our patients, it showed no statistical significance and might
result from learning curve on this specific disease entity.
Complications after tube thoracostomy, although a rela-
tively simple procedure, may occur in as many as 21% of
patients23. Residual hemothorax or pneumothorax, im-
proper tube positioning, empyema due to secondary
infection, and direct lung injuries by tube itself have been
reported. Thoracoscopy is considered as a safer and more
effective procedure with complication rates in large series
less than 10%24. Morbidities such as segmental lung atelecta-
sis and residual space problems were present only in the
thoracotomy group in our study, with subsequent recovery
all managed by conservative measures. The possible causes
of recurrent pneumothoraces or hemothoraces may be due
to sequelae of missed small lung parenchymal injuries or
inadequate expansion of the lung. Postoperative atelecta-
sis is often related to thoracotomy pain that seldom occurs
in patients receiving VATS procedure.
Our data suggest that early using thoracoscopic surgery

to manage clotted hemothorax in patients with blunt or
penetrating chest injuries, complete evacuation of retained
blood clots and full expansion of the affected lung can be
achieved. Under direct visualization, further exploration
of the pleural cavity for the sources of bleeding is possible,
potentially allowing for control of hemorrhage in a hemo-
dynamically stable patient, as well as direct positioning of
the chest tubes. If clinical situation turns out to be chronic,
which means formation of infected pleural hematoma or
empyema, it would often resort to more invasive proce-
dures than VATS and lead to prolonged duration of man-
agement and hospitalization. Clinical outcome of our pa-
tients revealed that VATS is a simple, safe, cost-effective
diagnostic and therapeutic option to achieve less pain,
shorter hospital stay, early functional recovery, decreased
total cost, and most important, improved quality of care, as
compared to such traditional measures as chest intubation
or standard thoracotomy. We recognize that this study was
limited by factors like relatively small size of patient
groups and low incidence of posttraumatic clotted he-
mothoraces after initial tube drainage. Further application
of the VATS procedure on more of those selected patients
should be continued for better evidence-based comparison
of different treatment strategies.
ACKNOWLEDGMENTS
This study was sponsored by grant from Armed Force
Taichung General Hospital (Project No. 9). The authors
thank our colleagues in related departments for their great
suggestions and help.
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