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... is generally taught that radial incisions in the breast give inferior cosmetic results to those placed along Langer's lines, the reason being that they cut across these lines, resulting in scars which tend to gape (Fig. 1). However, when considering wide local excision or segmentectomy it is much easier to excise a wedge of breast tissue through a radial rather than a circumferential incision and this is also arguably an oncologically preferable technique to taking a cylinder of disc tissue (lumpectomy) from skin down to pectoralis major through whatever ...
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... and elastin fibres within the skin, which become orientated perpen- dicular to the direction of the underlying musculature. Scars parallel to resting skin tension lines are not subject to muscular distraction and are therefore less likely to gape and hypertrophy. Skin incisions in the breast should therefore parallel RSTL and, as can be seen ( Fig. 1 A 45-year-old female presented following an assault in which she had been stabbed with a broken mirror in the left lumbar region. Initial chest radiograph and abdominal ultrasound showed a small left pleural effusion only and local exploration removed a large fragment of glass. After the subsequent development, 3 days later, of a left ...
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... the subsequent development, 3 days later, of a left haemothorax, a CT scan demonstrated three retained foreign bodies, two in the abdomen and a third which had penetrated the diaphragm and was lying adjacent to the pericardium. Video-assisted thoracoscopy facilitated the exploration of the chest, drainage of 700 ml of blood and removal of a 4.5x2 cm glass fragment from the left hemidiaphragm adjacent to the vertebral column ( Fig. 1 and Fig. 2). There was no evidence of pericardial or lung injury. ...
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... Table III. ThoraCosCopIC perICardIal wIndow for Trauma – reVIew of The lITeraTure Author Year No. of patients waller et al. 5 1996 2 morales et al. 1 1997 108 boyce et al. 6 1997 1 pons et al. 4 2002 13 Caceres et al. 7 2004 1 Total 125 pg 18-20.indd 20 3/6/06 12:40:33 PM ...
To report our experience with thoracoscopic pericardial window (TPW) for occult penetrating cardiac injury.
During the study period (1 January - 31 December 2000), a small group of haemodynamically stable patients with anterior left-sided praecordial wounds were selected for TPW. All patients underwent general anaesthesia with double-lumen intubation and collapse of the left lung. A rigid laparoscope was inserted through a 2 cm incision in the 5th intercostal space in the anterior axillary line. Another 3 cm incision was made in the fourth intercostal space over the cardiac silhouette. Conventional instruments were used to grasp and open the pericardium. Any myocardial injury identified was an indication to proceed to sternotomy. In the absence of a myocardial injury and bleeding, the procedure was terminated and considered therapeutic.
Seventy-one patients with suspected penetrating cardiac injuries were seen. TPW was successfully completed in 13 patients. All were men, with a mean age of 29.8 (range 19 - 38) years. Ten and 3 patients sustained stab and gunshot wounds, respectively. The mean revised trauma score was 7.84. Ultrasound was performed in 12 patients; the results were equivocal for 2 patients, and positive for an effusion in 4 patients. Haemopericardium was found in 3 patients, 2 of whom proceeded to sternotomy. No cardiac injury was found in 1, a left ventricular contusion was identified in the second, and the third patient had no further procedure after good video-thoracoscopic visualisation of the anterior myocardium revealed no injury. In another patient, pericardial bruising was evident without any haemopericardium. The mean operative time was 13.4 (range 10 - 15) minutes, with a mean hospital stay of 5.4 (range 3 - 8) days. There were no complications. The use of a double-lumen endotracheal tube increased the cost of TPW by 23% when compared with subxiphoid pericardial window (SPW).
TPW is a feasible, although in our setting not cost-effective, diagnostic option for occult penetrating cardiac injuries.
Das Thoraxtrauma ist eine der wichtigsten Teilverletzungen des polytraumatisierten Patienten.
Zusammenfassung Die videoassistierte Thorakoskopie (VATS) ist ein ergänzendes Verfahren in der Diagnostik und Therapie von Patienten mit stumpfem Thoraxtrauma. Indikationen für eine Thorakoskopie nach Thoraxtrauma sind die intrathorakale Blutung, der persisitierende Pneumothorax, der nicht ausreichend dränierbare Hämatothorax, der Chylothorax, das posttraumatische Pleuraempyem sowie in Ausnahmefällen die Zwerchfellruptur und mediastinale Verletzungen. Voraussetzung für die VATS sind stabile Kreislaufverhältnisse sowie die Möglichkeit zur Seitenlagerung und 1-Lungen-Beatmung. Kontraindikationen, weitere Verletzungen und der Gesamtzustand des Patienten müssen strikt beachtet werden. In der Akutphase können Blutungen gezielt gestillt werden. Bei Parenchymverletzungen kann eine Resektion, z. B. als Keilresektion, mittels Stapler erfolgen. Die konsequente Ausräumung intrathorakaler Hämatome verhindert die Ausbildung von Adhäsionen. Bei persistierendem Pneumothorax kann eine thorakoskopische Pleurodese durchgeführt werden. Komplikationen der VATS nach Thoraxtrauma, wie Hypoxämien, reversible Arrhythmien, iatrogene Lungenverletzungen, Thoraxwandblutungen und postinterventionelle Interkostalneuralgie, treten in etwa 2% der Fälle auf.
Minimal-invasive Eingriffe im Thorax sind durch ein geringes Zugangstrauma charakterisiert. Mindestens ein Drittel der thoraxchirurgischen
Eingriffe können videothorakoskopisch vorgenommen werden. Die Videothorakoskopie ist das Mittel der Wahl für die Abklärung
unklarer Lungenherde, des rezidivierten Pleuraergusses, die Therapie des Spontanpneumothorax und der Hyperhidrose. Die Vorzüge
der Videothorakoskopie gewinnen besonders bei der Lungenvolumenreduktionschirurgie und der Lobektomie beim nichtkleinzelligen
Lungenkarzinom im StadiumI an Bedeutung. Die videothorakoskopische Lobektomie ist sicher, onkologisch vertretbar und bezüglich
der lokalen Tumorkontrolle der konventionellen Lobektomie nicht unterlegen. Besonders zu empfehlen ist die Videothorakoskopie
zum Staging des Lungenkarzinoms, zur Abklärung mediastinaler oder pleuraler Raumforderungen wie auch zur Diagnostik und Therapie
des Thoraxtraumas.
Minimally invasive thoracic surgery is characterized by minimized chest damage. At least one third of thoracic surgery may
be performed by videothoracoscopy. Videothoracoscopy is the method of choice for the diagnostic work-up of lung lesions and
recurrent pleural effusion and in the treatment of spontaneous pneumothorax and hyperhidrosis. The advantages of videothoracoscopy
become most important in lung volume reduction surgery and thoracoscopic lobectomy in patients with stageI non-small cell
lung cancer. Videothoracoscopic lobectomy is safe, justifiable from an oncologic perspective, and not inferior regarding its
ability to achieve locoregional control in comparison with the conventional lobectomy. Videothoracoscopy should be recommended
especially for lung cancer staging, for diagnostics, and for therapy of mediastinal or pleural tumors as well as for chest
trauma.
SchlüsselwörterMinimal-invasive Thoraxchirurgie-Videothorakoskopie
KeywordsMinimally invasive thoracic surgery-Videothoracoscopy
The role of video-assisted thoracic surgery (VATS) in trauma has yet to be established. Up to the time of this writing, reviews of thoracoscopy in trauma have been primarily descriptive rather than analytic. This article analyzes the results of thoracoscopy (nonvideo and VATS) in trauma.
Analysis was done by reviewing 28 nonoverlapping studies since the introduction of thoracoscopy in 1910, with a combined total of more than 500 patients.
Diagnostically, thoracoscopy has been used primarily to evaluate diaphragmatic injury, continued chest tube bleeding, and suspected cardiac injury. Thoracoscopy has a 98% (188/191 patients) accuracy rate in diagnosing diaphragmatic injuries. Therapeutically, thoracoscopy has been used primarily to control chest tube bleeding, evacuate retained hemothoraces, and evacuate empyemas. Thoracoscopy is 90% (89/99 patients) effective in evacuating retained hemothoraces, 86% (19/22 patients) effective in evacuating empyemas, and 82% (33/40 patients) effective in controlling chest tube bleeding. Thoracoscopy benefits include preventing 62% (323/514) of trauma patients from having a thoracotomy or laparotomy. Risks include a 2% (11/534 patients) procedure-related complication rate and a 0.8% (4/471 patients) missed injury rate. Technical failure rates are 10% (10/99 patients) and 4% (7/199 patients) in evacuation of retained hemothoraces and evaluation of diaphragmatic injuries, respectively.
Analysis suggests that thoracoscopy (nonvideo and VATS) can be applied safely and effectively in the care of the injured patient.
