Thoracic injury requiring surgery

This report concentrates on the 15% of chest injuries requiring thoracotomy. Eighty-five percent of cases may be managed by a large-bore chest tube placed in the midaxillary line. The indications for thoracotomy following placement of a chest tube are immediate egress of 1,500 ml of blood, continued bleeding at a rate of more than 100 ml/h, and large air leaks that prevent re-expansion of the lung or that, on the ventilator, constitute a significant fraction of the tidal volume. Immediate thoracotomy is also indicated for the patient with a penetrating wound that may have reached the heart in association with acute loss of vital signs or shock that does not quickly respond to blood replacement. Emergency room thoracotomy may also allow salvage of blunt trauma patients with blood loss in the chest by allowing more effective control of blood loss, cardiac massage, and cross-clamping of the aorta. A persistent diagnostic suspicion of the hidden injuries such as aortic rupture, esophageal injury, airway rupture, blunt cardiac injuries, and diaphragmatic rupture must be maintained, so that these injuries are properly diagnosed and treated. Sepsis following trauma to the chest is generally related to retained hematoma and damaged tissue. It is probably wise to resect the pulmonary parenchyma damaged by a high velocity gunshot wound. Chest tubes for hemothorax should be placed so that the blood is totally evacuated; otherwise, the clotted blood usually restricts pulmonary ventilation and commonly leads to an empyema which requires surgery.     

Videothoracoscopy in the diagnosis and treatment of hemothorax

Video assisted thoracic surgery (VATS) has assumed greater importance in the management of pleural diseases. From 1994 to 1998 the Authors report their experience about 11 cases of hemothoraces depending on various causes: 6 hemothoraces and 3 hemopneumothoraces, some spontaneous or iatrogenic, others in patients with chest trauma; 2 clotted hemothoraces. All patients were studied by VAT detecting the source of bleeding in 6 cases of acute hemothorax and in 3 cases of acute hemopneumothorax; in 5 cases the lesions were successfully repaired with thoracoscopic technique. In others 4 patients the VATS approach was converted to thoracotomy for the seriousness of lesions: 3 acute hemothoraces (1 patient with penetrating thoracic firearms injury, 1 patient with extended lung laceration, 1 patient with iatrogenic lesion of right subclavian artery); 1 acute hemopneumothorax in one patient with penetrating thoracic firearms injury and left hemidiaphragmatic double perforation: in this case laparotomy was also operated in order to exclude others abdominal lesions. 2 cases of clotted hemothorax were operated by VATS performing the removal of clots after their fragmentation by endobabcock and pleural irrigation-aspiration with physiological solution. No procedure related complications were occurred. The authors conclude that the video-thoracoscopic approach is certainly advantageous for the management of spontaneous, traumatic or iatrogenic acute hemothoraces. This technique permits, with minimal traumatism and very little complications, the correct therapeutic programming (VATS operation or conversion to thoracotomy). However some hemothoraces (hemothoraces in patients with serious cranial trauma, with spleen rupture, with great vessels rupture, with heart rupture or with massive post-operating hemothorax) contro-indicate the thoracoscopic treatment: immediate thoracotomy and/or laparotomy, in these cases, is indispensable. In the treatment of clotted hemothoraces the VATS is a favourable alternative to thoracotomy, reforming the pleural cavity with minimal traumatism and avoiding tardive complications.     

Videothoracospy in thoracic trauma and penetrating injuries

Videothoracoscopy represents a valid and useful approach in some patients with blunt chest trauma or penetrating thoracic injury. This technique has been validated for the treatment of clotted hemothorax or posttraumatic empyema, traumatic chylothorax, traumatic pneumothorax, in patients with hemodynamic stability. Moreover, it is probably the most reliable technique for the diagnosis of diaphragmatic injury. It is also useful for the extraction of intrathoracic projectiles and foreign bodies. This technique might be useful in hemodynamically stable patients with continued bleeding or for the exploration of patients with penetrating injury in the cardiac area, although straightforward data are lacking to confirm those indications. Thoracotomy or median sternotomy remain indicated in patients with hemodynamic instability or those that cannot tolerate lateral decubitus position or one-lung ventilation. Performing video-surgery in the trauma setting require expertise in both video-assisted thoracic surgery and chest trauma management. The contra-indications to videothoracoscopy and indications for converting the procedure to an open thoracotomy should be perfectly known by surgeons performing video-assisted thoracic surgery in the trauma setting. Conversion to thoracotomy or median sternotomy should be performed without delay whenever needed to avoid blood loss and achieve an adequate procedure.     

The role of videothoracoscopy in management of precordial thoracic penetrating injuries.

OBJECTIVES: To report on the value of diagnostic videothoracoscopy in patients with possible penetrating cardiac wounds. METHODS: Thirteen patients admitted over a 4 year period with hemodynamic stability and a penetrating injury in cardiac proximity had exploratory videothoracoscopy. All data related to those patients were retrospectively reviewed. RESULTS: Eighty-five percent of patients had videothoracoscopy within 8 h of trauma. In most cases (eight of 13), operations were performed on patients in the supine position with the chest slightly rotated. Nine patients had a left hemothorax, five had pulmonary lacerations and five had a bleeding parietal vessel. Pericardial exploration was achieved either by direct vision (nine patients), or by the performance of a pericardial window (four patients). Acute hemopericardium related to a cardiac wound was diagnosed in two patients. Procedures included evacuation of clotted hemothorax (six patients), stapling of pulmonary laceration (four patients), and electrocoagulation of bleeding parietal vessel (four patients). Four patients required conversion to thoracotomy: two for repair of a cardiac wound, one for adequate exposure of the pericardium and one for ligation of a bleeding intercostal artery. The mean operative time was 37+/-23 min. Two patients experienced postoperative complications (coagulopathy, subcutaneous emphysema) and the in-hospital mortality was 0%. The mean hospital stay was 10+/-4 days. CONCLUSIONS: In the hands of an experienced surgeon, videothoracoscopy may represent a valid alternative to subxiphoid pericardial window in patients with hemodynamic stability and a suspected cardiac wound. Videothoracoscopy can rule out a cardiac injury and allows for the performance of associated procedures such as diaphragm assessment/repair, evacuation of clotted hemothorax, hemostasis of parietal vessels or pulmonary laceration and removal of projectiles.     

Timing, safety, and efficacy of thoracoscopic evacuation of undrained post-traumatic hemothorax.

Residual post-traumatic hemothorax (RPTH) occurs in 3 to 8 per cent of patients with tube thoracostomy and may cause serious infectious complications. Surgical evacuation is recommended, and thoracoscopic evacuation (THEVA) tends to replace open thoracotomy for this purpose. The objective of this study is to evaluate the optimal timing, safety, and efficacy of THEVA. Over 5 years patients with tube thoracostomy for trauma who had unresolved opacities on plain chest radiograph were evaluated by CT. If the residual fluid volume was estimated to be more than 500 mL3 on CT the patients were offered THEVA. Unstable patients were excluded. A score ranging from one (easy) to three (difficult) was used to grade the difficulty of the operation according to the attending surgeon's perception. Of 1728 chest trauma patients 143 (8%) were evaluated by CT for persistent opacity on plain film, 31 (1.8%) were found to have RPTH, and 24 (1.4%) were eventually taken for THEVA at 3.5+/-2 days after admission. Low oxygen saturation (less than 94%) was found in 58 per cent of patients before THEVA but in only 25 per cent after THEVA (P = 0.02). The majority of chest tubes (75%) were removed within 4 days of the operation. Two patients required conversion to thoracotomy. THEVA done within 3 days of admission was associated with a lower operative difficulty score, shorter hospital stay, and a trend toward shorter intraoperative time compared with THEVA done after 3 days of admission. All patients had effective resolution of their radiographic opacities after THEVA. Three patients developed a complication (urinary tract infection, pneumonia, and persistent air leak). We conclude that patients with significant RPTH and without major physiologic compromise are appropriate candidates for THEVA. The procedure is safe, evacuates PRTH effectively, and improves the respiratory function of affected patients. Ideally it should be performed within 3 days of admission.     

Bluntthoracic injury

Of 161 patients with blunt thoracic injury, 135 were male (83.9%). and 26 were female. The most common cause of injury was traffic accidents (130 patients, 80.7%), followed by falls (22 patients), and crushing (7 patients). There were 46 third decade and 36 second decade patients. Thirty-two patients had single thoracic injury and the other had multiple organ injury. The most common associated injury was head injury (65 patients). Most traffic accidents involved motorcycle accident. Forty-four patients died, 32 within 24 hours, and 4 died to thoracic injury. These 4 patients were shock on arrival and died within 24 hours. The injury severity score, which was under 30 in 78.3% of patients, correlated to the mortality rate. Rib fracture was the most common thoracic injury in 96 patients followed by hemothorax in 91, pulmonary contusion in 79, and pneumothorax in 64. Most of the thoracic injuries were treated conservatively. Thoracotomy was performed in 6 patients. Other than one patient with rupture of the left pulmonary vein, 5 patients recovered. Continued bleeding at a rate of more than 200 ml/h from the chest drainage tube or no recovery from shock and large air leakage preventing re-expansion of the lung are indications for emergency thoracotomy. Thoracotomy should also be considered after conservative treatment in patients with continued air leakage or intrabronchial bleeding negatively affecting respiration. Indications for thoracotomy should be determined individually based on evaluating of vital sign.     

Indications for thoracotomy: deciding to operate

Formal chest operations other than minor procedures are required by only 12 to 15 per cent of patients with thoracic trauma. For those patients requiring thoracotomy, the operation may be required acutely or on a delayed basis. Acute thoracotomy may be necessary urgently, but in most situations, it is performed after a systematic evaluation has revealed specific symptoms and proved injuries. Some conditions should NOT lead automatically to thoracotomy unless other indications for the operation are present. In some cases, thoracotomy is required on a delayed basis.     

Early evacuation of clotted hemothorax

Thoracotomy is infrequently required for penetrating or blunt thoracic trauma. Complications of thoracic trauma, such as clotted hemothorax and empyema, significantly increase morbidity, mortality, and length of hospitalization. Among approximately 9,000 patients with blunt or penetrating thoracic trauma seen during a recent eleven year period, 33 per cent (3,000 patients) presented with hemothorax or pneumohemothorax. The average length of hospitalization in the patient with uncomplicated thoracic trauma was less than six days. Among the 3,000 patients with hemothorax or pneumohemothorax, 2,600 (85 per cent) were treated with a drainage procedure. Among this group, clotted hemothorax or posttraumatic empyema developed in 85 (3.3 per cent). Among ten patients undergoing evacuation of a clotted hemothorax within five days of admission, there was zero mortality and an average hospital stay of ten days. Forty-one patients undergoing decortication more than five days after injury had a 2.4 per cent mortality, with the average period of hospitalization being twenty-five days. Thirty-four patients requiring decortication and drainage of empyema had a 12 per cent mortality and an average hospital stay of forty-one days. Among those patients in whom empyema developed, the most frequently associated injuries were enteric. These complications occurred due to inadequate evacuation of the original hemothorax, nonfunctioning tube thoracostomy, physician delay in recognition of the pathologic process, and bacterial contamination of the hemothorax. When complications secondary to tube thoracostomy dysfunction occurred, early operative evacuation of clotted hemothorax decreased the mortality, morbidity, and hospital stay and prevented the development of empyema.     

Causes and results of repeated videothoracoscopy

For 7 years videothoracoscopies for diseases and traumas of the chest were fulfilled in 2075 patients, abscessoscopy in 27 patients. Repeated videothoracoscopies were fulfilled in 41 (2%) patients operated for spontaneous pneumothorax, pleural empyema, exudative pleurisy and injuries to the chest due to recurrent hydropneumothorasx, prolonged abundant release by drainage, bleedings by drainage or formation of clotted hemothorax, not effectiveness of sanation, of the empyema cavity, reabscessoscopy - in 2 patients. Revideothoracoscopies were divided into groups with the presence of drainages or removed drainages according to the terms - into emergent (on the first day, immediately after the development of complications), urgent (from 2 to5 days), postponed (from 6 to 15 days), and late (more than 15 days). In 4 cases the conversion to minithoracotomy had to be done due to continuing bleeding, the absence of lung hermetism. All patients with spontaneous pneumothorax, pleuritis and chest trauma recovered. Lethal outcome was in 1 (2.4%) case from lung artery thromboembolism. It was concluded that revideothoracoscopy was an alternative thoracotomy of full value in reinterventions.     

Selective management of flail chest and pulmonary contusion.

Four hundred and twenty-seven patients with severe blunt chest trauma were treated resulting in (1) flail chest, (2) pulmonary contusions, (3) pneumothorax, (4) hemothorax, or (5) multiple rib fracture. The need for endotracheal intubation and mechanical ventilation was determined selectively by standard clinical criteria. Avoidance of fluid overload and vigorous pulmonary toilet was attempted in all patients. Three hundred and twenty-eight patients were treated by nonintubation; 318 patients (96.6%) had a successful outcome, while ten required intubation. Only one patient died. The 99 patients who required intubation and mechanical ventilation had a high mortality because of associated shock and head injury; however, the total mortality for the entire group of patients was 6.5%, with only 1.4% mortality caused by pulmonary injury. The incidence of pneumonia was high (51%), but there was only a 4% incidence of tracheostomy complications. Flail chest and pulmonary contusion without flail chest occurred in 95 and 135 patients, respectively. Half of the flail chest patients were intubated, but 69.5% were intubated less than three days. Twenty per cent of the patients with pulmonary contusion required mechanical ventilation, usually for less than three days. This study demonstrates that patients with severe blunt chest trauma can be managed safely by selective intubation and mechanical, ventilation and that the incidence of complications associated with controlled mechanical ventilation can be greatly reduced.     

Evaluation of chest tube administration of tissue plasminogen activator to treat retained hemothorax

Background

When retained hemothorax occurs, video-assisted thoracoscopy or thoracotomy is performed, but recently, tissue plasminogen activator (tPA) has been used. This study evaluated intrapleural tPA use for retained traumatic hemothoraces.

Methods

A retrospective review was conducted of trauma patients treated with intrapleural tPA for retained hemothorax. Data included demographics, past medical and surgical histories, injury details, treatment details, and outcomes.

Results

Seven patients (median age = 47 years, male = 6, blunt trauma = 6) met study criteria. All patients received a chest tube. Six patients later received computed tomography-guided drains for tPA infusion. Number of tPA treatments per patient varied from 1 to 5. Median total tPA dosage was 24 mg. Median time from injury to chest tube placement was 11 days and from chest tube placement to first tPA treatment was 4 days. No patients required a video-assisted thoracoscopy; however, 1 patient required thoracotomy. There were no deaths or bleeding complications attributed to intrapleural tPA.

Conclusion

Although future studies are needed to identify optimum treatment guidelines, intrapleural tPA appears to be a safe and efficacious treatment option.     

全胸腔镜肺叶切除术中转开胸的临床研究

目的:探讨全胸腔镜肺叶切除术中转开胸的原因,以降低中转开胸发生率,准确把握中转开胸的手术指征。方法:2010年9月至2015年11月共完成胸腔镜肺叶切除术1 230例。手术均通过2~3个小切口完成,按照手术常规行解剖性肺叶切除及系统性淋巴清扫术。如镜下操作遇到血管损伤性出血、肺门淋巴结粘连或转移等腔镜下无法处理的情况,及时中转为开胸手术。根据术中是否中转开胸分为胸腔镜组与中转开胸组,对比两组患者的临床资料,分析引起中转开胸的相关原因及采取的相应措施。结果:患者手术顺利,无严重并发症发生及围手术期死亡病例。58例中转开胸,中转率4.7%,其中25例术中出血,23例淋巴结粘连或侵犯。56例开胸后顺利完成了肺叶切除,仅2例施行了全肺切除。两组手术时间、术中出血量、引流管放置时间、术后引流量、住院时间差异均有统计学意义(P0.05)。肺动脉损伤出血、淋巴结干扰是导致中转开胸最常见的原因。结论:肺动脉损伤、淋巴结干扰是中转开胸的主要原因,应根据术中具体情况及时准确地把握中转开胸的手术指征。     

Intrapleural analgesia for postthoracotomy pain and blood levels of bupivacaine following intrapleural injection

An epidural type catheter was placed in the pleural space under direct vision before the closure of the chest in 24 patients who underwent thoracotomy for various types of lung or aortic surgery. All patients received intrapleural injections of 20 ml of 0.5 per cent bupivacaine with or without epinephrine as initial pain therapy. Patients also received subsequent doses of a similar volume of 0.375 per cent bupivacaine with epinephrine 1:200,000 up to four times a day for a maximum duration of seven days. Good pain relief was achieved in patients who underwent lateral and posterior thoracotomies. No pain relief was achieved in patients who underwent anterior thoracotomy or in patients in whom there was excessive bleeding in the pleural space. Bupivacaine blood concentrations were measured in 11 patients following the initial dose of 20 ml of 0.5 per cent bupivacaine (with epinephrine 1:200,000 in five of the 11 patients). The mean peak plasma concentration of bupivacaine when used with epinephrine was 0.32 +/- 0.02 microgram.ml-1. The mean peak plasma concentrations of bupivacaine when used without epinephrine was 1.28 +/- 0.48 microgram.ml-1. Our present data show that intrapleural analgesia is useful in the management of postoperative pain in patients who undergo thoracotomy. Our data also show that there is a significant decrease in peak plasma concentrations of bupivacaine when epinephrine is added to the solution (P less than 0.05).     

Early cardiorespiratory findings after severe blunt thoracic trauma and their relation to outcome.

This study examined the initial haemodynamic and oxygen transport patterns in 24 patients with severe blunt thoracic trauma in whom immediate monitoring with femoral and pulmonary artery catheters was required after admission to the intensive care unit. All patients required mechanical ventilation and were studied before receiving inhalational anaesthesia and within 12 h of injury. Two groups of patients were identified; nine patients (group 1) had an impaired left ventricular stroke work index (LVSWI) and 15 patients had a normal LVSWI (group 2). There were no significant differences in the abbreviated injury scale score for the chest, the total injury severity score, or the mean ages of the two groups. There were significant differences in stroke volume index, 32 versus 56 ml m-2 (P less than 0.001), and cardiac index, 3.2 versus 5.3 l min-1 m-2 (P less than 0.001), and therefore in oxygen delivery, 469 versus 852 ml min-1 m-2 (P less than 0.001), despite apparently adequate volume expansion using the same protocol and clinical criteria in both groups. Oxygen consumption was not significantly different in the two groups, 135 versus 157 ml min-1 m-2, because of a higher oxygen extraction ratio in group 1, 29 versus 19 per cent (P less than 0.001), and hence lower mixed venous oxygen saturation, 73 versus 82 per cent (P less than 0.02). Seven patients in group 1 died (78 per cent) compared with two in group 2 (13 per cent). Early depression of cardiac function is associated with poor outcome in patients with thoracic trauma, and measurements of oxygen transport variables may influence resuscitation and the timing of surgical procedures.     

Endovascular repair of aortic lesions associated to video-assisted thoracoscopy surgery after chest trauma

AIM: Trauma of the thoracic aorta for blunt trauma shows a very high incidence of mortality. Hospital mortality rate after aortic open surgery is between 15% and 30%. Endovascular management represents an alternative treatment Associated lesions are usually seen in those critical patients. Hemothorax may be present. The authors propose a combined treatment of endovascular repair for the aortic lesion and video-assisted thoracoscopy surgery (VATS) for the treatment of chest bleeding complications. METHODS: The authors report a series of three patients with post-traumatic aortic lesion and hemothorax. In two patients endovascular procedure was first performed, followed by VATS, few days later, for retained hemothorax. In the third patient the two procedures were performed at the same time because of the patient's critical conditions. RESULTS: There was technical success of stent-graft placement in all the treated cases. No postoperative mortality. No postoperative paraplegia. No VATS converted to thoracotomy. The postoperative follow-up time range between 10 and 19 months. CONCLUSION: Considering the relatively short procedural time and minimally invasive approach of both techniques, the concomitant use of them may represent an alternative to standard open surgery in cases of thoracic aorta lesions associated with hemothorax. Those procedures may be performed sequentially or together in emergency cases with intra-thoracic more active bleeding to exclude or to treat intra thoracic bleeding.     

Idiopathic Massive Spontaneous Hemothorax: Adhesion Disruption

Background  Hemothorax has been reported to occur along with spontaneous pneumothorax due to adhesion disruption. Rupture of pleural adhesions spontaneously or after unnoticeable trivial trauma causing massive hemothorax alone is rare. Methods  We present a series of seven cases of idiopathic massive spontaneous hemothorax due to adhesion disruption, of which all required emergency thoracotomy with ligation or cauterization of bleeding adhesions. Results  Six patients had bleeding pleural lung adhesions of which five involved the upper lobes. Another had bleeding from pleuropericardial adhesions. All patients are doing well on follow-up. Conclusions  Disruption of pleural adhesions may cause massive hemothorax, requiring early surgical intervention. After thoracotomy the outcome in these patients is excellent.     

Empyema and restrictive pleural processes after blunt trauma: an under-recognized cause of respiratory failure

Respiratory failure is a common complication among patients sustaining major blunt trauma. This is usually due to the underlying pulmonary injury, pneumonia, or adult respiratory distress syndrome. However, we have frequently found these patients to actually have a pleural process as the cause of their respiratory failure. Our objective was to assess the frequency of empyema and restrictive pleural processes after blunt trauma and their contribution to respiratory failure. We retrospectively reviewed all blunt trauma patients over a 5-year period who required a thoracotomy and decortication for empyema. Twenty-eight patients with blunt trauma required a thoracotomy and decortication for empyema. The most common finding was infected, loculated hemothorax/effusion in 23 patients, whereas 5 had an associated pneumonia. Chest radiographs were nondiscriminating, whereas CT scans in 25 patients showed previously unrecognized fluid collections, air-fluid levels, or gas bubbles. Neither thoracentesis nor placement of additional chest tubes was helpful. Positive cultures were uncommon. Ventilator dependence was present preoperatively in 13 patients who were on the ventilator an average of 13 days preoperatively and only 5.8 days postoperatively. Several patients believed to have adult respiratory distress syndrome were weaned within 72 hours of operation. All patients were ultimately cured. Empyema is an under-recognized complication of blunt trauma and may contribute to respiratory failure and ventilator dependence. Although difficult to diagnose, empyema should be considered in blunt trauma patients with respiratory failure and an abnormal chest radiograph. CT aids in the diagnosis, and the results of surgical treatment are excellent.     

Reoperation after abdominal trauma

A five year experience with 782 patients requiring laparotomy for trauma is reviewed. Specifically, the 70 patients requiring unplanned reexploration have been studied to delineate the indications for and implications of such repeat laparotomies. The major indications for such reoperation were intraabdominal abscess (45.7 per cent), bleeding (15.5 per cent), peritonitis (12.1 per cent), and small bowel obstruction (8.6 per cent). There were 16 negative reexplorations (13.8 per cent). Overall mortality in the reexplored patients was 21.4 per cent, all victims of gunshot or blunt trauma. Mortality correlated with the number of required reexplorations, being 67 per cent in those requiring four operations. Of the 31 laparotomies performed initially for diffuse or localized intraabdominal sepsis, only 15 were highly suspected, and 13 of these by simple chest x-ray findings. If after laparotomy for repair of intraabdominal trauma a patient fails to meet the anticipated norm of convalescence, a high index of suspicion for early postoperative hemorrhage, or later sepsis, should be maintained. Such patients have far more to gain than lose by reexploration.     

Thoracoscopy in the treatment of intrapleural bleeding due to injury of chest wall vessels

Thoracoscopy was used in the treatment of 141 patients with penetrating wounds of chest. Injuries of chest wall vessels were diagnosed at 68 (48.2%) patients. Rate of thoracoscopy conversion due to bleeding from chest wall wounds was 4.3%. Thoracoscopy is effective at injuries of intercostals arteries and their muscular branches, but injuries of internal thoracic artery require conversion into thoracotomy at 50% cases. It is revealed that expediency of thoracoscopy is in direct proportion to time from injury point and is inversely to hemothorax volume.     

Role of Videothoracoscopy in Chest Trauma

Background. The aim of this study was to evaluate videothoracoscopic procedures in the setting of chest trauma.Methods. We retrospectively analyzed our experience of videothoracoscopy in patients with either blunt trauma or penetrating thoracic injuries.Results. Forty-three procedures involving 42 patients were performed between July 1990 and April 1996. Indications for videothoracoscopy included suspected diaphragmatic injury (14 patients), clotted hemothorax (12), continued hemothorax (6), persistent pneumothorax (5), intrathoracic foreign body (4), posttraumatic chylothorax (1), and posttraumatic empyema (1 patient). Ten patients (24%) required conversion to thoracotomy. Two patients suffered postoperative pneumonia. There was one perioperative death. Mean hospital stay was 17 days; 21 days for patients with blunt trauma and 13 days for patients with penetrating injuries. There was no procedure-related complication. Videothoracoscopy allowed precocious discharge of patients suffering penetrating injuries and allowed faster recovery in the majority of patients suffering severe blunt trauma.Conclusions. Videothoracoscopy appears to be a safe, accurate, and useful approach in selected patients with chest trauma. It is ideal for the assessment of diaphragmatic injuries, for control of chest wall bleeding, for early removal of clotted hemothorax, for treatment of empyema, for treatment of chylothorax, for treatment of persistent pneumothorax, and for removal of intrathoracic foreign body. However, we do not recommend the use of this technique in the setting of suspected great vessel or cardiac injury.(Ann Thorac Surg 1997;63:327–33)© 1997 by The Society of Thoracic Surgeons