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A 40 year old woman presented to a district general hospital following a stabbing to the back of her chest with a large bread knife. She arrived with the knife still in situ (fig 1). On initial assessment she was found to be haemodynamically stable with no other injuries. Chest x ray revealed a knife and a small right pneumothorax (fig 2). An intercostal chest drain was inserted and 450 ml of blood drained. As she remained haemodynamically stable she was transferred to the regional cardiothoracic centre for further management. The knife was left in situ and she was managed prone. On arrival in the cardiothoracic centre she was taken to theatre and anaesthetised on her side. She then underwent a video assisted thoracoscopy (VAT) to visualise the extent of internal chest injuries and to see the entry point into the chest cavity. Fortunately the knife had entered her chest parallel to the chest wall beneath the scapula and had caused minimal injury to the underlying lung (pulmonary contusion only) without damaging the great vessels. It was then withdrawn under direct vision, with no bleeding from the chest entry site. A further chest drain was inserted and she made an uneventful recovery from her surgery.
VAT can be used for repairs of pulmonary and diaphragmatic lacerations, removal of foreign bodies and haematoma, and haemostasis.3 The limited literature on use of VAT in this setting reflects the low incidence of penetrating trauma in the UK. Retrospective studies confirm its safe use in stable patients and low rate of conversion to open thoracotomy.2,3 Nevertheless, VAT should be performed in a well-equipped cardiothoracic theatre where open thoracotomy sets and experienced theatre staff are available. In this case, the patient was appropriately positioned in the left lateral position and the facilities for open thoracotomy available. VAT could therefore have been immediately converted to open thoracotomy in event of difficulties.
Box 1 Key points for penetrating chest trauma
Adequate assessment and resuscitation
Leave any weapons in situ until definitive surgery is available
Minimally invasive surgery, such as VAT, allows full assessment and management without resorting to major thoracotomy in stable trauma patients with its associated decrease morbidity and shorter hospital stay.1–3
Competing interests: none declared
Patient consent was obtained
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