Narrative review of VATS for traumatic diaphragmatic injuries: a minimally invasive approach to diagnosis and repair

Introduction

Video-thoracoscopy or video-assisted thoracoscopy (VAT) has been an important tool for evaluating the thoracic cavity in the setting of trauma for the last 30 years. The first recorded cases of VAT in trauma were in 1993 (1), with the initial suggested use being the identification of traumatic diaphragm injuries (TDI). These first uses set the scene for significant development over the last decades, with the emergence of video-assisted thoracoscopic surgery (VATS), where the ports used for thoracoscopic visualisation can be used to pass instruments and perform repairs. Over time, the techniques used in VATS have trended towards a less and less invasive approach using fewer and fewer ports, with many procedures now being performed with uniportal VATS (2).

TDI are usually left-sided and more often due to penetrating trauma rather than blunt injury (3). Early suggestions stipulated that mandatory surgical exploration was necessary to detect TDI in trauma, as there is a high risk of missed TDI which progresses to herniation with potentially fatal consequences (1). Indeed, despite the development of imaging technologies which are now much better equipped to detect TDI in trauma (4), surgical exploration is still considered an important practice by many.

For surgical identification and repair of TDI, laparotomy was the preferred approach historically, though trends in the last decades have been towards minimally invasive approaches for stable patients, namely laparoscopy and VAT. Beyond using VAT for the identification of TDI, a VATS approach is an important option for the repair of these injuries. Recent reviews competently discuss TDI in general without discussing thoracic approaches in detail (5) or discuss VATS in TDI, but in the context of reviewing VATS in trauma more generally (6). In this review, the literature will be synthesised to describe the current understanding of the role of VATS in diagnosis and management of TDI specifically, with some discussion of the general methodology to perform a VATS repair of TDI. This is to allow surgeons to make a more informed decision about when to consider a thoracoscopic approach in cases of potential diaphragm injury. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0008/rc).

Methods

To complete this narrative review, a thorough search of the literature was conducted in February 2025. Keyword searches were conducted on PubMed and Google Scholar using keywords such as “VATS” and “Traumatic Diaphragm Rupture”, and the results screened for relevant papers. Screening was also undertaken of papers that were cited by or cited in other relevant papers, to more thoroughly explore the available literature. During the review and editing process, follow up searches were conducted to look for more recent publications relevant to the content of this review. Table 1 contains a full summary of the search strategy.

Equipment and technique

VATS is performed under general anaesthesia with single-lung ventilation using a double-lumen endotracheal tube (2,7), allowing better access and visualisation on the operative side as the lung is deflated (8). The operation is then performed with the patient in the lateral decubitus position (2,7). VATS requires an experienced assistant (8). The operator and the assistant are both positioned on the ventral side of the patient, facing one monitor, with the scrub nurse on the opposite side facing a different monitor (2).

VATS repair of the diaphragm can be performed using uniportal VATS (9). This is typically achieved with a single incision of 2–4 cm in the 5th intercostal space in the mid-axillary line (2,9), though some authors suggest using a different intercostal space (7) or making the incision anterior to the mid-axillary line (2) depending on the desired approach. No rib spreading is necessary. A wound protector is usually used to allow safe use of the port with multiple instruments. Instead of the uniportal approach, 2 or more ports can be placed along the mid-axillary line if more access is needed for the insertion of additional instruments (7,8).

A 30-degree video thoracoscope is usually used (2,7,8), with the choice of size (5 or 10 mm) depending largely on surgeon preference. Special instruments designed for use in uniportal VATS are required, which have a long, thin shaft and are curved with a dual pivot point (2).

Once the surgeon can visualise the interior of the thorax, a thorough inspection should be performed. The entire hemidiaphragm must be visualised and carefully inspected for small ruptures. Additionally, the surgeon should inspect the other thoracic structures (lung surfaces, parietal pleura, chest wall and pericardium) for injury in the setting of trauma (7). No. 0 or 1 monofilament (absorbable or non-absorbable) sutures can be used for the repair. Interrupted sutures can be used for small ruptures but larger ruptures of 5–6 cm or greater may require figure-of-eight or horizontal mattress suturing, or two-layer closure (3). Generally, patches are not necessary for diaphragm repair, though they are recommended by some authors for larger defects (10).

When the procedure is complete, a chest drain must be inserted (2,8). Two chest drains may be used if a large air leak is anticipated (8). If a uniportal approach is used, then the same incision will usually be used for the placement of the drain.

Diagnostic role of VATS in TDI

In the setting of thoracoabdominal trauma, TDI is a relatively common potential outcome (11), with incidences as high as 40% reported in left-sided penetrating injuries (12). Though common in this setting, many cases of TDI are clinically silent—as such, it is important to have a reliable method of detecting TDI beyond relying on clinical signs. There are a number of signs on computed tomography (CT) scan, that can be used to detect TDI: for instance, collar sign, diaphragm discontinuity, herniation, dependent viscera and diaphragm thickening, among others (13). Nonetheless, the use of CT scans for TDI detection has been historically controversial, with some analyses suggesting that CT has high sensitivity and specificity for the detection of TDI (14) whilst others have demonstrated low rates of discovery of TDI by initial interpreting radiologists, especially in the setting of penetrating trauma (15). A 2015 review on the subject (4) reports that penetrating trauma (when compared with blunt trauma) can cause TDI with subtle CT signs, making diagnosis a challenge—nonetheless, the authors suggest that with modern thin-section multidetector computed tomography (MDCT), in the hands of experienced radiologists, CT can be an accurate diagnostic tool for TDI. A different 2015 review agrees that CT is useful in diagnosis. However, it emphasises that it still has a limited ability to detect most non-herniating TDI, with most diagnoses in these cases being intraoperative (16), validating earlier suggestions and observations that more invasive diagnostic methods are necessary (1,17). A 2023 meta-analysis shows that MDCT has a sensitivity of 74% and a specificity of 92% in penetrating injuries (18), though the data from the individual studies included in the analysis were highly heterogeneous, calling for further investigation. A 2026 review on the subject (5) concludes that CT should be considered as gold-standard for investigating potential TDI, but that laparoscopy is a valid first line alternative in left sided penetrating trauma. Notably, this review does not extensively discuss thoracoscopic approaches. A large 2026 retrospective cohort study shows that many CT signs are highly reliant on mechanism of injury and therefore can often be obscured by concomitant injuries (13). For instance, TDIs are often missed on CT in blunt trauma where there are large haemothoraces or haemoperitoneum. Anterior penetrating injuries were also often underdiagnosed. These are scenarios in which surgical exploration could be useful.

Other imaging modalities may have a role in these cases too, though there is little evidence suggesting any other modality would outperform CT or surgical visualisation. A chest radiograph will almost always be performed in this case regardless, as part of the workup for thoracoabdominal trauma (19), though this is not necessarily specific or sensitive for TDI. Magnetic resonance imaging (MRI) also has some limited use. It has been suggested that in paediatric trauma, MRI could be used for assessing unclear cases of diaphragmatic hernia, though CT is still generally preferred (20). MRI is more widely used in congenital diaphragm defects, though one study shows that MRI might have similar performance to CT in the setting of TDI from left-sided penetrating injuries (21), though more research is needed, with larger case series, to understand the role MRI should have alongside direct visualisation and CT. This is a promising avenue of research, as MRI may be preferable for many patients due to the reduction of contrast/radiation exposure.

The lack of real consensus on this matter means that many surgeons continue to operate under the assumption that imaging is unreliable for the identification of TDI, preferring direct visualisation via VAT (9). There is a longstanding evidence base for the use of thoracoscopy in the exploration of thoracoabdominal trauma and potential TDI. In 1994, it was shown that thoracoscopy could be used to assess the diaphragm, preventing unnecessary laparotomy (22). Since then, the efficacy of VAT in TDI diagnosis has been repeatedly observed, with studies noting its use in detecting and sometimes allowing treatment of various thoracic injuries that may occur in the setting of trauma (8,23,24). Over time, the use of minimally invasive exploratory techniques such as laparoscopy and VAT has become more common. The most recent suggestions are for laparoscopy as the standard option (25,26), as it is also effective but, unlike VAT, does not require chest tube insertion in negative cases—however, with little direct comparative evidence of the two methods, it comes broadly down to the comfort of the individual surgeon with each technique, and the details of the specific case. VAT is a reliable option, especially when other potential thoracic pathology is suspected (25). Given the specific limitations of CT in anterior penetrating thoracic trauma, VAT should be considered especially in these cases (9,25).

In summary, TDI remains difficult to diagnose clinically, and the efficacy of imaging modalities such as CT remains controversial. Therefore, direct visualisation is still widely used in the diagnosis of TDI, with laparoscopy and VAT as the main options, with VAT being particularly useful if other thoracic pathology is strongly suspected. Unfortunately, without specific data on the value of VAT as a diagnostic tool for TDI itself, more research is required to be able to make specific recommendations of when to preferentially use VAT, so the choice of diagnostic investigations will have to be made based on the details of each clinical case until further research is carried out. This lack of evidence may be due to the fact that it is difficult to directly quantify the diagnostic accuracy of VAT, as surgical visualisation is often treated as a reference standard by which to measure the efficacy of imaging techniques. Consequently, false negatives are inherently hard to identify, unless delayed sequelae are used as a measure, such as later herniation; no papers containing such comparisons were identified in our search. One approach would be to study other VATS cases in the setting of trauma, such as rib stabilisation, and measure subsequent complications from occult diaphragm injury. One such study was found, however exploratory VAT was not performed alongside rib fixation (27). A similar study suggests exploratory VAT in these cases to reduce missed TDI (28).

Once VAT has been used for visualisation of the TDI, conversion to VATS can be used for repair, as discussed below.

Therapeutic role of VATS in TDI

At the present moment, there is no real consensus on whether to use a thoracic or abdominal approach for TDI repair. Nonetheless, VATS can be used to effectively repair TDI, especially when the injury is small or there are factors present that would make a laparoscopic repair more difficult.

The utility of VATS repair of TDI has been noted, especially in the context of thoracoabdominal penetrating trauma (29,30). VATS is often effective for the repair of small TDI, though, in larger diaphragm ruptures, a VATS-only approach is less supported (31,32). Therefore, when assessing if a diaphragmatic rupture will be amenable to repair by VATS, it is important to consider VATS most strongly for small injuries.

As the diaphragm divides the thoracic and abdominal cavities, it can be approached from either cavity for its repair. There are some scenarios in which VATS is specifically preferred to laparoscopic repair. For instance, when there are no concurrent abdominal injuries, when a thoracic injury is known to be present (or is visualised through a TDI from abdominal access), or when the presentation of TDI is delayed after trauma, and so the likelihood of abdominal injury is lower, a thoracic approach is preferred (3,33,34). In the setting of thoracic complications of chest trauma, VATS is generally reliable (35-37) and thus is a useful tool to the surgeon suspecting a potential TDI in the setting of other known thoracic trauma, as it allows the surgeon to confidently treat the other injuries whether or not a TDI is present. VATS is a reliable alternative when laparoscopy would likely be complicated due to concurrent intra-thoracic injuries (25,33) or other case-specific parameters such as posterolateral location of TDI, BMI >30 kg/m² or in right-sided defects in proximity to the vena cava (10). In these scenarios, VATS and laparoscopy may also be used together—this flexible, minimally invasive two-cavity approach is recommended for TDI management more generally by some authors (38,39). This approach was recommended in a recent case report for situations in which there are adhesions of hernia contents within the thoracic cavity (40), though stronger evidence is needed to support this suggestion more generally. In general, there is no consensus as to whether a thoracic or abdominal approach is preferred. Generally, there is a trend towards using minimally invasive approaches, either laparoscopy or VATS, though open approaches remain preferred in the haemodynamically unstable patient, particularly in cases of significant haemorrhage into the thoracic or abdominal cavities.

There is a gap in the availability of studies directly comparing the efficacy of laparoscopy to VATS for the treatment of TDI, making it hard to draw a definitive conclusion recommending one over the other (33). This issue was discussed in a recent literature review (6) that described the following benefits and drawbacks of each approach. Laparoscopy can be preferable because it allows the identification and treatment of intra-abdominal injuries, is considered less technically challenging, and does not require chest tube insertion; VATS can be preferable because it allows the surgeon to identify and repair intra-thoracic injuries and, unlike laparoscopy, carries no risk of tension pneumothorax from insufflation. In the setting of trauma, both intra-thoracic and intra-abdominal injuries are common, but intra-abdominal injuries are more likely to require surgical intervention, creating a general preference towards laparoscopy (33). Nonetheless, due to the lack of direct comparative evidence, surgeons are encouraged to use the approach that aligns best with the specific clinical case in question and their general level of familiarity and comfort with each approach.

Timeline of intervention

It is generally considered that TDIs are unlikely to heal themselves over time. Rather, due to the pressure gradient between the abdominal and thoracic cavities, there is a concern that, with time, the probability of herniation will increase. Indeed, the risk of undiagnosed herniation implies that the surgeon must maintain a high index of suspicion for TDI (41) and efforts must be taken to diagnose and treat these defects early, as subsequent herniation can have life-threatening consequences (42). A 2013 epidemiological study (43) found that acute TDI can be missed by initial assessments and that subsequently delayed diagnosis can result in the incidence of serious complications and increased mortality, echoing earlier data (44). As such, the general recommendation that emerges is that TDI must be identified and dealt with as a matter of urgency, as soon as possible, in the setting of acute trauma.

Practical considerations

• Technical demands: VATS approach requires specialised technical experience including a thoracic surgeon, skilled assistant, and trained scrub team. It also requires single-lung ventilation and an experienced anaesthetic team.
• VATS availability: access to VATS varies between trauma centres, which may represent a barrier to its regular use for such cases.
• Cost considerations: cost may vary according to the available resources in each institute. Reducing potential morbidity and subsequent admissions due to missed TDIs can justify the costs.
• Individual patient factors: previous abdominal surgery and intra-abdominal adhesions may favour a thoracic approach, whereas extensive thoracic adhesions or previous surgeries may limit the feasibility of VATS. As discussed above, the type and extent of suspected injury, as well as the haemodynamic status of the patient, play a key role in deciding on the surgical approach.

Conclusions

In summary, uniportal VATS is a viable approach for TDI repair. Despite modern developments in imaging technology, it is still practically useful to visualise the diaphragm in surgery, in the context of acute trauma. Laparoscopy and VATS are both useful for the diagnosis and repair of TDI. With a gap in the literature directly comparing the two methodologies, the use of one or the other comes down largely to availability and surgeon preference. However, VATS is generally more useful when associated thoracic pathologies are strongly suspected which will require surgical management, particularly when abdominal injuries are unlikely. Regardless, surgical exploration and repair should be performed as soon as possible in thoracoabdominal trauma, as there is a high risk of undiagnosed TDI which will worsen over time and lead to increased mortality.

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-2026-1-0008/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0008/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-2026-1-0008/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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