We prospectively analyzed our experience with operative videothoracoscopy (OVT) performed in a field military hospital in cases of penetrating firearms
wounds of the thorax (PFAWT) sustained in Chechnya. From February to April 1996, we treated 206 wounded patients, of whom 37 (18.0%) had sustained
chest injuries. PFAWT were present in 23 soldiers, accounting for 62.2% of all
chest injuries. Twelve
injuries were confined to the thorax, eight patients had associated
injuries, and three soldiers had thoracoabdominal
injuries. Nineteen patients had pleural drainage performed during medical evacuation. The
thoracic injuries were right-sided (17), involved bullets or shell splinters (23); were through and through (16), represented solitary
wounds (19), and were associated with internal organ
injuries (21). Fifteen patients had indications for OVT when they were delivered from the battle-field 1.5 to 22 hours after injury. All patients manifested signs of
hemorrhagic shock and hemodynamic instability. Indications for OVT were ongoing intrapleural
bleeding (6), clotted
hemothorax (6), or marked air leakage (3) preventing lung inflation with the OP-02 apparatus (field modification). OVT revealed 12 lung
wounds, nine of which were
multiple wounds, pleural
bleeding in 6 patients, clotted
hemothorax in 11 patients, and
foreign bodies in 5 patients. Two patients underwent
thoracotomy, one for suspicion of
heart injury and the second because we could not adequately visualize and control
bleeding revealed at OVT to be from the intercostal artery in the left costovertebral angle. Eight of 23 patients had no indication for operative videothoracoscopy and were managed with continued pleural aspiration and
drug therapy. Wedge resection of the lung using an Endo-GIA-30 stapler was necessary in two patients because of parenchymal destruction and
bleeding. Evacuation of clotted blood by fragmentation and aspiration was satisfactory in all cases. Satisfactory manual suturing of selected
lung injuries was obtained largely with intracorporeal knot tying. The duration of the procedures ranged from 40 to 90 minutes. No morbidity nor mortality was encountered in patients undergoing OVT.
Postoperative pain was minimized by using OVT placement of
catheters in the chest wall soft tissue with local administration of 2% Trimecain. Patients were able to stand in 10 to 12 hours and to walk by the end of the first postoperative day. All patients who underwent OVT were evacuated without drains by the third or fourth postoperative day, all tolerating sitting and standing positions. We conclude that early OVT in the military field hospital for continued
bleeding, clotted
hemothorax, and continued major air leakage has several advantages in military patients with PFAWT: early definition and management of organ injury; identification and control of
bleeding in most instances; earlier and more accurate assessment for
thoracotomy; vigorous lavage and removal of projectiles such as bone fragments and evacuation of clotted
hemothorax; early
debridement with
suture closure of the thoracic wall canal; and minimal
postoperative pain with dramatically reduced suppurative sequelae and bronchopleural fistulae.