Pulmonary Tractotomy Research Articles

A new approach for the acquisition of trauma surgical skills: an OSCE type of simulation training program.

BackgroundWorldwide, trauma-related deaths are one of the main causes of mortality. Appropriate surgical treatment is crucial to prevent mortality, however, in the past decade, general surgery residents’ exposure to trauma cases has decreased, particularly since the COVID-19 pandemic. In this context, accessible simulation-based training scenarios are essential.MethodsA low-cost, previously tested OSCE scenario for the evaluation of surgical skills in trauma was implemented as part of a short training boot camp for residents and recently graduated surgeons. The following stations were included bowel anastomosis, vascular anastomosis, penetrating lung injury, penetrating cardiac injury, and gastric perforation (laparoscopic suturing). A total of 75 participants from 15 different programs were recruited. Each station was videotaped in high definition and assessed in a remote and asynchronous manner. The level of competency was assessed through global and specific rating scales alongside procedural times. Self-confidence to perform the procedure as the leading surgeon was evaluated before and after training.ResultsStatistically significant differences were found in pre-training scores between groups for all stations. The lowest scores were obtained in the cardiac and lung injury stations. After training, participants significantly increased their level of competence in both grading systems. Procedural times for the pulmonary tractotomy, bowel anastomosis, and vascular anastomosis stations increased after training. A significant improvement in self-confidence was shown in all stations.ConclusionAn OSCE scenario for training surgical skills in trauma was effective in improving proficiency level and self-confidence. Low pre-training scores and level of confidence in the cardiac and lung injury stations represent a deficit in residency programs that should be addressed. The incorporation of simulation-based teaching tools at early stages in residency would be beneficial when future surgeons face extremely severe trauma scenarios.

Tractotomy using the Penrose drain guide for deep lung injury caused by chest drainage: a case report

BackgroundPulmonary tractotomy effectively treats deep pulmonary penetrating injuries; however, it requires the accurate insertion of forceps or a stapler into the wound tract. This report describes a case of tractotomy using the Penrose drain guide for a deep lung injury caused by chest drainage.Case presentationA 75-year-old man suffered multiple rib fractures and hemothorax. After admission, chest tube drainage was performed because the patient’s respiratory condition deteriorated due to increased right pleural effusion. However, as the chest tube was stabbing into the right upper lobe, a pulmonary tractotomy was performed to treat the injury. Cutting the visceral pleura just over the tip of the chest tube caused the tube to completely penetrate the lung. A Penrose drain tube was fixed to the chest tube, which was then removed. The Penrose drain tube completely penetrated the lung and was coupled to the anvil side of the stapler to guide it smoothly into the wound tract. After stapling left the wound tract open, selective suture ligation of the damaged vessel and bronchioles was performed.ConclusionsAlthough the indications for tractotomy using the Penrose drain guide are limited, we believe that this technique can be useful in patients with deep stabbing or penetrating lung injuries with rod- or tube-shaped foreign body remnants.

VATS pulmonary tractotomy for penetrating lung injury caused by a crossbow: A case report

VATS pulmonary tractotomy for penetrating lung injury caused by a crossbow: A case report

Achievement of effective cardiopulmonary trauma surgical skills training throughout the incorporation of a low-cost and easy to implement pulsatile simulation model

. In the last decade, concern regarding the preparedness of general surgery graduates to effectively manage thoracic trauma cases has been raised. However, due to limited availability and elevated costs, access to cardiopulmonary trauma simulation models is limited. This article describes our experience implementing a low-cost blended ex vivo tissue-based simulation model using animal by-products that incorporates pump perfusion and ventilation. . Firstly, for validation purposes 8 junior residents, 8 recently graduated general surgeons, and 3 cardiothoracic surgery attendings from Pontificia Universidad Católica de Chile Clinical Hospital were recruited. Proficiency in performing a pulmonary tractotomy and a myocardial injury repair was assessed with global and specific rating scales. Secondly, to evaluate the effectiveness of the model as a learning tool, 16 general surgery residents from different programs across the country were recruited receiving intensive, personalized training on the models. Proficiency was measured before and after the training. . For the validation phase, significant differences among groups according to the previous level of expertise were shown, and therefore construct validity was established. The results of the second phase showed a significant overall improvement in participant's performance. . Effective training and assessment for advanced surgical skills in cardiothoracic trauma can be achieved using a low-cost pulsatile simulation model.

Pulmonary Tractotomy for a Penetrating Lung Injury Caused by a Metal Fragment—Report of a Case—

Pulmonary Tractotomy for a Penetrating Lung Injury Caused by a Metal Fragment—Report of a Case—

Pulmonary tractotomy for penetrating pulmonary injuries caused by bull horn: a case report

In our environment, the seriously wounded and injured in the context of the taurine injuries (by definition of high energy) justify an important problem of health. The potential complexity of the situations to be resolved obliges the prioritization in the action. So, to improve the prognosis of the penetrating pulmonary injuries it is absolutely necessary to both know the specificities of this type of injuries such as adapting the initial care protocols to these particularities traumatized serious. The present case reports a multiple and bilateral penetrating pulmonary injuries caused by bull-horn. It is not often that injuries of this magnitude reach the hospital alive, which is why the exceptionality of the case and the challenge that arises. We used endostapler for the management of penetrating pulmonary injuries to perform the tractotomy. After a complicated postoperative period by multiple thoracic and abdominal injuries, the patient could leave the hospital showing full recovery of thoracic wounds. Stapled pulmonary tractotomy allows a rapid, effective, and safe approach to the exposure of bleeding intraparenchymal pulmonary vessels and transected bronchi. This technique can be used without any bleeding from the staple line. We believe that tractotomy can play an important role in treating penetrating lung trauma, specially with multiple or bilateral injuries in the lung and avoid formal resection preserving lung volume and reduces the operative time and blood loss.

Predictors of outcome in 101 patients requiring emergent thoracotomy for penetrating pulmonary injuries.

Operative interventions are uncommonly required for penetrating pulmonary injuries. Similarly, because their incidence is low, few series appear sporadically in the literature. Objectives of this study are to identify predictors of outcome for patients requiring emergent thoracotomy for penetrating pulmonary injuries and evaluate the use of tissue sparing versus resective techniques for their management. This is a retrospective 169-month study of all patients with penetrating pulmonary injuries requiring thoracotomy. The main outcome measures are: physiologic parameters, AAST-OIS injury grade, surgical procedures and mortality. Statistical analysis includes univariate and stepwise logistic regression. 101 patients required thoracotomy for penetrating pulmonary injuries. Mechanism of injury includes: gunshot wounds (GSW)-73 (72%), stab wounds (SW)-28 (33%). Mean systolic BP 97±47, mean HR 92±47, and mean admission pH 7.22±0.17. Mean RTS 6.25±2.7, mean ISS 36±22. The mean estimated blood loss (EBL) was 5277±4955mls. Predictors of outcome are: admission pH (p=0.0014), admission base deficit (p<0.0001), packed red blood cells (PRBCs) transfused (p=0.023), whole blood transfused (p<0.01). A total of 143 procedures were required in 101 patients: tissue sparing 114 (80%) versus resective procedures 29 (20%). Only pneumonectomy (p=0.024) predicted outcome. Overall survival 64/101-64%. American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) injury grades I-III versus IV-VI predicts survival (p<0.001). Stepwise logistic regression identified AAST-OIS injury grades IV-VI (p=0.007; OR 6.38 [95% CI 1.64-24.78]), intraoperative dysrhythmias (p=0.003; OR 17.38 [95% CI 2.59-116.49]) and associated cardiac injuries (p=0.02; OR 8.74 [95% CI 1.37-55.79]) as independent predictors of outcome. Predictors of outcome for penetrating pulmonary injuries requiring thoracotomy are identified and must be taken into account in their operative management. Tissue sparing techniques-stapled pulmonary tractotomy is once again validated, and it remains effective as the mainstay for their management; however, only pneumonectomy predicts outcome. AAST-OIS injury grades IV-VI predict outcome with higher injury grades requiring resective procedures.

Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: A content analysis and expert appropriateness rating study.

The use of abbreviated or damage control (DC) interventions may improve outcomes in severely injured patients when appropriately indicated. We sought to determine which indications for DC interventions have been most commonly reported in the peer-reviewed literature to date and evaluate the opinions of experts regarding the appropriateness (expected benefit-to-harm ratio) of the reported indications for use in practice. Two investigators used an abbreviated grounded theory method to synthesize indications for 16 different DC interventions reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. For each indication code, an international panel of trauma surgery experts (n = 9) then rated the appropriateness of conducting the DC intervention of interest in an adult civilian trauma patient. The 424 indications identified in the literature were synthesized into 101 unique indications. The panel assessed 12 (70.6%) of the coded indications for the 7 different thoracic, 47 (78.3%) for the 7 different abdominal/pelvic, and 18 (75.0%) for the 2 different vascular interventions to be appropriate for use in practice. These included indications for rapid lung-sparing surgery (pneumonorrhaphy, pulmonary tractotomy, and pulmonary wedge resection) (n = 1); pulmonary tractotomy (n = 3); rapid, simultaneously stapled pneumonectomy (n = 1); therapeutic mediastinal and/or pleural space packing (n = 4); temporary thoracic closure (n = 3); therapeutic perihepatic packing (n = 28); staged pancreaticoduodenectomy (n = 2); temporary abdominal closure (n = 12); extraperitoneal pelvic packing (n = 5); balloon catheter tamponade (n = 6); and temporary intravascular shunting (n = 11). This study identified a list of candidate appropriate indications for use of 12 different DC interventions that were suggested by authors of peer-reviewed articles and assessed by a panel of independent experts to be appropriate. These indications may be used to focus future research and (in the interim) guide surgical practice while studies are conducted to evaluate their impact on patient outcomes.

Disruptive technology in the treatment of thoracic trauma

The care of patients with thoracic injuries has undergone monumental change over the past 25 years. Advances in technology have driven improvements in care, with obvious benefits to patients. In many instances, new or “disruptive” technologies have unexpectedly displaced previously established standards for the diagnosis and treatment of these potentially devastating injuries. Examples of disruptive technology include the use of ultrasound technology for the diagnosis of cardiac tamponade and pneumothorax; thoracoscopic techniques instead of thoracotomy, pulmonary tractotomy, and stapled lung resection; endovascular repair of thoracic aortic injury; operative fixation of flail chest; and the enhanced availability of extracorporeal lung support for severe respiratory failure. Surgeons must be prepared to recognize the benefits, and limits, of novel technologies and incorporate these methods into day-to-day treatment protocols.

Argon Beam Coagulator: An Effective Adjunct to Stapled Pulmonary Tractotomy to Control Hemorrhage in Penetrating Pulmonary Injuries

Stapled pulmonary tractotomy with selective vascular ligation is a rapid technique used to control hemorrhage in penetrating pulmonary injuries and has assumed an important role in the trauma surgical armamentarium for the management of these injuries. This technique was designed as tissue sparing to avoid complications well known to occur with extensive pulmonary resections. Multiple studies have validated and reported this technique to be both safe and effective. Here we present the use of the argon beam coagulator as a valid adjunct to stapled pulmonary tractotomy for the management of penetrating pulmonary injuries. To our knowledge, the use of this technique has not been reported for control of massive intraparenchymal pulmonary hemorrhage.

Surgical management of penetrating pulmonary injuries

Chest injuries were reported as early as 3000 BC in the Edwin Smith Surgical Papyrus. Ancient Greek chronicles reveal that they had anatomic knowledge of the thoracic structures. Even in the ancient world, most of the therapeutic modalities for chest wounds and traumatic pulmonary injuries were developed during wartime.The majority of lung injuries can be managed non-operatively, but pulmonary injuries that require operative surgical intervention can be quite challenging. Recent progress in treating severe pulmonary injuries has relied on finding shorter and simpler lung-sparing techniques. The applicability of stapled pulmonary tractotomy was confirmed as a safe and valuable procedure.Advancement in technology have revolutionized thoracic surgery and ushered in the era of video-assisted thoracoscopic surgery (VATS), providing an alternative method for accurate and direct evaluation of the lung parenchyma, mediastinum, and diaphragmatic injuries.The aim of this article is to describe the incidence of the penetrating pulmonary injuries, the ultimate techniques used in its operative management, as well as the diagnosis, complications, and morbidity and mortality.

A middle lobe tractotomy of the lung for a stab injury: report of a survival case

We report the case of a patient who survived after a pulmonary tractotomy. A 54-year-old man was stabbed in the back with a knife and was admitted to our emergency department. Imaging findings showed that there was hemopneumothorax of the right lung. After inserting a chest tube, a massive air leakage from the chest drain continued, and a serial chest roentgenogram showed progressive lung collapse. The patient therefore underwent an emergency thoracotomy. It was found that the wound penetrated through a middle lobe to the surface of an upper lobe of the right lung. A right middle lobe tractotomy was performed, and the patient's postoperative course was uneventful. Selected patients can be rescued without resection of a massive amount of lung tissue.

Pulmonary Tractotomy for a Patient with Traumatic Penetrating Lung Injury: Report of a Case

We report a case of traumatic hemopneumothorax caused by penetrating lung injury in a 26-year-old man. The patient underwent emergency thoractomy, which revealed hemorrhage in the lingular segment of the left lung. We found the bleeding point and controlled the hemorrhage using pulmonary tractotomy by inserting a linear stapler into the stab wound in the pulmonary parenchyma. The original technique of pulmonary tractotomy was performed for complete through-and-through injury by dividing the bridge of lung tissue between the aortic clamps. We were able to apply this procedure safely to stop bleeding from a stab wound that did not go through the lung. Thus, pulmonary tractotomy is an effective damage-control operation for the lung with obvious advantages over major lung resection.

Limitations of Stapled Tractotomy for Central Lung Penetrating Injury

INTRODUCTION: The operative management of penetrating injury by pulmonary tractotomy with selective vascular ligation has been well described. We report a case of stapled tractotomy resulting in contralateral lung collapse.

Pulmonary Tractotomy versus Lung Resection: Viable Options in Penetrating Lung Injury

Emergency lung resection following penetrating chest trauma has been associated with mortality rates as high as 55-100%. Pulmonary tractotomy is advocated as a rapid alternative method of dealing with deep lobar injuries. We reviewed our experience with resection and tractotomy to determine whether method of management affects mortality or if patient presentation is more critical in determining outcome. A retrospective review of all patients with chest injury seen at an urban Level I trauma center from 2/89-1/99 was performed. All patients undergoing parenchymal surgery were included. Records were abstracted for grade of injury, type of resection, presenting systolic blood pressure (SBP), temperature, Injury Severity Score (ISS), operative time, and estimated blood loss (EBL). Mortality and thoracic complications were compared between groups. Two hundred forty-six of 2736 patients with penetrating chest trauma underwent thoracotomy, with 70 (28%) requiring some form of lung resection. There were 11 (15.7%) deaths. Patients who died had lower SBP (53 +/- 32 mm Hg vs 77 +/- 28 mm Hg), lower temperature (32.5 degrees +/- 1.3 degrees C vs 34.3 degrees +/- 1.2 degrees C), higher ISS (33 +/- 13 vs 23 +/- 9), and greater EBL (9.8 +/- 4.3 liters vs 2.8 +/- 2.1 liters) compared with survivors (p < 0.05 for all). Mortality was also increased in the presence of cardiac injury (33% with vs 12% without) and the need for laparotomy (26% with vs 9% without) (p < 0.05 for all). Tractotomy was associated with an increased incidence of chest complications (67% vs 24%, p = 0.05) compared with lobectomy with no difference in presenting physiology, operative time, or mortality. Lung resection for penetrating injuries can be done safely with morbidity and mortality rates lower than previously reported. Patient outcome is related to severity of injury rather than type of resection. Tractotomy is associated with a higher incidence of infectious complications and is not associated with shortened operative times or survival.

Damage control: collective review.

Damage control: collective review.

Pulmonary tractotomy as an abbreviated thoracotomy technique.

Operative abbreviated thoracotomy techniques in thoracic trauma include emergency center thoracotomy, ligation of major arterial branches, packing the thoracic cavity for diffuse bleeding, towel clip or Bogota bag closure of the chest, and pulmonary tractotomy. Pulmonary tractotomy with selective vascular ligation was originally described for deep through-and-through lung injuries that did not involve hilar vessels or airways. Pulmonary tractotomy has evolved into use as an abbreviated thoracotomy technique in patients with severe thoracic or multivisceral trauma. As with any operative technique in high-risk patients, specific procedure-related complications may occur and are analyzed herein. The objective of this manuscript is to review the indications, techniques, and results for pulmonary tractotomy in trauma patients requiring abbreviated thoracotomy. Medical records were retrospectively reviewed for 30 of 32 consecutive tractotomy patients treated at Ben Taub General Hospital, during a 3-year period. By using a model for logistic regression analysis, the characteristics of each patient and their clinical course were tested for impact on mortality. Seventy percent of patients had at least one intraoperative parameter indicative of acidosis (pH < 7.2), coagulopathy (prothrombin time > 13.8 or partial thromboplastin time > 38.0 seconds), or hypothermia (core temperature < 34 degrees C), and 50% of patients manifested two of these three parameters. The mortality rate among the 30 patients was 17%. Three of the five patients who died were noted to be acidotic, coagulopathic, and hypothermic. Twelve of 25 patients who survived more than 1 day had at least one thoracic complication. There were no late deaths. There was one failed tractotomy and one missed injury. A second thoracotomy was not required for control of a lung injury in any patient. Logistic regression analysis showed that intraoperative blood loss was the only predictive factor for mortality. Pulmonary tractotomy is a simple and effective technique in injured patients who require an abbreviated thoracotomy and has an acceptable mortality and complication rate. This follow-up report notes that as definitive therapy, tractotomy continues to allow for direct control of bleeding and air leak and obviates the need for formal resection.

Stapled pulmonary tractotomy: a rapid way to control hemorrhage in penetrating pulmonary injuries.

Stapled pulmonary tractotomy: a rapid way to control hemorrhage in penetrating pulmonary injuries.

Stapled pulmonary tractotomy: a rapid way to control hemorrhage in penetrating pulmonary injuries

Stapled pulmonary tractotomy: a rapid way to control hemorrhage in penetrating pulmonary injuries

DAMAGE CONTROL FOR THORACIC INJURIES

Some of the earliest damage control techniques were applied to the chest during emergency center thoracotomy. It provided a paradigm that was adapted to other areas. Damage control of chest injuries has a different philosophy than that of abdominal injuries. Damage control in the abdomen primarily consists of multiple staged operations with abbreviated closures. Damage control in the chest consists of different technical maneuvers to use quicker and technically less demanding operations to accomplish the same goal. The philosophy of doing only enough to restore a survivable physiology is still a common theme. The following are the major principles of damage control for thoracic injuries: 1. Emergency center thoracotomy is a damage control prototype. 2. Anterolateral thoracotomy is the empiric incision of choice in the patient in extremis. 3. Nonanatomically stapled lung resections, pulmonary tractotomy, and en masse lobectomy/pneumonectomy are pulmonary damage control procedures. 4. The unique physiology of the chest may require en masse closure of muscles or patch closure of the wound. 5. Cardiopulmonary physiology can be affected by packing. Packing thus has a limited role in thoracic damage control. 6. Prosthetic grafts, intravascular shunts, and ligation are common thoracic vascular damage control techniques. 7. With new technology, an increased role for cardiopulmonary bypass and cardiac assistance may develop. 8. New technology must not overly complicate a procedure if it is to be a valuable damage control adjunct.