The Surgical Treatment of Hemothorax: Which Videothoracoscopic Approaches?

Hemothorax, whether spontaneous or related to thoracic trauma lesions, is treated using basic principles that are well-accepted by trauma and cardiothoracic surgeons. Only a small percentage of patients require a tube thoracostomy; for the rest, a nonoperative technique is appropriate and safe. Only a small percentage of patients require surgical intervention due to retained hemothorax, persistent bleeding or incoming complications (i.e. pleural empyema or entrapped lung). Early in the 1990s, significant technological advancements led to an increase in diagnostic and therapeutic indications for Multi-port Video-assisted thoracoscopic surgery (VATS) as the gold standard therapy for retained and persistent hemothorax, allowing for earlier diagnosis, total clot removal, and better tube placement, with less morbidity, reduced post-operative pain, and a shorter hospital stay. Even if there is no agreement in the Literature about the timing for draining hemothorax, best results are obtained when the drainage is performed within the first five days after the onset. An important evolution of traditional multi-port approach is represented by uniportal approach, with the same results of open surgical technique and the real advantage of a non-rib-spreading single small incision. Currently, in experienced hands, this technique is used for diagnostic and therapeutic interventions as hemothorax evacuation as like as the more complex procedures such as lobectomies or bronchial sleeve and vascular reconstructions. Many authors have confirmed the advantages of single-port technique compared with multi-port in term of better post-operative pian control, easier surgical approach and better cosmetic results, but longer and harder learning curve.