Early video-assisted thoracoscopic surgery (VATS) in blunt chest trauma: a narrative review of indications, outcomes, and evolving practice patterns

Introduction

Background

Thoracic trauma occurs in 30–40% of all trauma patients and accounts for approximately 25% of trauma related deaths worldwide (1). These injuries are classified into blunt and penetrating mechanisms. Blunt chest trauma is most commonly caused by motor vehicle collisions (MVCs), pedestrian accidents, falls, and assault. On the other hand, penetrating injury is most commonly secondary to gunshots and stabbing. While penetrating injuries more commonly may require operative intervention, there are more trauma deaths related to blunt chest injuries due to the sheer number of patients presenting with blunt injury to the chest (2). Rib fractures and hemothorax are common complications of blunt chest trauma (2). Accurate diagnosis and timely intervention of these blunt injuries to the chest is vital to reduce significant morbidity and mortality related to these injuries. For example, delayed treatment of hemothorax can lead to increased rates of infection, prolonged hospitalization, and increased healthcare utilization (3). Operative management of thoracic trauma may be required emergently or in a delayed fashion, depending on the patient’s hemodynamic stability and clinical course. For instance, a patient presenting in extremis may require an emergent thoracotomy, performed either in the trauma bay or the operating room. Conversely, patients with retained hemothorax may not necessitate surgical intervention until several days into their hospitalization. Thoracic injuries managed operatively include, but are not limited to, tracheobronchial disruptions, hemothorax, pneumothorax, empyema, and complex rib fractures (2).

Rationale and knowledge gap

Prior to the advent of video-assisted thoracoscopic surgery (VATS), open thoracotomy was used as the standard approach for operative management of thoracic trauma. While equally effective, it carries with it prolonged recovery and increased pain. Since the 1990s when VATS was first introduced, there has been an increase in the use of minimally invasive techniques to address thoracic traumatic injuries (4). Despite widespread adoption of VATS for thoracic trauma, there is less consensus among institutions regarding its indications, timing and outcomes. Previous review articles, such as Chou et al., discuss similar topics like the use of VATS in the treatment of retained hemothorax (5). Our review adds to the literature by reviewing articles from 2015 to 2025 and adding a critical discussion of differences in outcomes and healthcare utilization between early and late interventions.

Objective

This narrative review serves to summarize some of the current literature to provide a broad discussion about the use of VATS for the treatment of blunt traumatic chest injuries. By synthesizing the current literature, we aim to clarify the role of VATS in this clinical context and highlight future areas of investigation. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-25-35/rc).

Methods

Searches in Ovid and PubMed of MEDLINE-indexed journals were conducted multiple times during the preparation of this article, on March 20, 2025, April 12, 2025, and July 5, 2025. Searches were conducted using combinations of both MeSH and free-text terms. The MeSH terms included were: “Thoracic Surgery”, “Video-Assisted”, “Hemothorax”, “Thoracic Injuries”. The free-text terms included were: “VATS”, “video-assisted thoracoscopic surgery”, “traumatic hemothorax”, “hemothorax”, and “guidelines”. Filters to included human subjects and English language journals were applied and the date range applied was from January 1, 1966 to July 5, 2025. Inclusion criteria were original studies, clinical guidelines, articles, and reviews addressing thoracic trauma injuries and the range of interventions used in the treatment of these patients, with a focus on early VATS for traumatic hemothorax (TH). Case reports, animal studies, and non-English language publications were excluded. All sources identified were manually reviewed by both authors to ensure inclusion criteria and relevance to the review. Additionally, further manual review of sources cited within these studies was carried out to identify additional eligible literature to include in the review. Priority was given to studies comparing early versus delayed VATS, or VATS versus other drainage/intervention strategies in the setting of trauma. Guideline documents from major surgical or trauma societies were also reviewed (Table 1).

Pathophysiology and mechanism of injury

The pathophysiology of traumatic chest injuries is best understood by considering the anatomy and normal physiology of the chest. Structurally, the chest wall is comprised of twelve ribs on either side, costal cartilage, the sternum and clavicles anteriorly, and the scapula posteriorly. Intercostal muscles are found between each rib. The innervation and blood supply of the chest wall arises from intercostal neurovascular bundles, which run on the inferior aspect of each rib. Deeper within the chest, the vital organs are found in the pleural space, which is lined with both visceral and parietal pleura. This lining secretes pleural fluid, which acts as a lubricant for the lungs to facilitate smooth respiration. The ability of the lungs to oxygenate blood for the rest of the body is facilitated by the creation of negative pressure within the chest cavity. The diaphragm works in coordination with the intercostal muscles to expand the chest cavity, thus creating negative pressure and allowing for air to enter the lungs (2). Blunt and penetrating trauma to the chest carries the risk of causing imminent danger to life as well as long term impairment in respiratory physiology.

Thoracic traumatic injuries, listed in order of decreasing frequency, include rib fractures, pneumothorax, hemothorax, pulmonary contusion, vascular injury, diaphragmatic injury, and cardiac injury. Rib fractures are the most common manifestation of blunt thoracic trauma (2). Although they are not typically immediately life-threatening, they are associated with substantial delayed morbidity and mortality, particularly in elderly patients. Isolated rib fractures cause significant pain, and when multiple fractures are present, especially bilaterally, patients may experience impaired ventilation. This impairment increases the risk of respiratory failure, necessitating intubation and mechanical ventilation, and predisposes patients to complications such as pneumonia (6). Both hemothorax and pneumothorax may result from blunt or penetrating mechanisms of injury.

Hemothorax is the accumulation of blood within the chest cavity, which can arise from various sources: intercostal vessels, pulmonary parenchyma or vasculature, major vessels in the chest, and even the heart (2). Treatment of hemothorax depends on multiple factors: the stability of the patient, the amount of blood, and reassessing the clinical picture with all evidence. In the absence of traumatic arrest, the initial surgical management of hemothorax is likely to be with tube thoracostomy. Further treatment depends on the clinical picture of the patient. Most patients may resolve their hemothorax with tube thoracostomy alone whereas some patients will have residual hemothorax either requiring placement of a second tube, administration of fibrinolytics, or surgical management with either thoracotomy or VATS (1,7,8). Failure to adequately evacuate a hemothorax increases the risk of serious complications, including empyema and fibrothorax, also colloquially known as trapped lung. Retained hemothorax provides a favorable environment for bacterial proliferation, predisposing the patient to empyema (9). Although no uniformly accepted definition exists, retained hemothorax is characterized by more than 300–500 mL of intrathoracic blood that persists more than 72 hours after initial tube thoracostomy (5). As the infectious process progresses, a fibrinous exudate may develop and organize into a fibrous rind encasing the lung parenchyma. This condition, termed fibrothorax, results in decreased pulmonary compliance and impaired lung expansion, ultimately contributing to reduced functional respiratory capacity. The push for early surgical management of hemothorax and other thoracic injuries arose from the goal of decreasing the longer-term consequences such as empyema and fibrothorax (10).

Role of VATS in blunt chest trauma

Before the 1990s and before VATS was readily available and accessible, open thoracotomy was the only true surgical option for patients with traumatic injuries requiring thoracic surgery (4,11). After being introduced, VATS was initially used in a diagnostic capacity to detect diaphragmatic injuries or in cases of high chest tube output and the need to identify a source (12,13). However, open thoracotomy was still the mainstay for definitive surgical management. Earlier articles attribute variability in surgical approach between open thoracotomy and VATS to limited experience and lack of surgeon comfort with the technique (11). Over time, the indications for VATS have broadened, and it is now considered a first-line surgical approach for both trauma and thoracic surgeons seeking to minimize the morbidity associated with open thoracotomy. The timing of surgical intervention has also evolved. While emergent procedures, typically performed in the trauma bay or operating room on hospital day one, have long been established, the optimal timing for subsequent interventions has been more variable. Current trends favor earlier operative management, with increasing preference for VATS over thoracotomy when feasible. Early VATS can safely be performed for both diagnostic and therapeutic indications. Such indications include retained hemothorax, ongoing hemothorax/bleeding despite tube thoracostomy, chylothorax, diaphragm injury, tracheobronchial tree injury/persistent air leak, or other missed injuries (14).

Timing of VATS

After thoracoscopy was introduced and more widely used, early studies in the 1990s and 2000s described a trimodal distribution of the timing of VATS for trauma patients—immediate [day 1–2], intermediate [day 2–7], and delayed [day 7+] (11,14). More recently, during the 2010s and 2020s, emerging evidence has increasingly supported early surgical intervention, typically defined as occurring within the first 72 hours of hospital admission. Ziapour et al. [2020] defined early interventions as happening between hospital day 1–3 (15), while Zambetti et al. [2022] employed the Trauma Quality Improvement Project (TQIP) database to identify benefit for interventions occurring prior to day 3.9 of the index hospital admission (9). However, Akkas et al. [2025] used a more traditional definition, with “early VATS” being defined as intervention occurring on day 3–7, reserving day 1–2 as immediate or emergent intervention and interventions after day 7 as late (14). Overall, there has been a shift towards earlier interventions with VATS for trauma patients. The timing of VATS is influenced by multiple factors and is not always feasible early in the clinical course. Patient stability and safety for general anesthesia are critical considerations. VATS typically requires the patient to tolerate single-lung ventilation, which imposes greater physiologic demands compared to open thoracotomy (16). Consequently, in patients who are hemodynamically unstable or who have more urgent concomitant injuries, thoracoscopic intervention may need to be postponed until clinical conditions permit.

Outcomes of early VATS

The data regarding the use of VATS interventions in trauma patients is widely positive and supports its implementation. Firstly, the use of VATS has been shown to be both safe and effective in trauma patients with blunt and penetrating chest injuries. There is no significant difference in mortality between patients who received thoracotomy versus thoracoscopic procedures (9,14,15,17). Additionally, VATS was demonstrated to be effective, with many patients avoiding thoracotomy and secondary procedures (11,18). However, this does not eliminate the need for thoracotomy. Multiple studies discussed its relevance when mentioning patients who were unsuitable to undergo VATS, or those patients with concomitant injuries necessitating thoracotomy. In patients for whom VATS was unsuccessful, thoracotomy remains a viable alternative surgical approach. When comparing early to late VATS, Alwatari et al. [2022] demonstrated a significantly lower rate of conversion to thoracotomy in the early group (1.9% vs. 6.5%, P=0.03) (19).

Early VATS has been shown to confer significant benefits in reducing both intensive care unit (ICU) length of stay and overall hospital length of stay. Several studies have demonstrated that undergoing “early” VATS is associated with shorter durations of ICU admission and hospitalization (3,9,14,17,19). For example, in Zambetti et al., there was significantly shorter hospital length of stay (11 vs. 19 days, P<0.0001), ICU length of stay (3 vs. 6 days, P<0.0001), and ventilator days (0 vs. 1, P<0.0001), when comparing early to late VATS, where “early” meant VATS on hospital days 1–7 and “late” meant VATS on hospital day 8 or later (9). Although the precise definition of “early” varies across the literature, the majority of studies define early intervention as occurring within the first seven days of hospitalization. In addition to reduced length of stay, earlier VATS has also been associated with shorter operative times (P=0.001) and decreased requirements for blood transfusions (P=0.001) (14). The improved outcomes observed with earlier intervention can be explained by the pathophysiology of retained hemothorax. As previously described, retained clotted blood within the pleural space provides a nidus for bacterial colonization and infection. During the infectious process, leukocyte infiltration promotes deposition of fibrinous material, leading to the formation of a fibrous rind along the pleura. This process results in fibrothorax, characterized by dense pleural adhesions that complicate surgical dissection (20,21). These pathophysiologic changes likely contribute to the increased operative difficulty and poorer outcomes associated with delayed intervention, thereby supporting the rationale for early thoracoscopic management.

In addition to comparing early versus late VATS, previous studies have also evaluated outcomes between VATS and open thoracotomy (22). These outcomes included duration of ventilatory support, postoperative infection rates, the necessity for additional surgical interventions, and postoperative pain. There is mixed evidence regarding ventilator requirements when comparing early VATS to other interventions. Kumar et al. [2024] identified no difference in ventilator days when comparing early VATS for retained hemothorax to their conventional control group, which consisted of their standard treatment of intrapleural fibrinolytic therapy for 3 consecutive days (17). However, Ouwerkerk et al. [2024] demonstrated that for each day that VATS was delayed, there were statistically significant increases in ventilator requirement (P<0.001), ICU stay (P<0.001), and postoperative hospital stay (P=0.007) (3). VATS has been demonstrated to be superior to open thoracotomy with respect to reducing postoperative infection rates and improving pain control (23,24). This advantage extends to trauma patients, where those undergoing VATS for thoracic injuries experience lower rates of infection (19) and improved postoperative pain management and outcomes (25) compared to patients treated with open thoracotomy.

When comparing early to late interventions with VATS, there is a paucity of data about postoperative pain control, infection rates, and functional status. However, given that earlier VATS is linked to shorter ICU and hospital length of stay, it would be reasonable to correlate this with improved outcomes for pain control and return to functional status. This would be an area to target for future research. Uma et al. [2024] examined the optimal timing of VATS from a healthcare cost perspective. Their study analyzed cases of traumatic retained hemothorax managed with VATS and compared total hospitalization costs relative to the timing of the procedure. They found that total costs were significantly higher when VATS was performed before hospital day 4 (26), suggesting an optimal intervention window between hospital days 4 and 7 that balances cost considerations with patient outcomes. Conversely, Wong et al. [2022] proposed that while VATS is effective in managing retained hemothorax, the combination of tube thoracostomy and fibrinolytic therapy may be more cost-effective and could potentially obviate the need for surgical intervention altogether (27).

Patient selection and contraindications

In the non-trauma setting, careful patient selection is critical to determine candidacy for minimally invasive approaches such as VATS and robotic thoracic surgery. This principle similarly applies to patients of traumatic injury, although their management is complicated by the nature and severity of their injuries. Fundamental criteria for VATS candidacy include hemodynamic stability and the ability to tolerate single-lung ventilation (16). Additionally, patients should be able to be positioned in the lateral decubitus position, for optimal positioning and ergonomics during surgery (11,16,28). Candidates for VATS should demonstrate adequate cardiopulmonary fitness and lack contraindications to required positioning. Patients with unstable spinal fractures or severe contralateral pulmonary contusions are generally poor candidates due to their inability to tolerate necessary operative positioning or single-lung ventilation, respectively. In polytrauma patients, the timing of thoracic surgical intervention must be carefully coordinated with other urgent surgical procedures. Management should prioritize interventions based on clinical urgency, with the timing of VATS planned accordingly in collaboration with the multidisciplinary surgical team.

While VATS can be performed safely before or after laparotomy and laparoscopy (11), another contraindication to VATS would be any injury that would require a sternotomy or thoracotomy (16). Patients with cardiac injuries or massive bleeding would not be appropriate candidates to undergo VATS. Diaphragm injuries, which can be seen in both blunt and penetrating trauma, can be repaired both from open techniques and minimally invasive techniques, with a shift towards minimally invasive (14).

Technical considerations

Thoracoscopy utilizes similar principles as used in laparoscopic surgery when it comes to camera handling and port placement. As discussed above, most patients undergoing VATS will be placed in the lateral decubitus position with the side of interest facing upwards. A double lumen endotracheal tube is used to isolate the lungs and only ventilate the contralateral lung, thus allowing for compression of the lung on the side of interest to increase the working area for VATS. The camera port should be placed first, usually in the seventh or eighth intercostal space just anterior to the mid axillary line. The second and third working ports should be positioned at an adequate distance from the camera port to reduce collisions with the camera. Usually these are placed in the fourth and fifth intercostal space along the anterior axillary line and another in either the fifth or sixth intercostal space anterior to the scapula (28,29).

In VATS for thoracic trauma, the most common procedures performed are evacuation of hemothorax and decortication with or without pleurodesis. In addition to an angled telescope, the most common instruments used are blunt tipped graspers, ring forceps, and suction appliances (28). The combination of these instruments allows for blunt dissection of the rind and evacuation of the clotted hemothorax. Important considerations for decortication are safe entry into the chest, identification of landmarks to correctly identify the plane of dissection, and gentle dissection of cortex off of the pleura and lung while maintaining hemostasis. Other instruments used to aid in hemostasis include surgical sponges attached to instruments, clip appliers, electrocautery, and hemostatic agents. Irrigation should also be available at the end of the procedure to aid in hemostasis and washing out the surgical wound. And lastly, the chest should be widely drained with at least two thoracostomy tubes applied to suction following decortication (28).

Controversies and challenges

Although there is evidence to suggest the ideal timing of VATS for cases of thoracic trauma, there are some caveats and considerations to discuss. Firstly, thoracic trauma severe enough to require an operation does not usually occur on its own. In complex polytrauma patients, the same recommendations for early VATS may not apply, as was discussed earlier. It is also important to take the total injury severity of trauma patients into account when interpreting the data gathered. Often, the injury severity score (ISS) of those patients undergoing early VATS interventions was lower than their counterparts receiving later interventions (19). This is logical, as patients with higher ISS are less likely to be clinically stable for early operative interventions, when compared to their counterparts with lower ISS due to competing injuries.

Disparities in both the availability of VATS and surgeon proficiency with the technique represent significant factors influencing its utilization in trauma care. The majority of published data originates from large institutions with certified trauma center designation, where specialized expertise and infrastructure facilitate the widespread implementation of VATS when clinically appropriate. However, access to VATS and surgeon comfort with this modality vary considerably across different geographic regions and healthcare settings, contributing to its continued underutilization in the management of traumatic thoracic injuries (1,19).

The integration of fibrinolytic therapy alongside early VATS represents an important consideration in the management of retained hemothorax following tube thoracostomy failure, which occurs in approximately 15% of cases (29). Uma et al. describe a complementary role for both interventions, with their application guided by the timing of treatment (26). Typically, following initial tube thoracostomy on hospital day 1, intrapleural fibrinolytic therapy is more cost-effective when administered up to day 4. Beyond this point, VATS becomes the preferred and more cost-efficient intervention. This position contrasts with that of Patel et al., who advocate for VATS over fibrinolytic therapy based on a lower rate of additional procedures among patients undergoing VATS (17.3%) compared to those receiving fibrinolysis (27%). Furthermore, patients treated with VATS experienced a reduction in hospital length of stay by an average of 3.8 days relative to those managed with fibrinolytic therapy (1). It is also essential to consider the contraindications of intrapleural fibrinolysis, which include, but are not limited to, active bleeding and traumatic brain injury (TBI).

Future directions and research gaps

As the adoption of early VATS for thoracic trauma injuries increases, future research efforts should focus on optimizing recovery through the development of standardized enhanced recovery protocols. While substantial evidence supports faster recovery following VATS compared to thoracotomy, there remains a paucity of data directly comparing early versus late VATS in trauma patients. Addressing this gap represents a significant opportunity for investigation.

Another critical area for future research involves establishing a consensus definition for retained hemothorax. Numerous studies have highlighted the limitation posed by the absence of standardized criteria, including a universally accepted volume threshold and diagnostic parameters, which complicates patient selection and outcome comparisons.

With the growing integration of machine learning and artificial intelligence in clinical practice, there is potential to leverage these technologies to identify trauma patients at increased risk for developing retained hemothorax. Specifically, predictive models based on imaging data such as computed tomography scans may enhance early risk stratification and guide management decisions.

Strengths and limitations of the review

This review provides an overview of the use of VATS in blunt thoracic trauma. The review draws from a diverse range of sources, including both narrative and systematic reviews, retrospective and prospective studies, and textbook chapters. It expands on previously published reviews by adding recent evidence from the last decade. This review is limited by the restriction to only English language publications and the heterogeneity of the included articles and studies, which vary in their methodologies and levels of evidence. The majority of sources included were retrospective in design (n=15). Among those, two were systematic reviews while the remaining thirteen were cohort studies or case series. A small proportion (n=3) of the sources were prospective studies, including one randomized pilot study. One evidence-based practice guideline was also included. The remainder of the sources comprised narrative reviews, expert opinions, and book chapters. As expected, the largest sample sizes were found within the systematic reviews and retrospective multicenter studies (sample size range, 406–793). In contrast, all retrospective case series and cohort studies included sample sizes of fewer than 100 patients. While the breadth of different types of evidence allows for a comprehensive review, there is a predominance of lower-level evidence, namely retrospective cohort and narrative reviews/expert opinions, which limits the strength of conclusions that can be made from this review.

Conclusions

For patients who sustain traumatic injuries to the chest, the implementation of VATS has allowed for a minimally invasive alternative to thoracotomy, with arguably equal to superior performance. Since its introduction, there has been no consensus on the optimal timing of VATS for traumatic chest injuries. This review summarizes the current evidence in the literature, which encourages early VATS within the first week of hospitalization, but not before three or four days. Although early intervention has not been shown to confer a mortality benefit, it is associated with significant reductions in both hospital and ICU length of stay without compromising patient safety. Despite these aggregate findings, clinical decision-making must remain individualized, as VATS may not be suitable for all patients depending on their specific clinical circumstances.

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-25-35/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-35/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-25-35/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/.

References

1. Patel NJ, Dultz L, Ladhani HA, et al. Management of simple and retained hemothorax: A practice management guideline from the Eastern Association for the Surgery of Trauma. Am J Surg 2021;221:873-84. [Crossref] [PubMed]
2. Edgecombe L, Sigmon DF, Galuska MA, et al. Thoracic Trauma. Treasure Island, FL, USA: StatPearls Publishing; 2025.
3. Ouwerkerk JJJ, van Ee EPX, Brown TA 2nd, et al. Video-Assisted Thoracic Surgery Evacuation of Retained Hemothorax; Timing May Not Increase Thoracoscopic Failure. J Surg Res 2024;293:168-74. [Crossref] [PubMed]
4. Bertolaccini L, Rocco G. History and development of minimally invasive surgery: VATS surgery. Shanghai Chest 2019;3:16.
5. Chou YP, Lin HL, Wu TC. Video-assisted thoracoscopic surgery for retained hemothorax in blunt chest trauma. Curr Opin Pulm Med 2015;21:393-8. [Crossref] [PubMed]
6. Peek J, Beks RB, Hietbrink F, et al. Epidemiology and outcome of rib fractures: a nationwide study in the Netherlands. Eur J Trauma Emerg Surg 2022;48:265-71. [Crossref] [PubMed]
7. DuBose J, Inaba K, Demetriades D, et al. Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study. J Trauma Acute Care Surg 2012;72:11-22; discussion 22-4; quiz 316.
8. Smith JW, Franklin GA, Harbrecht BG, et al. Early VATS for blunt chest trauma: a management technique underutilized by acute care surgeons. J Trauma 2011;71:102-5; discussion 105-7. [Crossref] [PubMed]
9. Zambetti BR, Lewis RH Jr, Chintalapani SR, et al. Optimal time to thoracoscopy for trauma patients with retained hemothorax. Surgery 2022;172:1265-9. [Crossref] [PubMed]
10. Carrillo EH, Richardson JD. Thoracoscopy in the management of hemothorax and retained blood after trauma. Curr Opin Pulm Med 1998;4:243-6. [Crossref] [PubMed]
11. Milanchi S, Makey I, McKenna R, et al. Video-assisted thoracoscopic surgery in the management of penetrating and blunt thoracic trauma. J Minim Access Surg 2009;5:63-6. [Crossref] [PubMed]
12. Jackson AM, Ferreira AA. Thoracoscopy as an aid to the diagnosis of diaphragmatic injury in penetrating wounds of the left lower chest: a preliminary report. Injury 1976;7:213-7. [Crossref] [PubMed]
13. Jones JW, Kitahama A, Webb WR, et al. Emergency thoracoscopy: a logical approach to chest trauma management. J Trauma 1981;21:280-4.
14. Akkas Y, Özdemir Ciflik B, Ciflik KB, et al. Timing of video-assisted thoracoscopic surgery in the management of thoracic trauma. BMC Surg 2025;25:264. [Crossref] [PubMed]
15. Ziapour B, Mostafidi E, Sadeghi-Bazargani H, et al. Timing to perform VATS for traumatic-retained hemothorax (a systematic review and meta-analysis). Eur J Trauma Emerg Surg 2020;46:337-46. [Crossref] [PubMed]
16. Diagnostic and therapeutic roles of bronchoscopy and video-assisted thoracoscopy in the management of thoracic trauma. Anesthesia Key. 2016 [cited 2025 Sept 10]. Available online: https://aneskey.com/diagnostic-and-therapeutic-roles-of-bronchoscopy-and-video-assisted-thoracoscopy-in-the-management-of-thoracic-trauma/
17. Kumar A, Gora D, Bagaria D, et al. Outcomes of Video-assisted Thoracic Surgery-guided Early Evacuation of Traumatic Hemothorax: A Randomized Pilot Study at Level I Trauma Center. J Emerg Trauma Shock 2024;17:73-9. [Crossref] [PubMed]
18. Goodman M, Lewis J, Guitron J, et al. Video-assisted thoracoscopic surgery for acute thoracic trauma. J Emerg Trauma Shock 2013;6:106-9. [Crossref] [PubMed]
19. Alwatari Y, Simmonds A, Ayalew D, et al. Early video-assisted thoracoscopic surgery (VATS) for non-emergent thoracic trauma remains underutilized in trauma accredited centers despite evidence of improved patient outcomes. Eur J Trauma Emerg Surg 2022;48:3211-9. [Crossref] [PubMed]
20. Zeiler J, Idell S, Norwood S, et al. Hemothorax: A Review of the Literature. Clin Pulm Med 2020;27:1-12. [Crossref] [PubMed]
21. Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg 2004;78:282-5; discussion 285-6. [Crossref] [PubMed]
22. Wu N, Wu L, Qiu C, et al. A comparison of video-assisted thoracoscopic surgery with open thoracotomy for the management of chest trauma: a systematic review and meta-analysis. World J Surg 2015;39:940-52. [Crossref] [PubMed]
23. Wang JQ, Ma ZJ. Impact of video-assisted thoracic surgery versus open thoracotomy on postoperative wound infections in lung cancer patients: a systematic review and meta-analysis. BMC Pulm Med 2025;25:159. [Crossref] [PubMed]
24. Nagahiro I, Andou A, Aoe M, et al. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 2001;72:362-5. [Crossref] [PubMed]
25. Ben-Nun A, Orlovsky M, Best LA. Video-assisted thoracoscopic surgery in the treatment of chest trauma: long-term benefit. Ann Thorac Surg 2007;83:383-7. [Crossref] [PubMed]
26. Uma CV, Risinger WB, Nath S, et al. Not So Vats: How Early Is Too Early in the Operative Management of Patients with Traumatic Hemothorax? Am Surg 2024;90:2149-55. [Crossref] [PubMed]
27. Wong WG, Perez Holguin RA, Oh JS, et al. The cost of treatments for retained traumatic hemothorax: A decision analysis. Injury 2022;53:2930-8. [Crossref] [PubMed]
28. Lomanto D, Chen WTL, Fuentes MB. editors. Mastering Endo-Laparoscopic and Thoracoscopic Surgery: ELSA Manual. Singapore: Springer Nature; 2023 [cited 2025 Sept 10]. Available online: https://library.oapen.org/handle/20.500.12657/60186
29. Lodhia JV, Konstantinidis K, Papagiannopoulos K. Video-assisted thoracoscopic surgery in trauma: pros and cons. J Thorac Dis 2019;11:1662-7. [Crossref] [PubMed]