Video-assisted thoracoscopic surgery for preventing and managing post-traumatic empyema: a narrative review
Introduction
Background
Retained hemothorax is a common complication following thoracic trauma and occurs in approximately 5–30% of patients, depending on the study population and diagnostic criteria used (1). It is a challenging clinical situation with heterogeneity in the approach to its management. However, when nearly a third of patients with retained hemothorax progress to empyema, clarity regarding diagnosis and management becomes increasingly important (2,3).
With ongoing advancements in minimally invasive surgical techniques, video-assisted thoracoscopic surgery (VATS) has gained increased prominence in the treatment of thoracic trauma and retained hemothorax. This technique offers a less invasive alternative to thoracotomy and is particularly beneficial in managing complications such as retained hemothorax and empyema following chest injury (4).
Rationale and knowledge gap
Despite emerging evidence regarding the utility of VATS in the management of retained hemothorax, as mentioned above, the current literature and certainly clinical practice lack a uniform approach in its employment. There persists a lack of agreement amongst thoracic surgeons regarding when a hemothorax should be observed versus intervened on, the timing of surgical intervention, its effectiveness when compared to intrapleural fibrinolytics or open approaches, and patient selection.
Prior reviews have examined the role of VATS in thoracic trauma broadly and in the management of retained hemothorax, with emphasis on technical feasibility and timing of operative evacuation (1,2,4-9). However, these reviews have largely focused on retained hemothorax as a procedural indication, rather than on post-traumatic empyema as a distinct clinical outcome. In addition, existing literature syntheses variably address comparative effectiveness against non-operative strategies, and few integrate contemporary trauma society recommendations into a unified, clinically oriented framework. As a result, uncertainty persists regarding optimal patient selection, timing of intervention, and escalation strategies for preventing and managing post-traumatic empyema. This narrative review seeks to address these gaps by synthesizing current evidence, pathophysiology, and guideline-based recommendations to support practical decision-making in trauma care.
Objective
The objective of this review is to summarize the current body of evidence regarding the use of VATS in preventing and managing post-traumatic empyema and to provide an overview of the associated current clinical guidelines. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-25-37/rc).
Methods
Our search of the literature was conducted between April 1, 2025, and June 1, 2025, and included the following databases: PubMed/MEDLINE, Google Scholar, and Western University Libraries Database. A summary of our detailed search strategy is included in Table 1. Articles were screened and included if they either described: (I) the use of VATS in managing post-traumatic empyema or retained hemothorax, (II) the diagnosis of retained hemothorax, (III) the treatment of retained hemothorax and post-traumatic empyema, and (IV) clinical guidelines outlining approaches to retained hemothorax and post-traumatic empyema. Articles were excluded if they were not related to traumatic hemothorax or post-traumatic empyema, focused on non-traumatic pleural infection, or did not address diagnostic or management strategies relevant to retained hemothorax. Title and abstract screening, followed by full-text review, was conducted by a single reviewer, consistent with the narrative review methodology. The last retrieval date was June 1, 2025. Given the narrative review design, a formal PRISMA flow diagram was not generated; instead, the literature selection process is described narratively to provide transparency while maintaining methodological flexibility. Pertinent details of our search strategy are outlined in Table 2.
Table 1
| Items | Specification |
|---|---|
| Date of search | April 1, 2025–June 1, 2025 |
| Databases and other sources searched | PubMed/MEDLINE, Google Scholar, Western University Libraries Database |
| Search terms used | “Video assisted thoracic surgery”, “VATS”, “hemothorax”, “retained hemothorax”, “trauma”, “empyema”, “post-traumatic empyema”, “treatment”, “diagnosis”, “guidelines” |
| Timeframe | No restriction was placed on the date of publication of included articles |
| Inclusion and exclusion criteria | No restrictions were placed on publication date or article type. Articles were included if they were written in English and met the following criteria: (I) the use of VATS in managing post-traumatic empyema or retained hemothorax; (II) the diagnosis of retained hemothorax; (III) the treatment of retained hemothorax and post-traumatic empyema; and (IV) clinical guidelines outlining approaches to retained hemothorax and post-trauma empyema |
| Selection process | Selection process was conducted by B.M. |
| Any additional considerations | A gray literature search of Google Scholar was conducted during the same search period (April 1 to June 1, 2025). Records were screened for relevance at the title and abstract level, and duplicate citations were removed during manual review. |
VATS, video-assisted thoracoscopic surgery.
Table 2
| Summary of MEDLINE search strategy |
|---|
| (“Retained hemothorax” AND “VATS”) |
| (“Retained hemothorax” AND “treatment*” OR “diagnosis*”) |
| (“Retained hemothorax” AND “guidelines”) |
| (“Retained hemothorax” AND (“VATS” OR “minimally invasive”) |
| (“Post-traumatic empyema” AND “VATS” OR “minimally invasive”) |
| (“Post-traumatic empyema” AND “etiology” OR “pathophysiology”) |
| (“Post-traumatic empyema” AND “treatment”) |
VATS, video-assisted thoracoscopic surgery.
Discussion
Pathophysiology and risk factors
Once diagnosed, a retained hemothorax tends to evolve in one of three ways: (I) complete spontaneous reabsorption of blood within several weeks, (II) progression to fibrothorax, or (III) empyema formation (10,11).
The pathogenesis of empyema also typically follows a progression through three stages: (I) the exudative phase, (II) the fibrinopurulent phase, and (III) the organizing phase (10,11). The exudative phase occurs in the first five days following injury and involves accumulation of protein rich fluid (exudate) in the pleural space (10). At this stage, the hemothorax remains treatable and progression can be halted with appropriate drainage (10). Occurring at days 5–10, the fibrinopurulent phase involves bacterial invasion of the exudative fluid (which is usually sterile) and deposition of fibrin within the pleural space leading to loculations and septations (10,11). Additionally, the fluid becomes thicker and increasingly purulent (10,11). The combination of these phenomena makes the drainage of this fluid increasingly challenging (10). The organizing phase occurs within 7–14 days following the initial trauma and involves the fibrinous material in the pleural cavity becoming organized into a dense, fibrinous peel restricting expansion of the lung and leading to a fibrothorax (10,11). Due to potential obliteration of the pleural space, progression to empyema now becomes possible (10). The fibrinopurulent phase usually transitions into the organizing phase within 7–14 days after symptom onset, emphasizing the importance of timely intervention. In addition, lung entrapment should be suspected when the pleural infection process is known to have been ongoing for longer than 10–14 days (10).
Empyema itself occurs in approximately 26.8% of patients with chest trauma and retained hemothorax, with a slightly higher prevalence observed in those with penetrating injuries (2). A similar report states that radiographically apparent hemothorax after chest tube placement leads to empyema in 33% of cases (3).
Multiple risk factors for progression to empyema from retained hemothorax have been identified. These include prolonged chest tube duration, the presence of rib fractures, Injury Severity Score greater than 25 or higher, and the need for additional interventions to evacuate retained blood from the thorax (2). These factors contribute to persistent pleural contamination and inflammation, thus leading to initiation and progression of the exudative, fibrinopurulent, and organizing sequence.
Diagnosis
The initial diagnostic work-up for suspected retained hemothorax or empyema usually involves a plain chest X-ray (CXR), which serves as a screening tool. However, computed tomography (CT) of the chest is the preferred modality for accurately evaluating the volume and location of retained blood or infected fluid, particularly when initial chest tube drainage is deemed inefficient.
In line with prior clinical studies, a retained hemothorax was defined as residual pleural blood that persists despite initial chest tube thoracostomy, often operationalized as residual fluid greater than 300 millilitres on imaging 72 hours after drainage, or as radiographically evident unresolving clots within the pleural cavity (5). This definition aligns with prior trauma and surgical literature and reflects the clinical concern for increased risk of complications such as empyema and fibrothorax which can result in significant morbidity (1,2,5,10).
Observation as a management strategy
There remains debate amongst clinicians regarding the size at which a hemothorax can be safely observed. Bilello et al. suggested that collections <1.5 cm on CT can be observed, but their report is limited by a lack of long-term follow-up to determine the true risk of fibrothorax or empyema (6). From our review, it is recommended that in clinically stable patients with small-volume retained hemothorax and no evidence of infection, an initial period of observation with serial imaging may be appropriate prior to escalation of intervention.
Timing of surgical intervention
Guideline-based recommendations regarding the timing of operative intervention are informed by the natural history of retained hemothorax and progressive pleural organization. Current guidelines from the Eastern Association for the Surgery of Trauma (EAST) provide a structured approach to the management of post-traumatic hemothorax and empyema (7). According to these recommendations, all hemothoraces should be evaluated for drainage regardless of their size with initial treatment consisting of placement of a tube thoracostomy (7). In cases where hemothorax persists despite adequate chest tube placement, early VATS is recommended as the preferred next step rather than the insertion of an additional chest tube (7). According to their guideline, the optimal window for performing VATS is within 3 to 7 days after injury as this approach has been shown to significantly reduce the risk of infection and the likelihood of conversion to open thoracotomy (7). In situations where surgical risk is prohibitively high, intrapleural fibrinolytics may be considered, particularly for loculated effusions developing between 6 and 13 days post-injury (7).
The timing of VATS plays a critical role in determining its effectiveness. Early VATS, performed within the first 3 to 5 days after trauma, facilitates easier clot evacuation, lowers the risk of infection, and reduces the length of hospitalization and intensive care unit (ICU) stay (12). If the pleural space is infected, VATS is highly effective in managing early-stage empyema, particularly during the exudative and fibrinopurulent phases. During these stages, the procedure allows for adequate drainage, debridement, and prevention of further progression (12). A proposed management algorithm is highlighted in Figure 1.
Delayed intervention beyond 10 days has been associated with increased pleural organization, higher technical complexity, and a greater likelihood of conversion to open thoracotomy or need for additional procedures (13). Although successful VATS evacuation has been reported in selected patients at later time points, reported success rates decline as adhesions mature and lung entrapment becomes more established, reinforcing the importance of early operative management when feasible.
Despite general support for early VATS, controversy persists regarding the optimal timing of intervention due to variability in patient selection, extent of retained hemothorax, presence of infection, and institutional resources. Reported timing thresholds for intervention differ across studies, and successful VATS has been described beyond early windows in selected patients, albeit with declining success rates and increased technical complexity. Further, differing reports of success rates of fibrinolytic therapy make an argument for non-operative management. These factors contribute to ongoing debate and underscore the need for individualized clinical judgment.
Comparative effectiveness of VATS
When compared to thoracotomy, VATS offers several distinct advantages. These include shorter post-operative recovery times, fewer pulmonary complications, reduced post-operative pain, lower intraoperative blood loss, and a shorter overall length of stay (LOS) (9,13). These benefits are particularly important in critically ill trauma patients who are at increased risk for morbidity from more invasive surgical procedures.
In comparison with non-operative management with fibrinolytics, VATS has consistently shown superior outcomes (7,14). While intrapleural fibrinolytics can facilitate clot evacuation in some patients, especially those who are not candidates for surgery, the overall success rate is lower than that of VATS (15,16). Moreover, VATS provides definitive mechanical evacuation and allows for visual inspection of the pleural cavity, which is not possible with fibrinolytic therapy alone (7).
When interpreting studies comparing VATS with intrapleural fibrinolytic therapy, it is important to recognize the substantial heterogeneity across the available literature (see Table 3). Included studies vary in patient selection, timing of intervention, extent of retained hemothorax, presence of infection, and clinical endpoints assessed. In many series, fibrinolytics were preferentially used in patients deemed poor surgical candidates or at later stages of disease, limiting direct comparability with operative cohorts. These differences underscore the need for individualized clinical decision-making and caution against overgeneralization of comparative effectiveness findings.
Table 3
| Study | Design | Population | Comparator | Timing of VATS | Outcomes | Key findings | Limitations |
|---|---|---|---|---|---|---|---|
| Heniford et al., 1997 |
Retrospective cohort | Trauma patients with retained thoracic collections | Continued tube thoracostomy/non-operative management | Early thoracoscopy after failure of tube drainage | Need for additional intervention, LOS, procedural success | Thoracoscopy was associated with effective evacuation of retained collections, reduced need for further intervention, and short hospital LOS | Retrospective, small sample size, heterogenous injury pattern |
| Oğuzkaya et al., 2005 |
Retrospective comparative study | Trauma patients with post-traumatic retained hemothorax | Intrapleural streptokinase | After failure of tube thoracostomy | Radiologic resolution, need for further intervention, LOS | VATS was associated with higher rates of complete evacuation and lower treatment failure compared with intrapleural streptokinase | Retrospective, non-randomized treatment allocation, potential selection bias |
| Ben-Nun et al., 2007 |
Retrospective cohort | Chest trauma patients with retained hemothorax | Open thoracotomy | After failure of tube thoracostomy | Post-operative morbidity, LOS, long-term outcomes | VATS was feasible and associated with lower morbidity and shorter LOS compared with thoracotomy in selected trauma patients | Retrospective design, heterogenous indications, selection bias |
| Kimbrell et al., 2007 |
Prospective observational | Trauma patients with retained hemothorax | None (fibrinolytics only) | N/A | Radiographic resolution, need for subsequent surgery, complications | Intrapleural thrombolytics resulted in complete or partial radiographic response in a proportion of patients. | No comparator group, small sample size, variable timing |
| EAST, 2011 | Evidence-based guideline | Trauma patients with hemothorax/retained hemothorax | Repeat tube thoracostomy, fibrinolytics | Recommended within 3–7 days post-injury | Empyema, need for thoracotomy, treatment failure | Early VATS is recommended for retained hemothorax after failed tube thoracostomy; fibrinolytics may be considered in selected high-risk patients | Recommendations based largely on observational data, heterogeneity across studies |
EAST, Eastern Association for the Surgery of Trauma; LOS, length of stay; N/A, not available; VATS, video-assisted thoracoscopic surgery.
Despite its numerous advantages, VATS is not appropriate for all patients. It is contraindicated in those who are hemodynamically unstable and require immediate thoracotomy. Additional relative contraindications include obliterated pleural spaces due to previous surgery or chronic infection, a history of coagulopathy or bleeding disorders, and moderate to severe obstructive pulmonary disease that precludes single lung ventilation.
At some institutions, chest tube irrigation with warm sterile saline is employed as an adjunct to standard drainage techniques (17,18). This method involves instilling and evacuating saline through the chest tube at the time of placement (17,18). A recent multicenter study by the Western Trauma Association (WTA) demonstrated that thoracic irrigation led to a 44% reduction in the need for subsequent surgical intervention in cases of retained hemothorax and was associated with a shorter ICU stay (18). These findings support the use of irrigation as a simple yet effective adjunctive therapy during initial tube thoracostomy.
Patient selection for VATS in trauma
In the context of traumatic empyema, selection for VATS must account for both patient physiology and disease stage rather than general indications for minimally invasive surgery in thoracic trauma. Current evidence and guideline recommendations support VATS primarily in hemodynamically stable patients with persistent retained hemothorax or early empyema, particularly within the fibrinopurulent phase before advanced pleural organization has occurred (1). Controversy remains regarding the upper temporal limits for successful thoracoscopic intervention and the role of VATS in later-stage disease, with reported success influenced by degree of pleural organization, infection severity, and institutional expertise. These considerations underscore the importance of individualized selection criteria when applying VATS specifically to traumatic empyema management.
Limitations
This review has several limitations inherent to its narrative design. As with all narrative reviews, the literature synthesis may be influenced by publication bias and variability in study quality. Additionally, the available evidence regarding retained hemothorax and post-traumatic empyema is heterogeneous, with differences in patient populations, timing of intervention, definitions of retained hemothorax, and reported outcomes, limiting direct comparison across studies. Nevertheless, this narrative approach allows for integration of pathophysiology, clinical evidence, and guideline-based recommendations to provide practical, clinically relevant guidance for trauma and thoracic surgeons.
Conclusions
VATS is a safe, effective, and minimally invasive technique for both preventing and managing post-traumatic empyema. Its early use in the hospital course of trauma patients who have thoracic injuries, namely retained hemothorax, has been shown to improve outcomes, reduce complications, and limit the need for more invasive procedures such as thoracotomy. While open surgery remains necessary in select cases, particularly those involving advanced empyema or hemodynamic instability, VATS should be considered as the preferred approach in stable patients with retained hemothorax or early-stage empyema. Future research may help further refine patient selection criteria and expand the indications for this valuable surgical tool.
Acknowledgments
None.
Footnote
Provenance and Peer Review: This article was commissioned by the Guest Editors (Savvas Lampridis and Andrea Billè) 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-25-37/rc
Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-37/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-25-37/coif). The series “The Role of VATS in Thoracic Trauma Management” was commissioned by the editorial office without any funding or sponsorship. 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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Cite this article as: Misheva B, Chaulk RC, Nayak R. Video-assisted thoracoscopic surgery for preventing and managing post-traumatic empyema: a narrative review. Video-assist Thorac Surg 2026;11:34.
