What is the recommended approach for a Video-Assisted Thoracic Surgery (VATS) procedure for a patient with a loculated hemothorax?

VATS Procedure for Loculated Hemothorax

Video-assisted thoracoscopic surgery (VATS) is the recommended first-line surgical approach for patients with loculated hemothorax, as it allows for effective evacuation with lower morbidity compared to open thoracotomy. 1

Initial Assessment and Indications

• Primary indications for VATS in loculated hemothorax:

  • Persistent pleural collection despite chest tube drainage
  • Failed medical management with antibiotics and fibrinolytics
  • Loculations that prevent adequate drainage via chest tube
  • Risk of developing empyema or fibrothorax

• Timing considerations:

  • Early intervention (within 6 days of diagnosis) is associated with better outcomes and lower conversion rates to thoracotomy 2
  • Surgical consultation should be obtained if there is no improvement after 5-7 days of conventional management 3

Preoperative Evaluation

• Imaging studies:

  • CT scan to assess the extent of loculations, pleural thickening, and underlying lung status
  • Ultrasound to identify loculations and guide placement of thoracoscopic ports

• Patient selection factors:

  • Hemodynamic stability is essential for VATS approach
  • Absence of active massive bleeding
  • Ability to tolerate single-lung ventilation

Technical Approach

• Standard VATS technique:

  • General anesthesia with single-lung ventilation
  • Three-port approach is most common
  • Camera port typically placed in 7th-8th intercostal space, mid-axillary line
  • Working ports placed under direct visualization based on loculation location

• Procedural steps:

  • Complete evacuation of blood and fibrinous material
  • Breaking down of loculations and adhesions
  • Decortication of visceral pleura if necessary to allow lung re-expansion
  • Irrigation of pleural space with warm saline
  • Placement of chest tubes under direct visualization

Special Considerations

• Conversion to thoracotomy:

  • Be prepared to convert to open thoracotomy in cases of:
    • Dense adhesions preventing adequate visualization
    • Active bleeding that cannot be controlled thoracoscopically
    • Inability to achieve complete evacuation of loculations
    • Conversion rates reported between 7-10% 2

• Massive contamination:

  • If pleural space is massively contaminated, extensive decortication combined with prolonged chest tube drainage may be more appropriate 4
  • Multiple chest tubes may be needed for chronic drainage

Post-Procedure Management

• Chest tube management:

  • Leave chest tubes until drainage is minimal (<150 mL/day)
  • Consider continuous drainage to underwater seal or suction
  • Early removal of chest tubes (within first week) is possible in approximately 90% of cases 2

• Adjunctive therapy:

  • Consider antibiotics if infection is suspected
  • Early mobilization and pulmonary rehabilitation

Outcomes and Benefits

• Advantages of VATS over thoracotomy:

  • Shorter hospital stay (approximately 3.7 days shorter) 3
  • Reduced postoperative pain and analgesic requirements
  • Fewer complications (99/1000 vs 138/1000) 3
  • Complete evacuation achieved in approximately 80% of cases 2
  • Earlier chest tube removal

• Potential complications:

  • Residual pleural thickening
  • Incomplete lung expansion
  • Recurrent effusion or infection
  • Bleeding

Special Populations

• Post-cardiac surgery patients:

  • VATS is effective for evacuating hemothorax after cardiac surgery in hemodynamically stable patients with healed sternotomy wounds 5
  • Avoids risks associated with repeat sternotomy

• Trauma patients:

  • VATS is safe and effective in hemodynamically stable trauma patients 6
  • Can prevent long-term complications like empyema and fibrothorax

By following this approach, VATS offers an effective method for managing loculated hemothorax with lower morbidity than traditional open thoracotomy while achieving comparable efficacy in evacuating the collection and allowing for complete lung re-expansion.