What are the alternatives for managing retained hemothorax when visualization is poor with Video-Assisted Thoracic Surgery (VATS)?

Management of Retained Hemothorax When VATS Visualization is Poor

When VATS fails due to poor visualization (typically from dense adhesions or obliterated pleural space), convert immediately to open thoracotomy to complete evacuation and achieve hemostasis. 1

Primary Alternative: Conversion to Open Thoracotomy

The definitive alternative when VATS visualization is inadequate is conversion to open thoracotomy. This is the standard approach when adhesions prevent safe thoracoscopic examination or when the pleural space cannot be adequately visualized. 1

Key Technical Considerations:

• Dense adhesions are the primary reason for VATS failure in retained hemothorax, occurring in approximately 20% of cases. 2

• The surgeon must be prepared to convert to thoracotomy at the start of any VATS procedure for retained hemothorax, as adhesions are often only appreciated intraoperatively. 1

• Open thoracotomy allows for:

  • Direct visualization despite adhesions 1
  • Extensive decortication when lung cannot be fully expanded 1
  • Definitive control of intercostal artery bleeding that may be difficult to ligate thoracoscopically 3
  • Complete evacuation of organized clot 2

Timing Considerations

The likelihood of VATS failure increases significantly with delayed presentation. 1

• Early intervention (≤4 days) has higher VATS success rates and should be prioritized. 4

• Mean time to conversion to thoracotomy in failed VATS cases is approximately 14.5 days from injury, compared to 13.3 days for successful VATS. 2

• Dense adhesions correlate with:

  • Longer time from injury 2
  • Presence of empyema 2
  • Massive pleural contamination 1

Surgical Approach for Conversion

When converting from VATS to open thoracotomy:

• Perform muscle-sparing thoracotomy through an intercostal space, with or without partial rib resection. 1

• Multiple chest tubes are often required for chronic drainage when extensive decortication is performed. 1

• Complete decortication should be performed to allow maximal lung re-expansion, even if cavity resection is not technically feasible. 1

Alternative Considerations (Less Applicable)

Image-guided interventions are NOT appropriate alternatives when VATS has already failed due to poor visualization, as they offer even less direct visualization than VATS. 1

Thrombolytic therapy should NOT be attempted as an alternative to surgical intervention in retained hemothorax, as VATS (or thoracotomy if VATS fails) is the recommended approach. 4

Critical Pitfalls to Avoid

• Do not persist with VATS when visualization is inadequate - this risks incomplete evacuation, missed bleeding sources, and prolonged operative time. 1

• Do not delay conversion - the presence of adhesions preventing safe thoracoscopic examination is an absolute indication for open approach. 1

• Ensure single-lung ventilation capability before attempting VATS, as inability to achieve this is a contraindication to VATS and mandates open approach from the start. 1

• Be prepared for extensive decortication - the pleural space may be massively contaminated requiring prolonged drainage rather than simple evacuation. 1