Application of Mini-Invasive Video-Assisted Thoracoscopic Interventions in Severe Chest Trauma

The dissertation investigates the possibilities of mini-invasive video-assisted thoracoscopic interventions in severe chest trauma, encompassing both penetrating wounds and blunt injuries, including those complicated by flail rib fractures and intrapleural complications. The author analyses a large clinical material, comparing the outcomes of treatment with and without video-assisted thoracoscopy, and develops an original method of mini-invasive fixation of flail rib fractures with special pins under video-assisted thoracoscopic control. A separate part of the work is devoted to a morphological study of lung tissue in those who died from combined trauma with dominant chest injury, which makes it possible to determine the causes of mortality at different periods of traumatic disease. The practical significance of the study lies in the introduction of video-assisted thoracoscopy into the standards of diagnosis and treatment of complicated chest trauma in inpatient facilities.

Road traffic accidents, the criminal situation, ongoing military conflicts, natural disasters, and high-rise construction account for the steady increase in the rate of injuries (Yermolov A. S. et al., 2003; Bondarenko A. V. et al., 2004; Bagnenko S. F. et al., 2007; Jacobs L. M. et al., 2000; Frykberg E. R., 2002; Cushman J. G. et al., 2003; Racioppi F., 2004; Mitchell A. et al., 2007).

Within the overall structure of injuries, chest injuries account for approximately 10%, ranking third after fractures of the limb bones and craniocerebral trauma (Abakumov M. M. et al., 2002, 2005; Yermolov A. S., 2004; Shulutko A. M. et al., 2006; Sirmali M., 2003). Up to 25% of patients with chest trauma sustain severe injuries that require emergency surgical intervention (Bagnenko S. F., 2007). According to forensic medical examination data, in every fourth person who dies from combined trauma, severe chest injuries are the immediate cause of death (Singayevskiy A. B. et al., 2002; Matthes G. et al., 2001; Asensio J. A. et al., 2002).

Despite the diversity of types of chest trauma, its danger lies in the direct damaging effect on the organs of the respiratory and circulatory systems that sustain vital activity. Therefore, the severity of the victim's condition is determined primarily by the degree of impairment of pulmonary and cardiac function. The social significance of this type of trauma is due to the fact that approximately 90% of victims are people of working age (Sharipov I. A., 2008; Kopits E. et al., 2003). Even in cases of an immediately favourable outcome of severe chest trauma, a considerable number of these patients become disabled due to developing complications.

In peacetime, blunt chest injuries are the most common (Seleznyov S. A. et al., 2004; Carli P. et al., 1997). In blunt trauma, the musculoskeletal framework, which is intended to protect the chest organs, often becomes the cause of their injury. Fragments of fractured ribs can damage intercostal arteries, lungs, and heart, which is frequently complicated by hemothorax, pneumothorax, and sometimes hemopericardium. Double, or so-called "flail" (segmental) rib fractures, which compromise the integrity of the rib cage, are particularly dangerous. As a result of the loss of the structural rigidity of the chest wall and impaired respiratory biomechanics, acute respiratory failure develops. With respiration, paradoxical movement (flotation) of this fragment occurs: it falls inward on inspiration and protrudes on expiration, disturbing respiratory rate, rhythm, and depth. It should be noted that chest trauma with disruption of the rib cage is accompanied by intrapleural complications—hemothorax, pneumothorax, pulmonary contusion or wound—in 80–90% of cases. Elimination of pathological rib mobility and intrapleural complications is the main task in normalizing respiratory function (Maslov V. I. et al., 2007; Shapot J. B. et al., 2007; Sirmali S. R. et al., 2004).

The current methods of external stabilization of flail rib fragments have a number of significant drawbacks: insufficient fixation, infection of traction devices, pressure sores from panels, and restriction of patient mobility leading to hypostatic pneumonia. The main drawback of any type of traction used is that the chest is fixed in the position of maximum inspiration, which disrupts intrathoracic pressure, ventilation, and pulmonary blood flow. In this connection, the search for more effective methods of fixation in flail rib fractures is constantly ongoing.

At present, video-assisted thoracoscopy has opened up not only limitless diagnostic possibilities but also a new strategy in thoracic surgery (Pé Yakli I. et al., 1999). The undoubted advantages of video-assisted thoracoscopy in chest trauma are: complete revision; precise diagnosis that eliminates diagnostic doubt and uncertainty during the waiting period; and determination of indications for drainage, operative thoracoscopy, or thoracotomy. The use of mini-invasive video-endoscopic technologies overcomes subjectivity and resolves many problems (Abakumov M. M. et al., 2009; Cherkasov V. A. et al., 2009). Despite the capabilities of endovideosurgery in the diagnosis and treatment of complicated chest trauma, pleural cavity drainage and dynamic monitoring remain the main methods used in broad surgical practice. Indications for operative treatment are established depending on the amount and rate of blood loss, without verification of the nature of the injury. At present, there is no doubt about the need to include video-assisted thoracoscopy in the standards of diagnostic and therapeutic measures in institutions that provide care to patients with chest trauma.

Unfortunately, to date, there is no unified doctrine for the treatment of this pathology. There are no clear guidelines for a number of key issues in providing care. First of all, the extent and method of surgery are not always defined. The above has served as the basis for undertaking this study.

Aim of the research

Based on the development and application of mini-invasive video-assisted thoracoscopic interventions, to improve the results of treatment of patients with complicated chest trauma.

Research objectives

1. To assess the possibilities and determine the indications, as well as the type of video-assisted thoracoscopic intervention, in chest wounds complicated by intrapleural hemorrhage.

2. To establish the indications and contraindications for mini-invasive thoracoscopic technologies in blunt complicated chest trauma. To study the effectiveness of mini-invasive fixation of multiple and flail rib fractures under video-assisted thoracoscopic control and to conduct a comparative assessment with other methods of stabilizing the disrupted chest wall framework.

3. To clarify the main causes of mortality in dominant blunt severe chest trauma. To study tactical errors and, depending on the pathomorphological changes identified in lung tissue at different periods from the moment of injury, to refine the sequence of diagnostic and treatment methods.

Scientific novelty of the research

For the first time, on a large clinical material, a comparative assessment has been made of the effectiveness of diagnosis and treatment of complicated chest trauma with and without the use of video-assisted thoracoscopy. It has been established that the use of video-endoscopic technologies in complicated chest trauma was effective in 113 (88.9%) patients. This made it possible to reduce the frequency of unjustified thoracotomies, the duration of pleural cavity drainage, the frequency of complications of traumatic disease, and the length of inpatient treatment. Mortality decreased by a factor of two and amounted to 3.14%.

For the first time, the pathomorphological pattern of lung tissue damage in severe chest trauma has been studied, with an analysis of the treatment provided. It has been revealed that those who died in the acute period of traumatic disease had significant damage to the air-blood barrier in the form of microcirculatory disturbances with increased vascular permeability, the formation of interstitial and alveolar edema, as well as dysatelectasis and atelectasis. These injuries, in combination with impaired local defense of the tracheobronchial tree, contributed to the development of severe bronchopulmonary complications.

It has been established that in flail rib fractures, intrapleural complications are always present: clotted hemothorax, lung ruptures, and intrapulmonary and subpleural hematomas of the chest wall of varying size. For the first time, a comparative evaluation of various methods of fixation of flail rib fractures has been carried out, and the undoubted advantages of the applied mini-invasive fixation with special pins under video-assisted thoracoscopic control have been established. As early as one day after fixation, an improvement in vital lung capacity parameters and blood oxygen saturation was observed.

For the first time, we have developed a device—an instrument for the removal of clotted hemothorax, pleurectomy, and lung decortication (utility model patent No. 84211 dated July 10, 2009 "Instrument for pleurectomy and lung decortication"). The instrument, introduced through a separate thoracoport, allows fragmenting and separating organized and firmly fixed blood clots under video-assisted thoracoscopic control.

Practical significance of the research

In complicated chest trauma, video-assisted thoracoscopy is the most effective method of topical diagnosis. In 66 (90.4%) patients with penetrating chest wounds and in 47 (87.04%) patients with complicated blunt trauma, good results were obtained using mini-invasive video-assisted thoracoscopic interventions.

Video-assisted thoracoscopy makes it possible to objectively determine the indications and contraindications for thoracotomy. Contraindications to video-assisted thoracoscopy in our observations were: total hemothorax, profuse intrapleural hemorrhage, injury to the heart and great vessels and trachea, damage to the trachea and major bronchi, and the agonal state of the patients.

In flail rib fractures with the presence of anterior and anterolateral "rib flap," restoration of the chest wall framework is indicated. The method of mini-invasive fixation of flail rib fractures under video-assisted thoracoscopic control provides reliable stabilization of flail rib fractures without incisions of the injured soft tissues, and simultaneously eliminates intrapleural complications.

In severe blunt chest trauma, the degree of morphological changes in lung tissue can be established using modern diagnostic techniques and, above all, video-assisted thoracoscopy. The main causes of death from severe chest trauma in the first 3 hours after admission are shock and blood loss. In most cases, death in the first day after admission occurs from pulmonary insufficiency due to disruption of the rib cage and contusion pneumonitis. Within 1 to 3 days, mortality was most often caused by respiratory failure due to the development of respiratory distress syndrome. In those who died later than 3 days, the causes of death were purulent complications and embolism. Consequently, the course of traumatic pulmonary disease is phasic in nature, which requires qualified correction at all stages of the treatment provided.

The results of the study make it possible to recommend video-assisted thoracoscopy for use in medical institutions providing care to patients with chest trauma.

Main propositions put forward for defence

1. Video-assisted thoracoscopy is the most effective method of topical diagnosis in penetrating chest wounds. In 66 (90.4%) patients with penetrating chest wounds, video-assisted interventions became the treatment of choice. Comparative studies have shown that the use of video-assisted thoracoscopy in penetrating chest wounds made it possible to reduce the frequency of thoracotomies by a factor of 2.1, the duration of pleural cavity drainage by a factor of 2, the frequency of complications by a factor of 3.3, the length of inpatient treatment by a factor of 1.5, and mortality by a factor of 2. Nevertheless, it should be emphasized that video-assisted thoracoscopic interventions do not replace traditional surgery in the presence of absolute indications for thoracotomy. Absolute contraindications to thoracoscopy are: reliable signs of injury to the heart and great vessels; hemopericardium and cardiac tamponade; hemomediastinum with compression of the airways and great blood vessels; rupture of the trachea or major bronchi.

2. In complicated blunt chest trauma, video-assisted thoracoscopy is an effective diagnostic and therapeutic method, allowing full-scale mini-invasive intrapleural interventions to be performed in 47 (87.04%) patients. Restoration of the chest framework in flail rib fractures using a mini-invasive technique under video-assisted thoracoscopic control most effectively stabilizes the chest wall and simultaneously eliminates, as a rule, the various intrapleural complications present.

3. The morphological changes in the lungs identified in those who died from dominant blunt chest trauma indicate substantial damage to the air-blood barrier, which, in combination with impaired local defense of the tracheobronchial tree, contributes to the development of severe bronchopulmonary complications. In severe blunt chest trauma, the degree of morphological changes in lung tissue can be established using modern diagnostic techniques and, above all, video-assisted thoracoscopy.

Implementation of the research results

Video-assisted thoracoscopic technologies are used for the diagnosis and treatment of complicated chest trauma in the daily practice of the Thoracic Surgery Department of the Regional State Healthcare Institution "Ivanovo Regional Clinical Hospital," and have also been introduced into the educational process at the V. V. Kulemin Department of Faculty and Hospital Surgery of the State Educational Institution of Higher Professional Education IvGMA of the Russian Federal Agency for Health Care and Social Development.

Approval of the dissertation

The results obtained were reported and discussed at the X Congress of Endoscopic Surgeons of Russia (Moscow, 2007); the 6th Interregional Scientific and Practical Conference "Road Traffic Accidents: Problems of Providing Medical Care to the Injured" (Ivanovo, 2007); the Interregional Scientific and Practical Conference Dedicated to the 60th Anniversary of the Sanitary Aviation Service of the Yaroslavl Region (Yaroslavl, 2008); the Regional Scientific and Practical Conference Organized by the Department of Health and Dedicated to Providing Care to Victims of Road Traffic Accidents (Ivanovo, 2008); the Regional Scientific and Practical Conference "Ways to Improve Medical Care for Victims of Road Traffic Accidents in the Ivanovo Region" (Ivanovo, 2009); the Interdepartmental Meeting of Surgical Departments of the State Educational Institution of Higher Professional Education IvGMA of the Russian Federal Agency for Health Care and Social Development (Ivanovo, 2009); the 20th Extended Plenum of the Problem Commission "Thoracic Surgery" of the Scientific Council on Surgery of the Russian Academy of Medical Sciences (Yaroslavl, 2009); the Interdepartmental Meeting of Surgical Departments of the State Educational Institution of Higher Professional Education YaGMA of the Russian Federal Agency for Health Care and Social Development (Yaroslavl, 2009).

Volume and structure of the dissertation

The dissertation is presented on 149 pages of typewritten text and comprises an introduction, a literature review, a description of the materials and methods of the study, three chapters of original research, a conclusion, findings, and practical recommendations. The bibliography includes 200 sources, of which 126 are domestic and 74 are foreign authors. The dissertation is illustrated with 16 tables and 50 figures and contains 6 clinical examples.