Preface on the role of VATS in thoracic trauma management

Thoracic trauma forces us to balance urgency with restraint. Most patients will never need a thoracotomy, yet avoidable pleural and parenchymal sequelae still account for a disproportionate share of morbidity in the days that follow injury. Blood and air may look “handled” once a tube is in place, but incomplete control can translate into infection, impaired ventilation, delayed mobilisation, and a longer admission. In haemodynamically stable patients, video-assisted thoracic surgery (VATS) has increasingly become less a technical preference and more a way to prevent that trajectory, if it is used thoughtfully and early enough to matter.

The value of VATS in trauma is not simply the size of the incision. It is what thoracoscopy allows us to do at the right moment: confirm what imaging cannot, address what tube drainage cannot, and restore the conditions for lung re-expansion and recovery. Tube drainage remains the starting point and, often, the endpoint. But when evacuation is incomplete, air leak persists, or uncertainty remains about intrathoracic injury, “watchful waiting” can quietly become the route to prolonged drainage, empyema, fibrothorax, and loss of momentum in a patient who should otherwise be improving. Delayed VATS, by contrast, more often means operating in a hostile, loculated field, with fewer minimally invasive options and higher conversion rates.

Across contemporary evidence, the most consistent message is that timing and intent matter. Earlier VATS (typically within the first few days after injury) aligns with shorter hospital stays and lower rates of pleural complications than delayed escalation. The benefit is seen most clearly in morbidity and resource use rather than mortality, which reflects the clinical reality: in stable patients, the objective is rarely rescue; it is prevention of predictable downstream harm and acceleration of recovery.

None of this negates the importance of selection. VATS is not a substitute for damage-control thoracotomy, and it does not belong in unstable physiology. Its strongest role is in stable blunt and penetrating trauma when the anticipated gain is definitive management with limited additional physiological insult. In that setting, VATS is both diagnostic and therapeutic: it can evacuate retained haemothorax, address persistent pneumothorax or air leak, clarify suspected diaphragmatic or other injuries when imaging is equivocal, and treat selected bleeding sources not amenable to tube drainage alone. Used well, it reduces uncertainty and shortens the distance between diagnosis and definitive treatment.

VATS in trauma, however, is also a systems issue. Early escalation requires rapid reassessment, timely repeat imaging when appropriate, and dependable access to the operating theatre and thoracoscopic expertise. Without that pathway, patients drift through incremental measures, such as additional drains, prolonged conservative management, and delayed referral, often at the cost of longer admissions and more complications. This variability in pathways and thresholds likely explains why VATS remains underutilised in some settings despite a recurring signal of benefit in trauma management.

The case for VATS is also increasingly aligned with what matters to patients and trauma systems: smoother recovery, earlier mobilisation, and discharge readiness. Even where index procedural costs are higher, downstream utilisation may favour early definitive management through reduced morbidity and shorter length of stay. For high-volume centres, that translates into capacity, throughput, and resilience.

Important gaps remain. The literature is still dominated by observational data, definitions and thresholds vary across institutions, and training and credentialing in thoracoscopic trauma practice remain uneven. The next step for the field is therefore not simply broader adoption, but more consistent pathways: clearer triggers for escalation, shared definitions, and pragmatic prospective evaluation embedded in real-world trauma workflows.

With this special series, we aimed to offer a focused, clinically useful synthesis of where VATS fits within contemporary thoracic trauma care. The contributions address the decisions that recur at the bedside: how VATS is applied across blunt and penetrating mechanisms; when and why to escalate beyond tube drainage; how retained haemothorax and post-traumatic empyema are managed; how timing shapes outcomes and conversion; and how to think about patient-centred endpoints alongside system-level resource use. We are grateful to the authors who contributed their time and expertise to produce a set of practical reviews for clinicians managing thoracic trauma.

Our hope is that readers come away not with a single slogan but with a clearer framework: how to select the right patient, how to match intent to timing, and how to build pathways that make minimally invasive definitive care achievable when it is most likely to change outcomes.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery for the series “The Role of VATS in Thoracic Trauma Management”. The article did not undergo external peer review.

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-2026-1-0005/coif). The series “The Role of VATS in Thoracic Trauma Management” was commissioned by the editorial office without any funding or sponsorship. S.L. serves as an Editor-in-Chief of Video-Assisted Thoracic Surgery. A.B. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from January 2026 to December 2027. S.L. and A.B. served as the unpaid Guest Editors of the series. 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/.

Savvas Lampridis

Andrea Billè