A novel, minimally invasive approach to assure hemostasis for intercostal bleeding after trauma

Jacob Glaser, MD, Habeeba Park, MD, Nathan Schmoekel, DO, Joseph Dubose, MD, Thomas Scalea, MD, Deborah Stein, MD, MPH. University Of Maryland Shock Trauma Center

Introduction: A major complication of blunt thoracic trauma is arterial bleeding, often due to rib fracture and associated injury to an intercostal artery. Tube thoracostomy reliably adresses most bleeding, but many patients are left with retained hemothorax, adn are pron to re bleeding events. A variety of methods have been identified to deal with these injuries, including thoracotomy. Identification and ligation of a bleeding intercostal artery can be difficult during thoracotomy, particularly when the bleeding is not active. A less morbid approach includes VATS, but often with this approach definitive vascular control of the intercostal arteries is not addressed. This increases the risk of re-bleeding. We present a novel minimally invasive technique for definitive vascular ligation during VATS.

Case presentation: A 46 year old female sustained multiple rib fractures and associated hemothorax after blunt trauma. The patient was treated with tube thoracostomy, and remained stable. Folow up x rays reveal a retained hemothorax, and early VATS was performed. This approach is necessary to address retained hemothorax and offer definitive fixation of the presumed intercostal bleeding.

Technique: During a standard VATS approach, a suture passer is aused to encircle the fractured ribs through 2mm multiplestab incisions. The fracture is proximally and distally encompassed, as well as one level of rib above and below the fracture. These are tied extracorporeally. This is all done under direct vision, with the intracorporeal assistance of previously placed instruments.

Conclusions: Effective celarance of retained hemothorax can be achieved through a VATS approach. Definitive vascular control of intercostal vessels, using percutaneous ligation across the area of rib fractures, can be doen with little added morbidity. This technique allows for definitive vascular fixation, maximizing the benefits of a minimally invasive approach, without the additional morbidity of thoracotomy.

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