The role of VATS for retained hemothorax in trauma: a narrative review

Introduction

Background

Chest trauma is common and a frequent cause of substantial morbidity and mortality. Approximately 50% of polytrauma patients sustain a chest injury, and chest trauma is found in up to a quarter of all trauma-related deaths (1-3). Upwards of one-third of all thoracic trauma patients will be diagnosed with a hemothorax, pneumothorax, or hemopneumothorax (4,5). While tube thoracostomy, often placed emergently in the trauma bay, is the appropriate primary intervention for these injuries, frequently additional interventions are needed throughout patients’ hospitalization. About 11% of both hemothorax and pneumothorax initially managed with observation only will require subsequent intervention, and 22% of hemothoraces initially managed with tube thoracostomy will require an additional intervention (5-7). With such a high rate of additional interventions required, often increasingly invasive, it is beneficial to have an arsenal of modalities available to manage such injuries. Over the last decade, the role of video-assisted thoracoscopic surgery (VATS) for the management of the initial injury as well as possible subsequent complications of blunt and penetrating chest trauma has dramatically expanded.

VATS has been shown to be particularly effective for the complication of retained hemothorax. Although there is no single valid definition of “retained hemothorax”, it is often described as a residual of at least 500 mL or of one-third of the initial total blood in the pleural space, measured 72 hours after initial intervention (8,9). Retained hemothorax is a common complication and can occur despite early use of tube thoracostomy, and it can result in substantial negative consequences for patients. The incidence of retained hemothoraces is reported to be between 17% to 31% (10-13). It is associated with longer chest tube duration, intensive care unit (ICU) length of stay (LOS), and hospital LOS (12-14). A retained hemothorax can also lead to other, even more morbid complications such as empyema, fibrothorax, or trapped lung (4,15,16). Multiple studies have identified risk factors for the development of a retained hemothorax, such as larger initial blood volumes and signs of severe blood loss on presentation, acute respiratory failure requiring mechanical ventilation, penetrating injury mechanism, higher injury burden (chest Abbreviated Injury Scale, AIS), and longer duration of an indwelling chest tube (11,13). How to best manage a retained hemothorax remains subject of ample debate.

Rationale and knowledge gap

Several current guidelines and studies recommend the use of early VATS for retained hemothorax as opposed to the placement of additional chest tubes and/or the instillation of lytics (3,17-20), but there remains a debate regarding patient selection and the optimal timing of surgical intervention, and VATS remains underutilized. The use of VATS for retained hemothorax has been previously reviewed (see Chou et al.); however, current data support benefits with even earlier operation than previously suggested, and other management techniques for retained hemothorax were not fully explored (9).

Objective

The purpose of this narrative review is to provide an overview of the evidence of VATS as a treatment modality for the management of retained hemothorax. This article will summarize the literature describing the effectiveness of VATS as compared to non-surgical interventions as well as to open thoracotomy. Additionally, the optimal timing for VATS and technical considerations will be described. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-25-28/rc).

Methods

Our literature search was conducted using the PubMed and Google Scholar databases. Original clinical studies, systematic and narrative reviews, clinical guidelines, and case series were included. Included studies were limited to those published in the English language, and dates of publication were limited from January 1997 to the present day. Single case reports, published abstracts, and basic science literature were excluded. The literature search was conducted from March through May 2025. Search terms used are included in Table 1. Search modifiers such as “incidence of”, “comparison of”, or “complications of” were used in specific searches to provide general background information for the topic. Referenced publications cited within other identified articles were also reviewed and included when deemed relevant and important to the objective of this review. All articles from searches were screened by title and abstract, and included articles were reviewed in detail for inclusion. Studies pertaining to non-traumatic hemothorax were excluded except for when they suggested potential uses of VATS that would be directly relevant to traumatic hemothorax patients. All authors assisted in literature review and evaluation.

VATS versus other established interventions for retained hemothorax

While the majority of traumatic hemothoraces can be effectively evacuated with a percutaneous chest drain, about one-fifth will become “retained hemothoraces”. Established management options include the placement of a second chest tube, the instillation of lytic agents, chest tube irrigation, VATS, or thoracotomy.

VATS vs. non-surgical management

While the appropriate initial intervention for a traumatic hemothorax is tube thoracostomy, the placement of a second tube for retained hemothorax despite the initial tube is not recommended. In an American Association for the Society of Trauma (AAST) prospective multicenter observational study for management of retained hemothorax, 64% of patients who were initially treated with a second chest tube would require another intervention (21). An early prospective randomized control trial (RCT) conducted by Meyer et al. randomized 39 patients who were diagnosed with post-traumatic retained hemothorax 72 hours after their initial tube thoracostomy to either a second chest tube or VATS. The VATS group was found to have a shorter duration of tube drainage, shorter hospital total LOS and post-procedural LOS, and lower total hospital cost (22).

Current guidelines from the Eastern Association for the Surgery of Trauma (EAST) conditionally recommend the use of VATS over lytic therapy for retained hemothorax (3). The EAST guidelines reference three studies as rationale for their recommendation: a retrospective observational study, a prospective observational study, and a RCT. The prospective observational study by DuBose et al. demonstrated that management with an additional chest tube was less likely to be successful if the retained hemothorax volume was 900 mL or more and if there was an associated diaphragm injury. The intervention was more likely to be successful if a pneumothorax was the initial indication for tube placement (21). Oğuzkaya et al. conducted a retrospective observational study comparing 31 patients treated with intrapleural streptokinase and 34 patients treated with VATS. Nine patients required decortication via open thoracotomy for resolution in the lytic group compared to two in the VATS group. Additionally, patients who underwent VATS had a significantly shorter LOS (17). One RCT directly compared intrapleural lytics to VATS for retained traumatic hemothorax, randomizing 17 patients to intrapleural streptokinase and 18 patients to VATS, with subsequent crossover of non-responders to the alternative treatment modality. They found that 71% of the streptokinase group patients and 72% of the VATS group patients had complete resolution of their hemothorax with their respective primary treatment modalities. Of those patients who were non-responders in their original treatment group and subsequently crossed over, all patients who then underwent VATS resolved their hemothorax, but only two of the five patients who received lytics did. The other three would require thoracotomy for decortication (10).

A meta-analysis found that 83% of patients treated with tissue plasminogen activator (tPA) and 87% of those treated with streptokinase and/or urokinase for retained hemothorax successfully avoided operative intervention, with an average hospital LOS for all patients of 14.9 days (23). No direct comparison was made in this meta-analysis between the three different agents, and no combination therapy was used. Although not specifically for traumatic retained hemothorax, the Second Multicenter Intrapleural Sepsis Trial (MIST2) was conducted to compare lytic agents for clearing empyema, and it was found that a combination infusion of tPA and DNase was superior to either agent alone in resolving infection and avoiding surgical referral. Additionally, when the agents were used individually, they were non-superior to placebo (24). This study suggests that if lytic therapy is to be studied, a combination regimen may be worth considering. In a cost-analysis using a national payer database, Wong et al. calculated the cost of lytic therapy as sole intervention as $33,954 [standard deviation (SD) $20,368]. The cost of VATS as sole therapy averaged $35,419 (SD $18,876). If failure of lytic therapy required subsequent VATS, the costs of the combined therapy add up to $57,266 (SD $20,810) (25).

While the existing data may not show clear superiority of VATS over lytic therapy in the initial management of retained hemothorax, the conditional recommendation in favor of VATS is based on the expectation of a decreased LOS and lower risk for needing a secondary intervention with VATS (3). None of the studies involving lytics specifically evaluated the bleeding risk with lytic therapy, which would be of particular concern in a polytrauma population. Further rigorous studies in a larger patient population will be necessary to obtain a more definitive answer as to which therapy should be preferred for the initial management of a retained hemothorax.

A technique aiming to prevent the development of a retained hemothorax is pleural irrigation via tube thoracostomy upon chest tube placement. After initial evacuation of the hemothorax when blood return has become minimal, 500 mL of warm Normal Saline solution are instilled and evacuated. This process is performed twice (26). An increasing number of studies, including a recent meta-analysis (to date all retrospective or prospective observational studies), show that pleural space irrigation significantly decreases the risk for subsequent interventions such as second chest tube placement, lytic therapy, VATS, or thoracotomy (26,27), in addition to decreasing ICU and hospital LOS (28). Most of the data comes from a younger, penetrating chest trauma cohort and thoracic irrigation should strongly be considered for this patient population, with further data needed for recommendations applicable to all settings of traumatic hemothorax.

A table summarizing the above key studies for VATS versus nonsurgical interventions is provided as Table 2.

VATS vs. thoracotomy

If surgical management is required for retained hemothorax and its complications, VATS is superior to open thoracotomy in appropriately selected patients. The candidacy for a minimally-invasive surgical approach needs to be carefully assessed in patients with polytrauma, labile hemodynamics, or poor respiratory function, and VATS is contraindicated in hemodynamically unstable patients. Single-lung ventilation and lateral decubitus positioning during surgery greatly facilitate a successful VATS, and patients who would not tolerate either are similarly poor candidates for a VATS approach. As in any minimally-invasive operation, surgeons should be prepared and comfortable to convert to open thoracotomy should the need arise (9,19,29).

In a single-center prospective RCT which enrolled 60 patients with a post-traumatic retained hemothorax (defined as at least 500 mL residual or one-third of the initial pleural blood at least 72 hours after initial chest tube placement), those randomized to the VATS group had significantly shorter chest tube duration, operative duration, and hospital LOS in addition to lower post-operative pain ratings and rates of wound infection than those in the open thoracotomy group (8).

Timing of operative intervention: early vs. delayed VATS

Once a patient has been found to have a retained hemothorax, proceeding to the operating room for VATS expeditiously is essential for the best outcome. The EAST guidelines recommend performing early VATS (≤4 days) compared to late VATS (>4 days) for drainage of retained hemothorax, measured from the day of initial chest tube placement (3).

Using Trauma Quality Improvement Program (TQIP) data, Zambetti et al. found that patients undergoing VATS for retained hemothorax within the first 4 days had fewer pulmonary complications (defined as repeat VATS, tracheostomy, pneumonia, unplanned intubation, acute respiratory distress syndrome (ARDS), or pulmonary embolism) and shorter hospital LOS (30). Ouwerkerk et al. also using TQIP data, demonstrated that each day that VATS was delayed after the diagnosis of retained hemothorax increased hospital LOS, ICU LOS, and ventilator days by 1.17 days, 0.66 days, and 0.48 days, respectively. Additionally, they found an increase in the adjusted odds of infectious complications by 1.10 for each day of delay (31). A retrospective observational study of 136 patients by Lin and colleagues compared patients who underwent VATS within 2 to 3 days of initial injury (Group 1), 4 to 6 days (Group 2), and more than 6 days (Group 3). Diagnosis of retained hemothorax was made by repeat chest computed tomography (CT) scan after routine chest x-ray performed at least 48 hours after injury, and criteria for undergoing VATS were defined as a retained pleural volume >300 mL or separate lobulated pleural collections. Group 3 had the highest rates of infection and longest ICU and hospital LOS. Group 1 had significantly shorter duration of chest tube usage. For all patients, shorter time to VATS was associated with shorter LOS (32). A meta-analysis using the same group divisions with a total inclusion of 476 patients found that Group 1 patients were less likely to need a secondary intervention than Group 3 and that Group 1 patients had a shorter LOS than Group 2 (33). While early VATS clearly demonstrated substantial benefits in all of these studies, none of them found a mortality difference attributable to the timing of VATS. A summary table of the above studies can be found in Table 3.

Even in high-risk patient populations, if selected carefully, early VATS has demonstrated benefits. Huang et al. found that poly-trauma patients with major blunt head and thoracic trauma benefited from decreased ICU and hospital LOS, fewer ventilator days, and lower infection rates if they underwent VATS within 4 days from injury (34). This study suggests that patients with traumatic brain injury may be appropriate candidates for early VATS if selected appropriately. A TQIP-based study for pediatric trauma patients with hemothorax demonstrated that VATS was feasible and successful in 82% of children with penetrating and 79% of patients with blunt injury for definitive treatment without the need for conversion to thoracotomy (35). A scoring system using demographics, mechanism, and organ injury has also since been developed to help predict whether pediatric patients will require early VATS (36).

Despite the existing data that strongly suggest that VATS should be performed early, most frequently defined as within four days of initial injury, early VATS remains underutilized. A TQIP study by Alwatari et al. covering the 12-month period after the publication of the EAST guidelines found that 61% of VATS procedures for pulmonary decortication were performed late, i.e., after hospital day 5. The well-established benefits of shorter ICU and hospital LOS, lower complication rates such as unplanned intubation or ICU admission were also confirmed (37). Therefore, more progress needs to be made towards establishing early VATS as the preferred modality for operative chest trauma.

VATS for the management of the complications of retained hemothorax

Untreated or undertreated retained hemothorax can lead to a variety of complications, most importantly empyema and fibrothorax. VATS is the most commonly used approach for rescue therapy if these complications arise. Known risk factors for empyema following a traumatic chest injury include retained hemothorax, pneumonia, penetrating injury, tube thoracostomy, and diaphragm injuries in the setting of contaminated abdominal trauma (38-41). A particularly high risk is represented by the combination of traumatic hemothorax and tube thoracostomy, if it results in inadequate drainage. A prospective multicenter observational trial found that among 328 consecutive patients who had a thoracostomy tube placed within 24 hours of initial presentation and subsequently developed a retained hemothorax, the incidence of empyema was 26.8% (16). An observational study of 28 consecutive patients requiring decortication for empyema after blunt chest trauma found that 82% had a component of hemothorax (42). Much of the data on VATS for empyema that applies to the trauma population comes from the thoracic surgery literature. For patients with empyema who had not yet undergone invasive intervention, treatment success with chest tube vs. VATS as an initial intervention was 40% vs. 81% (43). The American Association for Thoracic Surgery consensus guidelines for the management of empyema recommend that VATS should be the first line approach for all patients with fibropurulent empyema, preferable to both intrapleural lytics and open decortication (44). Post-traumatic empyema may even have a higher rate of requiring decortication than non-traumatic parapneumonic empyema and effusion. In a single institution study at an academic trauma center, in 125 consecutive patients with post-traumatic empyema, all of them required surgical decortication. The institution’s protocol included placement of at least one chest tube and a follow up chest CT scan to assess adequacy of pleural drainage prior to the operating room, which was not adequate in any patient (45). Therefore, the evidence strongly supports VATS for the management of empyema as a progression of a retained hemothorax.

If left untreated, a retained hemothorax can organize into a fibrothorax, which occurs when a fibrous peel or rind develops over the visceral and/or parietal pleura, causing dense adhesions. This has the effect of encasing fluid collections and entrapping the lung by preventing excursion due to the tethering of the thick rind. The incidence of fibrothorax after retained hemothorax has been estimated at approximately 1% (4). While relatively rare, this complication is highly morbid. The standard of care for a fibrothorax is surgical decortication, with the minimally-invasive VATS approach being the preferred in these patients. In a retrospective, propensity score matched study of 217 patients with late organizing stage empyema (i.e., fibrothorax), patients undergoing VATS had a shorter hospital LOS as compared to open thoracotomy, though no reduction of mortality or chest tube duration was shown (46). Unfortunately, the conversion rate of VATS to open thoracotomy for the management of fibrothorax is high with rates between 0–44% (47). Although not as established as the standard of care for late stage organized fibrothorax, VATS is a well-described approach as a technique for management of this complication of retained hemothorax.

VATS: considerations for the surgical technique

While any operative intervention should be tailored to the individual patient, the following section outlines a standard operative approach to VATS for a retained hemothorax and decortication. Particularly in the setting of the multi-trauma patient, there may be multiple additional factors to consider: port placement may need to be adjusted based on concomitant injuries such as chest wall soft tissue lacerations or rib fractures; patients with severe lung contusions (or underlying chronic lung disease) may not tolerate single lung ventilation; cervical, thoracic, or lumbar spine injuries may require maintenance of a cervical collar, log-roll precautions (e.g. prohibiting “breaking” the bed), and complicate the intubation process.

The patient should be intubated in a supine position with a double lumen endotracheal tube (or subsequent usage of a bronchial blocker) to allow for single-lung ventilation. Bronchoscopy should be used to confirm proper positioning of the endotracheal tube. The patient should then be moved into lateral decubitus position with pressure points appropriately padded, including a roll in the dependent axilla and pads between the legs. A bean bag is ideal to stabilize the patient in decubitus position. The patient’s iliac crest should be positioned over the break in the bed, and the table should be flexed in order to open the chest and widen the intercostal spaces. The whole exposed chest should be prepped in case urgent conversion to thoracotomy is required.

Entry to the pleural cavity for port sites can be gained by multiple techniques. An incision can be carried down with electrocautery through the fascia and muscle layers, or a hemostat can be used to dissect the layers bluntly. The incisions should be parallel to the ribs and positioned just on top of the rib to avoid injury to the neurovascular bundle, which courses along the inferior aspect of each rib. The standard location for the camera port is in the 7^th intercostal space (ICS) in the mid-axillary line. Working ports can then be placed typically in the 4^th or 5^th ICS in the anterior axillary line and the 7^th ICS between the posterior axillary line and the lateral edge of the scapula. The intention is to be able to triangulate the ports in order to gain adequate exposure and reach within the pleural cavity. Diagrams of standard port placement are shown in Figures 1,2. Port incision size can be adjusted as needed to accommodate more than one instrument (see Figure 2). A wound protector can be placed in the utility incision as this will be the main working port through which multiple instruments can be placed. A 30-degree thoracoscope is placed through a short metal or plastic trocar, but the working instruments typically do not require trocars. VATS instruments are long and thin in order to reach throughout the chest. Typical instruments include, but are not limited to, long DeBakey forceps, straight and angled ring forceps, triangular lung grasping forceps, Yankauer suction, long-tipped Bovie electrocautery, and Kittner sponges. Pictures of example instruments are shown in Figure 3 (48). Preoperative scans should be carefully evaluated to obtain a sense of the pleural space as it can often be distorted. This is particularly important for deciding on the first incision. It may often not be easy to determine whether the 7^th ICS will be located as expected in the pleural cavity or if such low placement results in the risk for inadvertent intra-abdominal placement. In such case, the first port instead can be placed in the posterior location, where there is usually more space, or the first port can be in the 4^th ICS, where the utility incision will be. After cleaning out the hemothorax and lysing the adhesions, other ports can then be placed safely under direct visualization.

Figure 1 Standard port placement for VATS decortication. Adapted from Agarwal and Kukreja, “Basic Principles and Advanced VATS Procedures”, 2023 under the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/) (48). VATS, video-assisted thoracoscopic surgery.

Figure 2 VATS port sites demonstrating the use of multiple instruments. Adapted from Agarwal and Kukreja, “Basic Principles and Advanced VATS Procedures”, 2023 under the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/) (48). VATS, video-assisted thoracoscopic surgery.

Figure 3 Examples of thoracoscopic surgical instruments. Adapted from Agarwal and Kukreja, “Basic Principles and Advanced VATS Procedures”, 2023 under the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/) (48). VATS, video-assisted thoracoscopic surgery.

To evacuate the retained hemothorax, a combination of grasping forceps and suction can be used to evacuate as much blood and clot as easily accessible. Fingers, forceps, and Kittners can be used to break up fibrous loculations and attachments to open up the pleural space for further drainage and to free a potentially trapped lung. As much fibrous material and clot should be removed as possible. A careful survey of the entire pleural space should be conducted to identify any areas of ongoing bleeding. The lung parenchyma should also be thoroughly examined for evidence of injury that could be repaired or resected.

A retrospective study of patients who underwent resection of lung lacerations at the same time of VATS for evacuation of retained hemothorax found lower infection rates, shorter durations of chest tubes and ventilator usage, and decreased hospital and ICU LOS for patients who underwent synchronous lung laceration resection (49). Ring forceps and Kittners can be used to carefully remove any rind developing over the lung parenchyma and prevent a trapped lung. Intermittent ventilation of the lung can be used to assess the lung’s ability to re-expand against any tethering fibrous attachments. After hemostasis is ensured, thorough irrigation of the pleural cavity with warmed saline should be performed. At the end of the case, large bore chest tubes should be placed anteriorly and posteriorly, angling towards the apex, under direct visualization. Lastly, the muscle and skin should be closed in sequential layers (48).

Strengths and limitations of current evidence

Chest wall trauma has been well-studied and is the topic of many guidelines. A large proportion of the existing literature consists of retrospective studies, but there are several high-quality clinical trials, including RCTs, and systematic reviews and meta-analyses. Many major trauma and thoracic surgery societies have compiled clinical practice guidelines to provide evidence-based recommendations for the clinical management of traumatic hemothoraces and retained hemothoraces.

The evidence demonstrates tangible benefits for patients with the use of early VATS for retained hemothorax. This narrative review includes recent major studies investigating retained hemothoraces and various management strategies as well as guidelines and best practice recommendations. It primarily focuses on more recent studies and guidelines as comfort and expertise with the technique have dramatically changed over the past two decades since the introduction of VATS as an operative technique for trauma patients in the 1990s.

While quality and quantity of literature on the topic are quite strong, most studies about chest wall trauma emphasize anatomy over physiology, i.e., number of rib fractures or presence of hemo- and pneumothorax, but few studies account for patients’ functional status. Additionally, traumatic hemothorax are often binary choices in studies, i.e., present/not present, not accounting for volume and extent. Furthermore, even though chest trauma is highly prevalent, the vast majority of patients are able to be adequately managed with observation or just tube thoracostomy. Only a relative paucity of patients will require operative intervention for retained hemothorax. Therefore, sample sizes for prospective studies can be quite limited. More robust studies are still needed to provide evidence for optimal management strategies, especially for the use of lytics vs. VATS.

Conclusions

In conclusion, VATS is an effective management technique for retained hemothorax and its complications in trauma patients with tangible benefits as compared to lytics and open thoracotomy, though further investigations are needed to better delineate the role of lytic therapy, particularly in patients in whom VATS may be physiologically or anatomically less desirable. VATS should be employed as early as clinically possible during a patient’s hospital course once the diagnosis of a retained hemothorax is established, and efforts to educate clinicians about the existing evidence in support of early VATS should be continued and increased given the suboptimal adoption rates shown in several studies.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Savvas Lampridis and Andrea Bille) for the series “The Role of VATS in Thoracic Trauma Management” published in Video-Assisted Thoracic Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-25-28/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-28/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-25-28/coif). The series “The Role of VATS in Thoracic Trauma Management” was commissioned by the editorial office without any sponsorship or funding. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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