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Eur J Cardiothorac Surg 2002;22:7-12
© 2002 Elsevier Science NL

The role of videothoracoscopy in management of precordial thoracic penetrating injuries

F. Pons*, L. Lang-Lazdunski, X. de Kerangal, O. Chapuis, P.M. Bonnet, R. Jancovici

Department of Thoracic and General Surgery, Percy Military Hospital, Clamart, France

Received 14 December 2001; received in revised form 1 April 2002; accepted 4 April 2002.

* Corresponding author. Service de Chirurgie Thoracique et Générale, Hôpital d'Instruction des Armées Percy, 101 avenue Henri Barbusse BP406, 92141 Clamart Cedex, France. Tel.: +33-1-41-46-61-62; fax: +33-1-41-46-61-69
e-mail: fpons{at}mail3.imaginet.fr


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Comment
 5. Conclusion
 References
 
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.

Key Words: Videothoracoscopy • Cardiac wound • Chest trauma • Penetrating injury


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Comment
 5. Conclusion
 References
 
Eighty to 70% of patients with penetrating cardiac injury decease before reaching the hospital. Among those that finally reach the hospital, 80% have hemodynamic instability requiring emergent median sternotomy or thoracotomy [1]. However, the remaining 20% of patients have no hemodynamic instability and may even be relatively asymptomatic [1,2]. As those patients may suddenly deteriorate and bleed to death, ruling out a cardiac wound should be achieved as soon as possible. Transthoracic echocardiography (TTE) and diagnostic subxiphoid pericardial window have been advocated as first line examinations [3,4].

Videothoracoscopy has been reported recently as a useful approach in the initial management of patients with penetrating chest trauma, but its use has remained controversial in patients with suspected penetrating cardiac injury [5]. The goal of this study was to report our experience of videothoracoscopy in patients at risk of suffering a penetrating cardiac injury and to propose a logical algorithm for the management of patients with penetrating injury in cardiac proximity.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Comment
 5. Conclusion
 References
 
We retrospectively reviewed all the data concerning patients admitted in our department for a penetrating injury of the torso or the upper abdomen over a 4 year period. All patients included had a penetrating injury located in an area limited by the clavicles superiorly, the costal margin inferiorly, and the midclavicular lines laterally. Among those patients, we included only those that had exploration by videothoracoscopy. The trauma mechanism, the location of the entrance wound, the hemodynamic status on admission, chest X-ray findings, chest computed tomography (CT) findings and echocardiographic findings were systematically reviewed. We also reviewed the operative findings and postoperative course.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Comment
 5. Conclusion
 References
 
Between April 1997 and April 2001, 34 patients with a penetrating injury in cardiac proximity were admitted to the resuscitation unit at our institution, a military hospital and level I national trauma center providing services to French armed forces and to the neighboring civilians. Eleven patients required thoracotomy or median sternotomy in emergency because of hemodynamic instability; among them two patients sustained a cardiac wound and no patients died; the mean in-hospital stay was 7.5±1 days. Ten patients had only chest tube insertion (there were no obvious differences between these patients and those who underwent videothoracoscopy, but some surgeons did not perform videothoracoscopy in emergency); no complications were reported in this group; one patient required a secondary videothoracoscopy for the aspiration of a clotted hemothorax; the mean in-hospital stay in this subgroup was 3.5±1.5 days.

Thirteen patients had diagnostic videothoracoscopy for exploration of the pericardium. We included only these latter patients.

3.1. Clinical status on admission and preoperative diagnostic imaging
All patients but one were males and the mean age was 34±11 years (range 17–60 years). The cause of penetrating injury was a stab wound (ten patients), a gunshot wound (two patients), and shrapnel (one patient). All patients were in a stable condition on admission (systolic blood pressure >90 mmHg), and only received more than 500 ml of crystalloid solution administration before reaching the hospital. Eleven patients were admitted within 6 h of trauma and two patients within 24 h of trauma. The distribution of the entrance wounds is depicted in Fig. 1 . Only one patient suffered a through-and-through chest gunshot wound.



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  		Fig. 1. Localization of entrance wounds.

 
All patients had preoperative chest X-ray. Nine patients had moderate to massive hemothorax (>500 ml), one patient had a left pneumothorax and two patients had an intrathoracic bullet. No patient had bronchoscopy because we do not use it systematically in the management of penetrating chest injuries. We use it when we suspect a tracheo-bronchial injury, especially in the management of blunt trauma. Six patients had a chest CT to rule out pericardial effusion and other intrathoracic or intraabdominal lesions. Chest CT demonstrated no obvious acute hemopericardium, but was doubtful in two patients: one with a bullet located in the anterior pericardial fat and the other one with a minimal pericardial effusion and a hematoma in the pericardial fat. Eight patients had preoperative echocardiography. This echocardiography demonstrated significant pericardial effusion in one patient and was doubtful in three patients. All patients with hemothorax or pneumothorax had placement of a chest tube before CT examination or before leaving the emergency room.

3.2. Operative approach and findings
Four patients were operated on in the right full lateral decubitus position, one patient in the left decubitus lateral position and eight in the supine position with the chest rotated 30° with the help of a cushion and the upper limb being abducted. All patients except one had a double-lumen endotracheal tube allowing for single-lung ventilation. Videothoracoscopy was performed on the left side in eight patients and on the right side in five. Eleven patients were operated on within 8 h of trauma and two patients between 24 and 48 h after trauma. The surgical procedure was performed through three ports (seven patients), two ports (five patients) and one port (one patient). The entrance wound was used for port access in five instances. We used a 0° videoendoscope. Operative findings are reported in Table 1. All patients had assessment of the pericardial sac, nine had aspiration of significant clotted hemothorax, five had hemostasis of a bleeding parietal artery (four intercostal artery, one internal mammary artery), four had stapling of a pulmonary laceration, and three had removal of intrathoracic projectiles (two bullet, one shrapnel). The pericardial sac was judged normal in seven patients. Serous pericardial effusion was diagnosed in three patients, one of whom had echocardiography quoted as positive. Acute hemopericardium was diagnosed in two patients. Adequate lung exclusion and pericardial assessment could not be achieved in only one patient. Four patients had conversion to a limited thoracotomy because of the presence of hemopericardium related to a cardiac wound (two patients), or because of the impossibility to adequately explore the pericardium and pleural cavity (one patient), or to control bleeding from a transected intercostal artery (one patient). One cardiac wound involving the right ventricle was repaired through a left anterior thoracotomy and another cardiac wound involving the apex of the left ventricle was repaired through a lateral thoracotomy. The mean operative time was 37±23 min (range 5–75 min). The mean postoperative stay in the intensive care unit was 2.4±2 days (range 1–8 days). The postoperative course was uncomplicated in 11 patients. One patient experienced severe postoperative bleeding due to major coagulopathy and one patient suffered massive subcutaneous emphysema. Chest tubes were removed after a 4±2 day period (range 2–10 days). In-hospital stay was 10±4 days (range 5–18 days). There was no in-hospital mortality.


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  		Table 1. Patient data

 

   4. Comment
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Comment
5. Conclusion
 References
 
All patients suffering a penetrating injury in cardiac proximity should be considered at risk for a cardiac wound. In the present study, cardiac proximity was defined as an area bounded superiorly by the clavicles, inferiorly by the costal margin and laterally by the midclavicular lines (‘cardiac box’) [6]. A small amount of patients admitted with a cardiac wound have only minor symptoms or may even be asymptomatic [1,2]. On the other hand, it is difficult to anticipate on a clinical basis which patient with a penetrating torso or upper abdomen injury has a cardiac wound, because the classical Beck's triad (low blood pressure, raised central venous pressure, and distant cardiac sounds) is observed in less than 50% of cases [1]. Ordog et al. [2] reported 4106 asymptomatic patients with penetrating chest injuries and a normal chest X-ray. Among those patients, 1725 had an anterior torso injury and four had a cardiac wound. It is intimidating to observe that those cardiac wounds were diagnosed through a rapid decompensation, with a 50% mortality rate due to delayed diagnostics and operation. This illustrates well the diagnostic and therapeutic challenge in those patients: diagnosing a cardiac wound early will allow for the avoidance of a brutal decompensation and a fatal issue. The hemodynamic decompensation occurs classically within 6 h of trauma, but may be delayed up to 3 weeks [7,8]. Moreover, it is of overwhelming importance to know whether there is a cardiac wound or not in patients requiring immediate surgery for another penetrating injury in the chest, abdomen, or any other area.

Chest X-ray is often performed in asymptomatic or paucisymptomatic patients, with only a minor contribution for the diagnosis of cardiac wound. ECG is also poorly diagnostic in most cases [1]. Chest CT can be used to rule out a hemopericardium in hemodynamically stable patients. On the other hand, chest CT is very helpful for the diagnosis of associated thoracic injuries and for the precise localization of projectiles. However, patients with cardiac injury may suddenly deteriorate during the performance of this CT [9]. The management of these patients could be very difficult inside the CT machine. Therefore, we prefer to perform an echocardiography in the emergency room or the operative room in patients with possible cardiac injury.

TTE is considered by most surgeons as the first-line examination [3,6,10,11]. It can be performed easily in the emergency room or in the operative room by a surgical resident, an on-call cardiologist, or a technician and has excellent sensibility and specificity rates [11]. However, TTE may suffer several limitations, the main one of which being the absence of an experienced surgical resident or cardiologist familiar with the trauma setting. Thus, the presence of major chest wall injury, of subcutaneous emphysema, of massive hemothorax, or of abundant pericardial fat may limit the validity of this examination in our experience. Meyer et al. [12] reported that the sensibility of TTE fell from 91 to 20% when a massive hemothorax was present. TTE can also be falsely positive in patients with serous pericardial effusion. However, a recent study including 261 patients prospectively reported a sensitivity rate of 100%, a specificity rate of 96.9% and an accuracy rate of 97.3% for TTE [11].

Transesophageal echocardiography (TEE) may be more sensitive and more specific than TTE [13], but its realization may be difficult in the setting of penetrating trauma, particularly when patients are critically ill or not cooperative enough.

Most surgeons agree that diagnostic pericardiocentesis should be avoided. It is poorly reliable as a diagnostic procedure due to the presence of clots that can not be aspirated within the pericardium and it may cause iatrogenic injury to the heart or lungs. However, this procedure may be lifesaving in moribund patients, or just before operation, in order to improve the hemodynamic status [1,14].

Some surgeons advocated the performance of a systematic thoracotomy or median sternotomy in patients at risk for a cardiac wound [1,15]. This attitude may be justified in some institutions dealing with a large volume of cases. However, this may result in a high rate of negative thoracotomies or sternotomies with subsequent unnecessary morbidity and cost.

Diagnostic subxiphoid pericardial window has been advocated by many surgeons. This procedure can be easily and quickly performed in the intensive care unit or in the emergency department with sensitivity and specificity rates of 100 and 98%, respectively [4,10,16]. Moreover, the subxiphoid approach allows for the performance of a rapid conversion to median sternotomy when blood is found within the pericardial sac. The main drawback of this approach is the impossibility to adequately explore the left or right thoracic.

Some surgeons advocated the performance of a laparoscopy allowing for the assessment of the abdominal cavity and the diaphragm, as for the performance of a pericardial window through the diaphragm in patients with thoracoabdominal penetrating injury [17,18]. Although this approach may be interesting in few selected patients with an entrance wound in the upper abdomen, it does not seem adequate for most patients suffering a thoracoabdominal penetrating injury, due to the impossibility to explore the chest with this technique, and due to the potential risk of tension pneumothorax associated with pneumoperitoneum in this setting [19].

Videothoracoscopy has emerged recently as a valuable diagnostic therapeutic tool in patients with chest trauma. The main indications of this technique are the evacuation of clotted hemothorax, assessment of the diaphragm, achievement of hemostasis or aerostasis, and sometimes the removal of intrathoracic projectiles or foreign bodies in close contact with major vessels or heart [5,20,21]. For most surgeons, patients at risk of suffering a cardiac wound should not be explored through this technique. However, Morales et al. [22] reported a series of 108 hemodynamically stable patients with possible penetrating cardiac wounds explored by videothoracoscopy. Preoperative TTE was not performed in any of those patients. Thirty-three of those patients had hemopericardium diagnosed and 30 had an occult cardiac wound. All cardiac wounds were repaired through a thoracotomy, with no mortality. The main advantage of videothoracoscopy over subxiphoid pericardial window is the opportunity to adequately explore the thoracic cavity and to treat an associated thoracic injury (i.e. stapling of a pulmonary laceration, clipping or electrocoagulation of a bleeding chest wall vessel, suture of a diaphragmatic tear, or evacuation of a clotted hemothorax).

Whether there is a role for videothoracoscopy in patients with possible penetrating cardiac wound, or there is any advantage in justifying the performance of a videothoracoscopy rather than a subxiphoid pericardial window remains to be confirmed by large prospective studies. In our opinion, TTE should remain the cornerstone of diagnosis. Videothoracoscopy would be indicated only if TTE is doubtful or cannot be performed, or if there is an associated intrathoracic penetrating injury that needs to be ruled out or treated. In patients with negative TTE second ultrasound examination should be performed within 6 h [3,11] (Fig. 2) . At the present time, we advocate the performance of a videothoracoscopy rather than a subxiphoid pericardial window, with the restriction that the surgeon performing videothoracoscopy is familiar with Video-Surgery and also with the trauma setting. Thus, prompt conversion to either median sternotomy or thoracotomy may be required and the performance of a videothoracoscopy with the patient in the supine position requires some experience with this approach. From a technical viewpoint, we recommend a double-lumen tracheal tube for each procedure and an installation allowing for rapid conversion, should it be necessary. A cushion placed below the injured side helps to rotate the chest 30° and facilitates the procedure. Likewise, abduction of the ipsilateral upper limb by 90° allows for the performance of an anterior thoracotomy, should it be necessary. Videothoracoscopy should be performed on the injured side and the entrance wound may be enlarged and used as an access port. Two ports are usually necessary to adequately expose the pericardium, but three are required to perform a pericardial window.



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  		Fig. 2. Proposed algorithm for the management of patients with penetrating wound in cardiac proximity.

 
Should the performance of a pericardial window be systematic? If the entrance wound is adequately visualized on the parietal pleura and if there is no evident pericardial fluid, we estimate that the performance of a pericardial window is not mandatory. However, if the entrance wound is not appropriately visualized, if there is a hematoma in the pericardial fat, or if there is some intrapericardial fluid, it is mandatory to perform a pericardial window.

Should the discovery of an acute hemopericardium lead to a systematic conversion to thoracotomy? Although some proposed to perform a pericardoscopy to explore the pericardial sac and rule out a cardiac wound responsible for the bleeding, we do not recommend this attitude. Conversion to thoracotomy or median sternotomy should be performed each time that a hemopericardium is found at videothoracoscopy, because videothoracoscopic repair of a cardiac wound may be extremely hazardous.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Comment
 5. Conclusion
References
 
This short study suggests that videothoracoscopy may represent a reliable option in hemodynamically stable patients with penetrating injuries in cardiac proximity and doubtful pericardial ultrasound examination, or associated thoracic injury needing to be ruled out or requiring surgical treatment. Further prospective study is warranted to confirm that videothoracoscopy is useful and safe in those patients.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Comment
 5. Conclusion
 References
 

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