European Journal of Cardio-thoracic Surgery 23 (2003) 424–425
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How-to-do-it
Thoracoscopical water jet lavage in coagulated hemothorax
Florian Tomaselli*, Alfred Maier, Heiko Renner, Freyja Maria Smolle-Jüttner
Department of Surgery, Division of Thoracic and Hyperbaric Surgery, University Medical School, Auenbruggerplatz 29 A-8036 Graz, Austria
Received 15 September 2002; received in revised form 6 November 2002; accepted 25 November 2002
Abstract
We propose the use of a pulsatile high-speed irrigation device during video-assisted thoracoscopy for retained, in part coagulated
hemothorax. Blood clots and membranes adhering to intrathoracic structures are easily removed by the water jet without damaging underlying structures. The efficient dilution of the sticky retained blood and the fragmented coagula enable their quick removal over a suction
catheter.
q 2002 Elsevier Science B.V. All rights reserved.
Keywords: Chest trauma; Hemothorax; Video-assisted thoracic surgery; Pulsatile jet lavage
1. Introduction
2. Surgical technique
Insufficiently treated posttraumatic hemothorax carries a
number of problems. Large accumulations of fluid and
coagula cause compression of the lung and, if untreated,
more or less extended pleural callosities in the later course.
Super infection of posttraumatic hemothorax either occurring spontaneously or following repeat thoracocentesis is an
additional risk [3–5].
Once coagula have formed, both thoracocentesis and
chest tube drainage will not be able to evacuate the pleural
cavity. Though video-assisted thoracic surgery (VATS) has
shown to be effective in such cases [1,2], the removal of
coagula adhering to the underlying structures usually proves
to be a tiresome work: the vision is poor since the dark
coagula absorb a large proportion of light, mechanical
crushing of coagula by clamps or suction devices provokes
repeat obstruction of the suction tube, since the fluid that can
be aspirated is thick and gluey.
Jet lavage, a pulsatile high-speed irrigation device similar
to the ‘water-pick’ systems has been successfully used in the
treatment of crushed wounds and in conditioning infected
soft tissue [6]. We applied High Speed Pulse Lavage w
(MicroAire, Surgical Instruments, Charlottesville, VA
22911 USA) during thoracoscopy for posttraumatic retained
hemothorax (Fig. 1).
VATS is performed under general anesthesia using a
double-lumen endotracheal tube, bringing the patient into
a standard lateral decubitus position. The thoracoscope is
inserted through a standard incision in the fifth or sixth
intercostal space in the midaxillary line. Two additional
incisions are made, the positions of which are determined
according to the findings on preoperative CT scan and to the
videothoracoscopic aspect of the pleural space.
Fluid components and small, floating clots are evacuated
with the help of a wide-bore suction catheter (5 mm
diameter), collecting also fluid for microbiological examination. As soon as no further retained material can be
removed by suction alone, the jet lavage (physiological
saline solution, warmed up to 358C) catheter is inserted:
blood clots or fibrinous membranes adhering to the lung
surface or to the parietal pleura are gently and thoroughly
peeled from the underlying tissue. They can then be easily
removed from the pleural cavity by suction, by gently grasping them with an atraumatic clamp or by crushing them
prior to removal by suction. Due to the high flow rate (2 l/
min under 1 bar pressure) delivered by the jet lavage system
the intrapleural fluid can be quickly cleared from all residual
blood, clots or debris, ensuring an excellent view of the
surgical team. Moreover, the dilution of the sticky blood
oozing from the crushed coagula prevents obstruction of
the suction catheter. Two large 28 French silicon chest
tubes are inserted. They remain under continuous suction
until less than 200 ml/24 h are evacuated. Antibiotic treat-
* Corresponding author. Tel.: 143-316-385-3302; fax: 143-316-3854679.
E-mail address: [email protected] (F. Tomaselli).
1010-7940/02/$ - see front matter q 2002 Elsevier Science B.V. All rights reserved.
doi:10.1016/S 1010 -79 40(02)00803-5
F. Tomaselli et al. / European Journal of Cardio-thoracic Surgery 23 (2003) 424–425
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of them had been unsuccessfully treated by chest tube drainage; the others had had attempts of thoracocentesis. In two
of the latter, who presented with leukocytosis yet without
elevated temperature the thoracoscopical aspect suggested
incipient empyema, which was verified in the microbiological specimens. The course of all 10 patients was uneventful with a median drainage duration of 3.4 days (range: 2–5
days) and a median postoperative hospital stay of 4.6 days
(range: 3–6 days). Routine follow-up after 6 weeks, including clinical examination and chest roentgenogram showed
no recurrences of pleural infusion.
3. Discussion
The rationale of pulsatile jet lavage for the removal of
adhering clots or membranes is the ‘air-gap’ within the
water jet which enhances its capacity to dissect. In spite
of the fact that the jet is sufficiently powerful to detach
adhering coagula or fibrinous membranes, there is no danger
to supple underlying structures such as nerves or vessels.
References
Fig. 1. (A,B) Thoracoscopically useable water jet lavage system ‘High
Speed Pulse Lavage w’ (MicroAire, Surgical Instruments, Charlottesville,
VA 22911 USA).
ment is only administered in case of suspected incipient
pleural empyema.
The technique was successfully applied in ten patients
with retained and largely coagulated hemothorax following
chest trauma sustained 7–19 days before admission. Seven
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