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.