Operative videothoracoscopy in the surgical treatment of penetrating firearms wounds of the chest
Brusov, P G
We prospectively analyzed our experience with operative videothoracoscopy (OVT) performed in a field military hospital in cases of penetrating firearms wounds of the thorax (PFAWT) sustained in Chechnya. From February to April 1996, we treated 206 wounded patients, of whom 37 (18.0%) had sustained chest injuries. PFAWT were present in 23 soldiers, accounting for 62.2% of all chest injuries. Twelve injuries were confined to the thorax, eight patients had associated injuries, and three soldiers had thoracoabdominal injuries. Nineteen patients had pleural drainage performed during medical evacuation. The thoracic injuries were right-sided (17), involved bullets or shell splinters (23); were through and through (16), represented solitary wounds (19), and were associated with internal organ injuries (21). Fifteen patients had indications for OVT when they were delivered from the battle-field 1.5 to 22 hours after injury. All patients manifested signs of hemorrhagic shock and hemodynamic instablity. Indications for OVT were ongoing intrapleural bleeding (6), clotted hemothorax (6), or marked air leakage (3) preventing lung inflation with the OP-02 apparatus (field modification). OVT revealed 12 lung wounds, nine of which were multiple wounds, pleural bleeding in 6 patients, clotted hemothorax in 11 patients, and foreign bodies in 5 patients. Two patients underwent thoracotomy, one for suspicion of heart injury and the second because we could not adequately visualize and control bleeding revealed at OVT to be from the intercostal artery in the left costovertebral angle. Eight of 23 patients had no indication for operative videothoracoscopy and were managed with continued pleural aspiration and drug therapy. Wedge resection of the lung using an Endo-GIA-30 stapler was necessary in two patients because of parenchymal destruction and bleeding. Evacuation of clotted blood by fragmentation and aspiration was satisfactory in all cases. Satisfactory manual suturing of selected lung injuries was obtained largely with intracorporeal knot tying. The duration of the procedures ranged from 40 to 90 minutes. No morbidity nor mortality was encountered in patients undergoing OVT. Postoperative pain was minimized by using OVT placement of catheters in the chest wall soft tissue with local administration of 2% Trimecain. Patients were able to stand in 10 to 12 hours and to walk by the end of the first postoperative day. All patients who underwent OVT were evacuated without drains by the third or fourth postoperative day, all tolerating sitting and standing positions. We conclude that early OVT in the military field hospital for continued bleeding, clotted hemothorax, and continued major air leakage has several advantages in military patients with PFAWT: early definition and management of organ injury; identification and control of bleeding in most instances; earlier and more accurate assessment for thoracotomy; vigorous lavage and removal of projectiles such as bone fragments and evacuation of clotted hemothorax; early debridement with suture closure of the thoracic
wall canal; and minimal postoperative pain with dramatically reduced suppurative sequelae and bronchopleural fistulae.
As a result of the continuing perfection of firearms since the World War II, and with these firearms having been used in local military conflicts, the destructive potential of wounding projectiles has greatly increased, leading to the increased severity of the chest wounds sustained.
The incidence of penetrating firearms wounds of the thorax (PFAWT) in contemporary military conflicts ranges from 4 to 6%. These wounds are characterized by considerable injury of the skin and bony structures, destruction of organs and disruption of their functions, and high levels of bacterial contamination. The mortality rate in these patients has been reported to be 20 to 40%, as a result of traumatic shock, major hemorrhage, and severe respiratory dysfunction. ‘-5 In spite of the widespread use of individual protection means, including chest vests, the frequency of firearms wounds of the thorax continues to increase in military conflicts. On the one hand, these findings could be explained by the perfection of modern firearms, with high targeting of the casualty; on the other hand, this seeming increase in the incidence of PFAWT could be the result of improvements in the delivery of the wounded from the battlefield to medical institutions. The modern doctrine of military surgery is based on the concept of maximal and, if possible, simultaneous surgical aid to the wounded in the shortest period of time after injury. This aid may be achieved by placing specialized surgical stations near the front or by improving medical evacuation. These are the conditions required for the application of modern methods of treatment and the perfection of surgical strategies for the wounded. This latter approach has made it possible to improve the treatment of patients with PFAWT, in contrast to the treatment during past wars. During World War II, suppurative complications developed in 41.1% of the wounded and were the cause of 56 to 59% of all deaths attributable to PFAWT.23,24 During the Soviet Afghanistan campaign, these figures decreased to 21.8 and 16.2%, respectively.1
The results of the treatment of patients with PFAWT are mainly determined by the type and severity of injury and by the ability of the surgeon to anticipate and diagnose the complications in time and then choose the correct surgical strategy. The necessity of thoracotomy, according to the literature, ranges from 9.1 to 45%.1,4,6-11 Today, more surgeons subscribe to the principle that the indications for thoracotomy in patients with PFAWT must be strictly individualized.1,4,7,11 Surgical intervention is frequently limited to closed drainage of the pleural cavity and local procedures for wounds of the thoracic wall. However, in severe or major PFAWT, the determination of the correct surgical strategy is still a very difficult task. The main reason for this is the difficulty of adequately determining the character of injuries of the thoracic organs using the standard diagnostic tools, including physical examination, laboratory tests, and Xray studies, that are used routinely in military hospitals. Therefore, the real indications for thoracotomy are probably overestimated, and this procedure imposes additional operative trauma to the wounded. If thoracotomy is performed to control ongoing intrapleural bleeding, the operation consists of suturing the lung wounds, electrocautery hemostasis, and irrigation and drainage of the pleural cavity. Resection of the lung by lobectomy or pneumonectomy are performed less frequently.
Closed active suction drainage avoids the additional risk and complications associated with thoracotomy but prevents the surgeon from controlling bleeding in many instances, and also prevents irrigation of the pleural cavity, suturing of the thoracic wall and lung wounds, and adquate debridement and retrieval of projectiles and bony fragments. In some cases, closed drainage may be unfavorable for the patient because of the inadequacy of suction and failure to inflate the lung. Clotted hemothorax, local pneumothorax, and bronchilar fistulae are frequently diagnosed in such cases and are common causes of pleural suppurative complications. It is our opinion that improvements in the diagnosis and treatment of patients with PFAWT may be established by the widespread early use of operative videothoracoscopy (OVT).
Thoracoscopy as a widely used method of diagnosis and treatment of thorax injuries started in the 1990s, when the possibility of intrapleural manipulation with the use of video technology was realized. Surgeons who used videothoracoscopy for diagnostic and curative purposes in thoracic injuries have been unanimous in their endorsement of the method.10,12-21 We did not find any literature source that mentioned the use of OVT in the treatment of thoracic injuries in the military field hospital.
The possibility of performing most surgical manipulations of the thorax wall, the pleural cavity, the lung, and the mediastinum with minimally invasive videothoracoscopy, the availability of up-to-date endoscopic instruments and suturing devices, and the publication of studies regarding OVT25 treatment for wounded and injured civilian patients10,17,20 provided the impetus for the use of this method in patients with PFAWT during the military conflict in Chechnya.
Materials, Methods, and Results
We used OVT in the treatment of patients with PFAWT in the military hospital in Vladikavkaz from February to April 1996. The purpose of this work was to study the feasibility of OVT in a local military conflict. The equipment and instruments for endoscopic operative procedures were contained in a surgical set provided by AutoSuture USSC and included products from Stryker (United States), Karl Storz (Germany), and Endomedium Tatarstan). The instruments for endosurgery, suturing devices, suturing material (Polysorb), and other products were also provided by AutoSuture USSC. During the period mentioned above, the hospital admitted 206 wounded patients, including 37 with chest injuries (18.0%). PFAWT was diagnosed in 23 soldiers, accounting for 62.2% of all chest injuries. In this group, 12 patients had isolated thoracic injuries, 8 had associated injuries, and 3 had thoracoabdominal injuries. The characteristics of the PFAWT are shown in Table I. Nineteen patients had pleural drainage performed during medical evaluation. PFAWT patients were delivered directly from the battlefield generally within 1.5 hours after the injury; the longest time to presentation was 22 hours.
Qualified surgical aid was given to the wounded at aid stations within 20 to 30 minutes after injury. All of the patients had undergone thoracentesis followed by drainage, reinfusion of the blood from the pleural cavity, and surgical evaluation and management of chest wall wounds. This wound processing consisted of excision of necrotic tissues from the wound edges, removal of bone fragments and foreign bodies, drainage of the wound, and dressing with water-soluble liniment. In cases of open pneumothorax, the wounds were sutured (except the skin) to seal the pleural cavity. One patient in this group at the field hospital underwent emergency thoracotomy and suturing of the lung wound for ongoing massive bleeding with reinfusion of 21 of blood. The wounded were delivered to the military hospital 1.5 to 22 hours after injury, depending on circumstances in the field. On admission, the patients were sorted into three groups based on injury character, previously rendered aid, and the need for intensive therapy and emergency operation. General laboratory blood and urine tests, radiography, and electrocardiography were performed.
Eleven of 15 patients with pleural drains and 4 patients delivered from the battlefield had indications for videothoracoscopy. These indications (Table II) included ongoing intrapleural bleeding, clotted homothorax, and marked leakage of air through the drain, making lung inflation impossible with the OP-02 apparatus (field modification).
The condition of the patients in both groups remained serious. Each patient had signs of hemorrhagic shock (stages II and III) and hemodynamic instability. In the remaining eight men, who constituted a third group, there were no indications for additional operations because of the effectiveness of the previous procedures. In these patients, we continued pleural aspiration and drug therapy. In two patients (one each in groups II and III), thoracotomy was performed. In one there was suspicion of heart injury (major hemothorax, ongoing bleeding, and the bullet in the region of the cardiac silhouette on x-ray film); during operation, a thoracoabdominal injury was revealed. In the other patient, thoracotomy was performed because of the inability to visualize the bleeding source, which at OVT was identified to be an intercostal artery in the left costovertebral angle.
We believe that separate intubation of the bronchi and onesided ventilation are obligatory for the OVT procedure. It is necessary to stop lung ventilation temporarily on the injury side to achieve maximal visualization and provide appropriate space for free technical manipulations. Even minimal lung motion during ongoing bleeding resulted in optical lens soilage and circumvented further manipulations.
All of the OVT procedures were performed in the lateral thoracotomy position (injury side up), with the abducted arm and the transverse bag placed under the chest. The sites for thoracoports were as follows: 10-mm port for the camera in the seventh or eighth intercostal space at the midaxillary line, or the port was introduced through the thoracentesis puncture wound if drainage had been performed previously. Thoracoscopic inspection was done, and then, depending on the results and the planned operative procedure, two or three additional thoracoports were introduced under visual control. The choice of the sites for additional ports was made to avoid crossing the working planes and instruments in the hemithorax cavity; therefore, the trajectory of the instruments was in the same direction as the optical tube axis. As a rule, we worked simultaneously with the EndoBabcock dissector and elevator; this technique allowed satisfactory inspection, removal of foreign bodies, and control of the bleeding from the thoracic wall vessels. If suturing was necessary, the two instruments were used to expose the lung, and the third port (12 mm) was used for application of the hemostatic stapler or for a needle holder and appropriate manual continuous suturing. The findings of this inspection are shown in Table III.
Suturing of the lung wounds, situated peripherally, was performed with an Endo-GIA-30 staler without lung tissue resection or with edge resection in cases of destruction or rupture of the parenchyma. Reinfusion of the blood from the pleural cavity was done in five cases; the volume of the blood reinfused was 1.2 to 2.2 1. If the stapler could not be used, especially for the wounds in the middle parts of the lung or to prevent the danger of lobe deformity, we used a manual suturing device (EndoStitch USSC), usually with intracorporeal knot tying. The deep wounds were processed with antiseptic solution (0.2% aqueous chlorhexedinum) to wash away clots of blood and thus prevent intrapulmonary hematoma formation. Figure-eight sutures were then applied to the whole depth of the thoracic wall canal. The technical construction of the -manual sewing machine makes it possible to move the needle to an adequate position without removing the instrument from the thoracoport. This kind of suture was used 10 times and proved to be effective for hemostasis and aerostasis. In two cases, we performed wedge-like resection with the Endo-GIA-30 stapler because of destruction of the lung tissue and rather intense bleeding. The bleeding from the thoracic wall wounds was controlled with electrocautery. In one case of intercostal artery injury (noted previously), it was impossible to visualize the source of bleeding and control it; the procedure was converted to thoracotomy in the sixth intercostal space. The clotted hemothorax was removed by fragmentation and washing out and aspiration of clots using large-diameter tubes. Much attention was paid to surgical processing of the wounds of the thoracic wall, removal of the foreign bodies, and meticulous irrigation/aspiration of the pleural cavity with warm antiseptic solution. The drain tubes were positioned with graspers under video control. The procedure was terminated after visual control of hemostasis, control of the air leak, and lung inflation were achieved.
The duration of the procedures ranged from 40 to 90 minutes. In the postoperative period, we performed active aspiration of the pleural cavity using the OP-01 apparatus and prescribed anti-inflammatory, antibacterial, infusion/transfusion, and symptomatic therapy.
It is worth noting that pain after the OVT was minimal: narcotic analgesics were prescribed extremely rarely. To diminish the pain, we used 2% trimecaine solution injected into the soft tissues of the thoracic wall via a catheter positioned during thoracoscopy. The injection of 20 to 30 ml of trimecaine stopped the pain and induced the feeling of “spreading warmth and anesthesia for 4 to 6 hours. There was no need for additional anesthesia. The patients were able to stand up in 10 to 12 hours and to walk by the end of the first postoperative day. The drains were removed when stable vacuum was achieved, the aspirated fluid was serum-like and less than 100 ml/day, and good inflation of the lung was proven by radiography. The drains in 75% of the wounded were removed on the second or third day after the procedure. In patient group III, the drains were removed by this time in only 10%; in the remainder of these patients, the drains were removed on the fourth and fifth days after injury. All of the wounded who underwent OVT were evacuated without drains on the third or fourth postoperative day, all of them tolerating sitting and standing positions.
We want to illustrate the successful use of OVT for PFAWT with a brief case report. Serviceman Y., 20 years old, was injured on March 15, 1996, by a bullet in the right side of the chest. Twenty minutes after the injury, he was delivered to the aid post of the unit, where he underwent thoracentesis and drainage of the right pleural cavity in the second and seventh intercostal spaces for hemothorax and reinfusion of 1.81 of blood. Blood substitute, analgesics, and antibiotics were administered. There were no signs of ongoing bleeding. Twelve hours after the injury, he was delivered to the hospital.
During transportation, the condition of the patient grew worse. Tachypnea and subcutaneous emphysema increased, and 200 ml of dark blood, with signs of clotting, flowed through the drain. On admission to the hospital, the patient was pale, tachypneic (up to 30 breaths per minute), and tachycardiac (120 beats per minute); his blood pressure was 90/50 mm Hg, and respiratory sounds of the right lung were not audible. Laboratory tests gave hemoglobin of 78 g/l and hematocrit of 0.241/1. For 1 hour, the patient underwent intensive antishock therapy, and active aspiration of the pleural cavity was continued. During this time, 150 ml of blood returned, laboratory results showed that the pleural space aspirate varied little from the circulating blood, significant air leakage continued through the drain, and subcutaneous and intermuscular emphysema increased. The bullet entry wound (6 mm in diameter) was in the region of the second intercostal space; the exit wound was on the back side of the chest, in the sixth intercostal space at the posterior axillary line. There was little bleeding. The x-ray film revealed total shading of the right hemothorax and displacement of the mediastinum to the left.
The diagnosis was ongoing bleeding from a right-sided clotted major hemothorax. After a short preparation, the patient was operated on thoracoscopically by the senior author (P.G.B.). This resulted in control of the bleeding from the thoracic wall wound, suturing of the upper- and lower-lobe lung wounds, removal of clotted blood (800 ml), and irrigation/aspiration and drainage of the pleural cavity. The sources of bleeding were intercostal artery and lung wounds. The 11 of blood from the pleural cavity was reinfused. The lung wounds were washed with antiseptic solution and closed with two figure-eight sutures using Endostitch and an Endo-GIA-30 stapler without resection. A subpleural catheter for injection of local anesthetics in the postoperative period was placed under visual control, as noted above. There were no untoward events postoperatively. The vacuum in the pleural cavity was restored directly after the procedure. The patient was able to stand up and walk within 24 hours after the operation, and 250 ml of serum-like fluid discharged during 2 days. The drains were removed on the third day. The patient was evacuated to a hospital near his home in a sitting position on the fourth day in rather satisfactory condition.
All patients were followed postoperatively. None had suppurative complications. The wounds of the thoracic wall healed as intended, and the sutures were removed on the seventh or eighth day. The mean duration of inpatient treatment was 20 days, with a rehabilitation period of 14 days.
Based on our experience during the military conflict in Chechnya, we make the following recommendations regarding the use of early OVT in patients with PFAWT.
(1) OVT is minimally invasive and provides an effective means of early diagnosis and treatment of patients with PFAWT. It appears from our experience that OVT in selected patients with PFAWT is at least as effective as an open procedure, although the cases reported here were not randomized.
(2) In most cases, thoracoscopic intervention precluded thoracotomy when the indications established previously by the senior author were applied. This would be extremely advantageous in severely wounded patients with thoracoabdominal and other associated chest injuries, minimizing additional operative stress and trauma.
(3) OVT facilities defining the character and severity of chest injuries and also appears efficacious in the control of bleeding from thoracic wall wounds, management of lung wounds, and for surgical debridement of wounds of the thoracic wall.
(4) Repair of lung wounds by debridement and suturing with the EndoStitch or Endo-GIA-30, removal of destroyed lung tissues, removal of loose foreign bodies (rib fragments, wounding projectiles), fragmentation/aspiration of clotted blood, and performance of meticulous irrigation/aspiration of the pleural cavity with video-assisted active drain placement may all be accomplished through the working trocars.
(5) Closed drainage of the pleural cavity in most instances provides no accurate assessment of bleeding or clotted hemothorax, does not define the character of thoracic organ injuries, and does not prevent subsequent complications. We believe that videothoracoscopy should be performed as soon as possible after the injury if drainage does not appear effective, as demonstrated by continued bleeding, clotted hemothorax, and continuing major air leakage.
We acknowledge with gratitude the technical assistance of Donna Valentine and Professor George W. Lucas in the preparation of this paper.
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Department of Surgery, Central Military Clinical Hospital, Moscow, Russia.
This manuscript was received for review in September 1997 and was accepted for publication in November 1997.
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