Yonago Acta medica 2008;51:73–76

Video-Assisted Thoracic Surgery (VATS) for Stabbing
Thoracic Injury
Yuji Taniguchi, Hiroshige Nakamura*, Tomohiro Haruki*, Shinji Fujioka*, Yoshin
Adachi*, Ken Miwa*, Satoshi Kamihira†, Kengo Nishimura† and Motonobu
Nishimura†
Operating Room Division, *Division of Thoracic Surgery, Tottori University Hospital and †Division of Organ Regeneration Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Yonago 683-8504 Japan

The patient was a 30-year-old male who was found after he had stabbed himself in theleft side of the chest and collapsed. He was brought to our hospital to undergo immediatedrainage of the thoracic cavity. The chest X-ray and chest computed tomography findings
showed that the knife was situated from the left cardiac border toward the proximity ofthe diaphragm, thus resulting in hemopneumothorax. The patient’s vital signs were stable, and we believed that it was important to avoid secondary injury when removing theknife from the thoracic cavity. Therefore, we performed video-assisted thoracic surgery(VATS). We resected the considerably crushed lung and sutured the lacerated myocardium by VATS. The postoperative course was good. We believe that VATS for thoracic
injury can be an effective surgical option if a patient’s vital signs are stable.
Key words: stab wound; thoracic injury; video-assisted thoracic surgery

Re cent ly video -assiste d t horacic su rger y(VATS) has become widely used for treatmentin thoracic surgery. VATS is now performed inapproximately 50% of all respiratory surgicalprocedures in Japan (Kazui et al., 2006). In
this report, we show that VATS is performed forapproximately 88% of all cases of pneumothorax,
which is a commonly treated quasi-emergency
operation. On the other hand, due to the low
rate of VATS for thoracic injury, which is treatedwith emergency surgery, the frequency of VATS
for thoracic injury is not described. However, insome hospitals, VATS has been performed forchest trauma (Manlulu et al., 2004; Maitani et al.,2006). We performed emergency VATS to treat astab wound in the chest incurred during a suicide
attempt.

Patient Report
The patient was a 30-year-old male who had
been receiving inpatient care at a local hospitalfor schizophrenia. During a short leave fromthe hospital, he was found lying on the floor
after he had stabbed himself in the left side of
the chest with a knife. He was brought to ouremergency room at Tottori University Hospital.
His blood pressure and pulse were 95/52 mmHg
and 110 bpm, respectively, and he had a clear
sensorium. The knife was inserted from the4th left intercostal midclavicular line and wasdirected slightly laterally and downward (Fig. 1).
According to the chest X-ray and chest computed
tomography findings, the knife appeared to belodged from the left cardiac border toward theproximity of the diaphragm, thus resulting in

Abbreviation: VATS, video–assisted thoracic surgery
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Y. Taniguchi et al.

A1
Fig. 1. The wound before surgery.

A2

Fig. 2A. Chest X-ray at the time of admission. A1: Posteroanterior view. A2: Lateral view.

B1

B2

Fig. 2B. Chest computed tomography at the time of admission. B1: Lung window image. B2: Mediastinal window image.

hemopneumothorax (Fig. 2). At the Division ofEmergency Medicine, the patient was immediately
inserted into a thoracostomy tube from the 5th leftintercostal posterior axillary line. Immediately
after insertion, approximately 500 mL of blood
was drained, but subsequent hemorrhaging wasonly in small amounts, and the hemodynamics
were stable. The patient was diagnosed as having
left hemopneumothorax, which was caused by thestab wound to the chest. He was then referred to
the Division of Thoracic Surgery for emergency
operation approximately 2 h after arriving at
our hospital and taken to the operating room toundergo VATS within 3 h after his arrival.
The operation was performed in the left halflateral decubitus position with care to maintainthe position of the knife. A trocar was inserted
from the 8th intercostal anterior axillary line,
and the thoracostomy tube that had been inserted
from the 5th intercostal posterior axillary line

was removed for insertion of a trocar. Roughadhesion and moderate hematoma were observedin the thoracic cavity, but there was almost nocontinuous bleeding in the thoracic cavity orfrom the thoracic wall. The knife was locatednear the anterior mediastinum in the proximityof the pericardium without penetrating the heartor lungs (Fig. 3), and it was removed withoutFig. 3. The knife has not reached the heart or lungs.

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VATS for stabbing thoracic injury

causing any secondary injury to the heart or lungs
under thorascopic vision. The 4th left intercostal
wound caused by the knife was extended toapproximately 10 cm for a minithoracotomy
and was supplemented with a Multi-Flap Gate
(Akita Sumitomo Bake, Akita, Japan). There

was a severely crushed perforating wound causedby the knife in the lingular segment, which wasresected with an automatic suturing instrument(Fig. 4). In addition, the pericardium was gapedin the length of about 2 cm, and the surface of theheart was lacerated about 1 cm (Fig. 5A). Afterthe epicardium had been sutured under direct
vision without extending the minithoracotomy,
the suture line was reinforced with fleece-coatedfibrin glue (Fig. 5B). The wound was sutured andtemporarily closed. The surgery time was 2 h and
8 min, and the amount of intraoperative bleedingwas 200 mL. The postoperative course was good.
The patient was transferred to the Division ofNeuropsychiatry on day 5 after the surgery andtransferred to the hospital where he had originallybeen 6 weeks after the surgery.

Fig. 4. Excised specimen. The perforating woundcaused by the knife (arrow).

Discussion
It appears as though few hospitals use VATS as
their primary method in emergency surgery forstab wounds of the chest. We believe the reason
for this is that injury to the heart and great vessels
is often life threatening and is believed to bedifficult to treat by VATS. In fact, 70 to 80% of
all patients with injury to the heart die before
arriving at the hospital (Demetriades and van derVeen, 1983). Even among patients who survive
and arrive at the hospital, 80% have unstable
hemodynamics and thus undergo emergency
thoracotomy. However, it is believed that theremaining 20% have stable hemodynamics(Demetriades and van der Veen, 1983; Ordoget al., 1994). Based on this, Pons et al. (2002)
have reported that when videothoracoscopy wasimplemented for a case of a penetrating injury
with stable hemodynamics, it was safe andeffective in determining the degree of damage.
Moreover, Manlulu et al. (2004) implemented
VATS for chest trauma and defined the following
conditions for application: i) bleeding thatpersists even after drainage of the thoracic cavity,ii) stable hemodynamics and iii) no findings

Fig. 5A. The lacerated wound in the myocardium
caused by the knife (arrow).

Fig. 5B. The wound after being sutured and reinforced
with fleece-coated fibrin glue.

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Y. Taniguchi et al.

in the diagnostic images that would indicate
injury to the great vessels. In their report, 45%of all patients with chest trauma met the above
conditions, and therefore VATS was performed,
and no patients had to be converted from VATS
to a conventional thoracotomy dur ing thesurgery or there were no cases of intraoperative
mortality or reoperation. In the present case, theamount of bleeding after drainage of the thoracic
cavity was relatively small, and the patient’s
hemodynamics were stable, thus matching theconditions that have been defined by Manlulu etal. (2004). Moreover, the knife was lodged fromthe left cardiac border toward the proximity ofthe diaphragm, and therefore it was important
to avoid injury to the heart, pulmonary arteryand pulmonary vein when removing the knife
during surgery. Therefore, we selected VATS
rather than conventional thoracotomy as a method
in which the position of the knife would not
be easily displaced during the approach to thethoracic cavity. In addition, the laceration woundin the myocardium and the penetrating woundin the lung, which constituted the injuries in thiscase, corresponded to the category of non-fullthickness-type myocardium lacerated wound in
the Cardiovascular Classification of the Japanese
Association for the Surgery of Trauma (1999)
and a deep-seated lacerated wound such aslung damage in the Thoracic and Lung Damage
Classification by the same association (2000).
Many believe that these types of damage do
not require emergency surgery but may require
thoracotomy in some cases. Accordingly, it
appears as though our decision to use VATS
in this case was appropriate. In addition, theMulti-Flap Gate that we used is a tool that has
been developed for spreading wounds for small
incision surgery that is also used frequently
for VATS lobectomies and enables treatmentof the pulmonary artery and pulmonary vein.
Furthermore, in this case, the damaged area of themyocardium was identified under direct vision,

thereby allowing for safe suture treatment.
VATS for stab wounds in the chest can be avery effective surgical procedure if the patient’s
vital signs are stable and some concern exists forsecondary injury caused by a knife or other object
that is lodged in the thoracic cavity. However,
we believe that there should be no hesitationin converting the treatment to a conventional
thoracotomy if there is more serious injury thaninitially predicted preoperatively.
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Received June 23, 2008; accepted August 5, 2008
Corresponding author: Yuji Taniguchi, MD76