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Ann Thorac Surg 1997;63:1783-1785
© 1997 The Society of Thoracic Surgeons

Case Report

Thoracoscopic Retrieval of Foreign Bodies After Penetrating Chest Trauma

James P. Bartek, MD, Anthony Grasch, Pa-C, Stephen R. Hazelrigg, MD

Department of Thoracic and Cardiovascular Surgery, Southern Illinois University School of Medicine, Springfield, Illinois

Accepted for publication January 25, 1997.


   Abstract
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Video-assisted thoracic surgery or thoracoscopy has proved to be valuable in many settings in thoracic surgery. The use of video-assisted thoracic surgery in trauma has been limited, especially with respect to penetrating trauma. We report the use of thoracoscopy to remove intrathoracic fragments of glass and avert the need for a thoracotomy.


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A 25-year-old intoxicated man sustained an injury to the left side of his chest in an altercation in which he was pushed through a glass door. In the emergency department the patient denied dyspnea but did complain of pain with deep inspiration. Physical examination was remarkable for 3-cm wound to the left anterior chest in approximately the third intercostal space, medial to the nipple. A small amount of subcutaneous emphysema was present over the left side of the chest, and the chest roentgenogram showed a left pneumothorax. After tube thoracostomy the patient underwent a computed tomographic scan; two fragments of glass were seen, one (2.5 cm in greatest dimension) was immediately adjacent to the cardiac apex (Fig 1Go), whereas the larger 3.5-cm glass fragment was adjacent to the diaphragm. The patient was taken to the operating room. After general anesthesia was obtained using a double-lumen endotracheal tube, thoracoscopy was performed through two 10-mm thoracoscopic ports.



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  		Fig 1. . Fragments of glass abutting the pericardium.

 
The two glass fragments were easily seen and were retrieved with ring forceps (Fig 2Go). Further inspection showed no injuries to the diaphragm or the pericardium. The patient's postoperative course was uneventful. The chest tube was removed on postoperative day 1, and he was discharged home.



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  		Fig 2. . Two glass fragments removed thoracoscopically.

 

   Comment
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Thoracoscopy has a long history and has enjoyed a recent resurgence in popularity due to improvements in technology and instrumentation [1]. The indications for thoracoscopy in the trauma patient have only recently been addressed and include the use of thoracoscopy to evaluate possible diaphragmatic or vascular injury in the hemodynamically stable patient. Thoracoscopy may later play a role in management of retained hemothoraces and in the treatment of empyema [2].

Jones and associates [3] evaluated 36 patients with penetrating chest trauma who presented with hemothoraces. Thoracoscopy was performed using local anesthesia in most of the patients (33 of 36 patients), and anatomic definition of the injury was correctly identified in all but 1 patient. Thoracoscopy was determined to alter management in 16 patients (44.4%).

Diaphragmatic injury may be difficult to diagnose in patients with chest trauma; hence Ochsner and colleagues [4] prospectively evaluated 14 patients with suspected diaphragmatic injury. Thoracoscopy correctly identified the presence of diaphragmatic injury in 9 and the absence of diaphragmatic injury in 5 patients. The value of thoracoscopy for diaphragmatic injuries was confirmed by Uribe and colleagues [5] in another prospective study involving 28 patients with suspected diaphragmatic injuries: thoracoscopy identified 9 patients with diaphragmatic injury.

Smith and associates [6] categorized 24 patients into three groups: (1) suspected diaphragmatic injury, (2) continued bleeding after tube thoracostomy, and (3) clotted hemothorax unresponsive to tube thoracostomy. Of the 10 patients with suspected diaphragmatic trauma, injury was confirmed in 5 patients, and repair was successfully performed with the thoracoscope in 4 patients. In the second group, 5 patients had continued bleeding after tube thoracostomy. At the time of thoracoscopy, intercostal artery lacerations were found in all patients. Although hemorrhage was controlled with the thoracoscope in 3 patients, open thoracotomy was needed to control bleeding in 2 patients. In the third group, 8 of 9 patients with clotted hemothorax unresponsive to tube thoracostomy were successfully treated by removing the clot with the thoracoscope. The single failure in this category was in a patient who underwent thoracoscopy 21 days after a gunshot injury and was found to have a dense fibrous peel requiring thoracotomy and decortication.

The thoracoscopic drainage and decortication in patients in whom an empyema developed after penetrating chest trauma was studied by O'Brien and associates [7]. Eight patients were initially treated with tube thoracostomy, but empyema developed an average of 24 days after the injury. All patients underwent thoracoscopic drainage and decortication, and chest tubes were removed a median of 8.5 days after the procedure.

There have been reports of the use of thoracoscopy to retrieve retained sponges and instruments after surgical procedures [8]. This case report identifies a patient who had a penetrating injury and was hemodynamically stable. Because of the anatomic location of the glass, resection was recommended. Thoracoscopy allowed the avoidance of a thoracotomy, and a rapid discharge from the hospital and return to normal activity.


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Address reprint requests to Dr Hazelrigg, Department of Thoracic and Cardiovascular Surgery, Southern Illinois University School of Medicine, PO Box 19230, Springfield, IL 62794-1312.


   References
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 References
 

  1. Hazelrigg SR, Nunchuck SK, LoCicero J, The Video Assisted Thoracic Surgery Study Group. Video Assisted Thoracic Surgery Group data. Ann Thorac Surg 1993;56:1039–44.[Abstract]
  2. Simon RJ, Ivatury RR. Current concepts in the use of cavitary endoscopy in the evaluation and treatment of blunt and penetrating truncal injuries. Surg Clin North Am 1995;75:157–74.[Medline]
  3. Jones JW, Kitahama A, Webb WR, McSwain N. Emergency thoracoscopy: a logical approach to chest trauma management. J Trauma 1981;21:280–4.[Medline]
  4. Ochsner MG, Rozycki GS, Lucente F, Wheery DC, Champion HR. Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: a preliminary approach. J Trauma 1993;34:704–10.[Medline]
  5. Uribe RA, Pachon CE, Farme SB, et al. A prospective evaluation of thoracoscopy for the diagnosis of penetrating thoracoabdominal trauma. J Trauma 1994;37:650–4.[Medline]
  6. Smith RS, Fry WR, Tsoi EKM, et al. Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury. Am J Surg 1993;166:690–5.[Medline]
  7. O'Brien J, Cohen M, Solit R, et al. Thoracoscopic drainage and decortication as definitive treatment for empyema thoracis following penetrating chest injury. J Trauma 1994;36:536–40.[Medline]
  8. Thannikkotu B, Vallieres E, Urschel J. Open tube thoracoscopy for removal of intrapleural foreign bodies. J Crit Care 1994;37:409–10.



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