Feasibility and efficacy of video-assisted thoracoscopic surgery for the surgical stabilization of rib fractures: a single-center retrospective cohort study

Abstract

Purpose

Surgical fixation of traumatic multiple rib fractures is becoming more common; video-assisted thoracoscopic surgery (VATS) is reportedly useful in such cases. Therefore, we aimed to explore the feasibility and effectiveness of VATS for surgical stabilization of rib fractures (SSRF).

Methods

We conducted a single-center, medical record-based retrospective cohort study including 52 patients with traumatic multiple rib fractures who underwent SSRF with or without VATS. All patients were admitted to our hospital between January 2017 and March 2024. Patient characteristics and perioperative outcomes were compared between the groups, and the frequencies of relevant VATS outcomes were investigated.

Results

VATS was performed in 42 patients. The with-VATS group had significantly more isolated thoracic trauma (p =.04) and lower thoracic Abbreviated Injury Scale and Injury Severity Score (p =.015, p =.017) than the without-VATS group, albeit no differences in perioperative outcomes were found. In the VATS group, common intraoperative findings included sharp bone fragments protruding into the thoracic cavity, lung entrapment at fracture site, lung and diaphragm injuries, and intrathoracic hematomas. These injuries were managed through repair, as well as hematoma irrigation and evacuation.

Conclusions

VATS was feasible in 80% cases and was not associated with adverse outcomes. The addition of VATS to SSRF facilitated missed-injury identification and repair, enhanced intrathoracic visualization during fixation, and enabled hematoma evacuation, potentially reducing perioperative complications.

Introduction

Rib fractures are observed in 10% of blunt trauma cases and approximately 6% of trauma inpatients [1, 2]. In the short term, they are associated with increased mortality, pneumonia, prolonged mechanical ventilation, intensive care unit (ICU) stay, and hospital length of stay. Long term complications include increased hospital readmissions, decreased activities of daily living, and increased treatment costs [3–7]. Surgical stabilization of rib fractures (SSRF) for traumatic rib fractures, once primarily reserved for flail chest, has shown benefits even in patients without flail chest [8, 9], leading to broader indications and widespread use [10].

Video-assisted thoracoscopic surgery (VATS) has been reported to aid in detecting missed injuries, preventing perioperative complications, and minimizing invasiveness [11]. However, there are cases wherein thoracoscopic surgery cannot be performed owing to difficulties in maintaining one-lung ventilation due to unstable respiratory status, positional restrictions caused by combined injuries, or poor visual field in the thoracic cavity caused by adhesions in the thoracic cavity. Current literature includes only a few case reports with small sample sizes; further, there are few reports on the feasibility of SSRF combined with VATS for traumatic rib fractures and on comparing a VATS and a non-VATS combination group [12–17].

Therefore, we aimed to evaluate the feasibility and effectiveness of VATS for SSRF by investigating the number of SSRF cases wherein VATS was performed, comparing patient characteristics and treatment outcomes in those undergoing SSRF for traumatic rib fractures assigned to with-VATS and without-VATS groups, and elucidating the frequency of relevant VATS outcomes.

Methods

Study design and data collection

This was a single-center, medical record-based retrospective cohort study. Among 506 patients with traumatic rib fractures admitted to Sakai City Medical Center (referred to as “our hospital” from here on) between January 2017 and March 2024, 52 patients who underwent SSRF were included.

From medical records, data was obtained regrading patient characteristics, including age, sex, comorbidities, detailed mechanism of injury, isolated thoracic trauma versus multiple trauma, thoracic trauma severity using the Abbreviated Injury Scale (AIS), and overall trauma severity using the Injury Severity Score (ISS).

Surgical parameters (use of thoracoscopy, time from injury to surgery, operation time, and intraoperative blood loss), and treatment outcomes (postoperative complications, mortality, duration of postoperative mechanical ventilation, postoperative ICU stay, postoperative hospital stay, total hospital stay, and discharge destination [home versus transfer]) were assessed.

Additionally, we analyzed intraoperative findings and associated injuries identified using thoracoscopy, as well as the incidence and frequency of additional surgical procedures performed.

Statistical analyses

Categorical variables are presented as numbers and percentages. Group comparisons were performed using chi-square tests and Fisher’s exact tests when more than 20% of expected frequencies were below five. Continuous variables are presented as medians and interquartile ranges; group comparisons were performed using U tests. Statistical significance was set at p <.05 for group comparisons, and analyses were performed using IBM^® SPSS Statistics version 26 (New York, NY, USA).

Surgical indications and treatment strategies

Surgical indications and treatment strategies for traumatic rib fractures at our hospital were based on the guidelines of the Chest Wall Injury Society [18] (Fig. 1). Morphological evaluation of traumatic rib fractures was performed using computed tomography (CT), while pain control, mobilization status, and respiratory function were assessed through physical therapy in conjunction with appropriate analgesic administration. In patients with hemodynamic instability due to severe trauma, initial resuscitation is prioritized; surgical evaluation is deferred until after the patient is stabilized. As access to the first and second ribs is challenging due to their localization near major blood vessels and nerves, they are excluded from fixation. The eleventh and twelfth ribs were also excluded because they are floating ribs. Anatomical surgical indications included flail chest, severe displacement, and injury to surrounding organs (the lung, diaphragm, major blood vessel).

Fig. 1.

Flowchart of the treatment strategy for traumatic rib fractures at our hospital ^*1CT: Computed tomography ^*2Other-organ injury: lung parenchyma, diaphragm, and aortic injuries ^*33 + > 50% displaced rib fractures: three ipsilateral consecutive or non-consecutive ribs, each with a 50% fracture displacement of the rib width on axial CT ^*4SSRF: Surgical stabilization of rib fractures ^*5VATS: Video-assisted thoracoscopic surgery

Clinical surgical indications included three or more consecutive rib fractures with ≥ 50% displacement, persistent respiratory failure despite adequate analgesic administration and physical therapy intervention preventing ventilator weaning, inability to mobilize or expectorate, or poor progression in mobilization.

The exclusion criteria included poor general condition such as being originally bedridden, or inability to tolerate general anesthesia due to severe cardiac, pulmonary, or hepatic comorbidities. Furthermore, in cases with injuries requiring priority treatment such as pelvic fractures, vertebral fractures, aortic injury, or injury to abdominal solid organs or hollow viscera, treatment of these injuries took precedence, and were subsequently re-evaluated for SSRF indications.

The surgical approach involved VATS under general anesthesia with one-lung ventilation, with the patient’s position adjusted from supine to lateral, depending on the fracture location. VATS was used to identify fracture sites, detect and repair associated intrathoracic injuries, verify fracture locations, observe fixation procedures from within the thoracic cavity, and perform intrathoracic irrigation and hematoma evacuation following fixation (Fig. 2). Our strategy was to perform SSRF with VATS in all cases eligible for SSRF; however, there were cases wherein VATS could not be performed owing to an unstable respiratory status, those wherein one-lung ventilation cannot be maintained during surgery, or those wherein intrathoracic adhesions or combined injuries restrict the patient to a supine position, making it impossible to obtain a clear view of the thoracic cavity. The above points were evaluated and considered before and during surgery to determine whether VATS was possible. If VATS was not possible, thoracotomy for pleural exploration was not performed and just SSRF was performed.

Fig. 2.

Patient positioning and surgeon positioning during surgery. a, b Position of the patient adjusted from the lateral to supine position depending on the location of the fracture. The patient’s position is fixed using a negative pressure surgical positioning mat. In this figure, the model is a surgeon, and thus, he is wearing blue scrubs. c Surgery performed with video-assisted thoracoscopic surgery under one-lung ventilation and performed jointly with an orthopedic surgeon. The left side of this figure is the patient’s head side. An orthopedic surgeon in the center of the figure is fixing the rib fracture with a plate. A surgeon stands to the right of the orthopedic surgeon at the patient’s leg side, observing the surgical procedure from inside the thoracic cavity using a thoracoscope. The monitor on the back left shows an image of the inside of the thoracic cavity as seen through the thoracoscope, and the monitor on the right shows an image of the process of fixing the plate from the chest wall side

Results

Patient cohort and group allocation

Among the 506 patients with traumatic rib fractures treated at our hospital during the observation period, SSRF was performed in 52 patients (10.2%). Of these, 42 patients (80.7%) were assigned to the with-VATS group and 10 (19.2%) to the without-VATS group (Fig. 3). The decision to not perform VATS was based on specific clinical constraints, including difficulty in achieving one-lung ventilation owing to respiratory failure, positional limitations caused by combined injuries, and poor visualization due to intrathoracic adhesions.

Fig. 3.

Patient cohort and group allocation ^*1SSRF: Surgical stabilization of rib fractures ^*2VATS: Video-assisted thoracoscopic surgery

Clinical characteristics and perioperative outcomes

Tables 1 and 2 summarize the baseline characteristics and perioperative outcomes for all 52 patients, with a comparison between the with-VATS and without-VATS groups. The median age of the cohort was 70.5 years, with males accounting for more than 70% of the study population. Regarding trauma characteristics, the with-VATS group had a significantly higher incidence of isolated thoracic trauma (p =.04), and significantly lower thoracic AIS and ISS (p =.015, p =.017), compared to the without-VATS group. Although differences did not reach statistical significance, there was a trend toward longer operation times and greater intraoperative blood loss in the with-VATS group (p =.078 and 0.094). Although there was no statistically significant difference, the VATS group had shorter postoperative days on a ventilator, ICU stays, hospital stays, and total hospital stays.

Table 1.

Baseline characteristics and perioperative outcomes in all patients

	n = 52
Age (years)	70 [50–82]
Sex (male)	39 (75)
Mechanism of injury
Blunt/Penetrating	52/0
Isolated thoracic injury	20 (38.5)
Multiple trauma	32 (61.5)
Chest AIS	3 [3–4]
ISS	17 [9–28]
Time from injury to SSRF (days)	3 [2-5.3]
Operation time (minutes)	190 [143–222]
Intraoperative bleeding (ml)	200 [73–357]
Post-operative complications
Bleeding	1 (1.9)
Revision surgery	4 (7.7)
Wound infection	1 (1.9)
Excess pleural fluid	10 (19.2)
Hemothorax	3 (5.8)
Pneumothorax	1 (1.9)
Empyema	1 (1.9)
Delirium	15 (28.8)
Pneumonia	10 (19.2)
Tracheostomy	7 (13.5)
In-hospital Mortality	0 (0)
Post-operative length of ventilator days	1 [1–4]
Post-operative length of ICU stay (days)	3 [2–6]
Post-operative length of hospital stay (days)	20 [9–33]
Length of hospital stay (days)	23 [11–41]
Discharge destination
Home	18 (34.6)
Other hospital	34 (65.4)

Continuous data are shown as median [range]. Categorical data are shown as n (%)

AIS Abbreviated Injury Scale, ISS Injury Severity Score, SSRF surgical stabilization of rib fractures, ICU intensive care unit

Table 2.

Comparison of baseline characteristics and perioperative outcomes between the with-VATS and without-VATS groups

	With VATS n = 42	Without VATS n = 10	p
Age (years)	70 [50–84]	69 [50–77]	0.862
Sex (male)	32 (76.2)	7 (70)	0.697
Mechanism of injury
Blunt/Penetrating	42/0	10/0
Isolated thoracic injury	19 (45.2)	1 (10)
Multiple trauma	23 (54.8)	9 (90)	0.04
Chest AIS	3 [3–4]	4 [3–5]	0.015
ISS	15 [9–25]	24 [19–41]	0.017
Time from injury to SSRF (days)	3 [2–6]	2 [1–4]	0.223
Operation time (minutes)	194 [150–223]	145 [103–208]	0.078
Intraoperative bleeding (ml)	230 [87–378]	100 [0-214]	0.094
Post-operative complications
Bleeding	1 (2.3)	0 (0)	0.808
Revision surgery	4 (9.5)	0 (0)	0.413
Wound infection	1 (2.3)	0 (0)	0.808
Excess pleural fluid	9 (21.4)	1 (10)	0.375
Hemothorax	1 (2.3)	2 (20)	0.091
Pneumothorax	0 (0)	2 (20)	0.625
Empyema	1 (2.3)	0 (0)	0.808
Delirium	13 (30.9)	2 (20)	0.396
Pneumonia	8 (19.0)	2 (20)	0.625
Tracheostomy	3 (7.1)	4 (40)	0.02
In-hospital mortality	0 (0)	0 (0)
Post-operative length of ventilator days	1 [1–3]	4 [18–46]	0.162
Post-operative length of ICU stay (days)	2 [2–4]	6 [2–12]	0.099
Post-operative length of hospital stay (days)	18 [9–29]	41 [18–46]	0.106
Length of hospital stay (days)	21 [11–39]	42.5 [22–56]	0.170
Discharge destination			0.068
Home	17 (40.5)	1 (10)
Other hospital	25 (59.5)	9 (90)

Continuous data are shown as median [range]. Categorical data are shown as n (%)

VATS video-assisted thoracoscopic surgery, AIS Abbreviated Injury Scale, ISS Injury Severity Score, SSRF surgical stabilization of rib fractures, ICU intensive care unit

Intraoperative thoracoscopic findings and additional procedures

Detailed intraoperative outcomes and missed injuries identified during VATS are shown in Table 3; Fig. 4. Among the 42 patients in the VATS group, eight (16%) exhibited sharp bone fragments penetrating the thoracic cavity or lung entrapment at fracture sites (Fig. 4a, b). Lung injuries were observed in seven patients (12%), and diaphragmatic injuries were detected in four patients (8%), including one with a transmural laceration (Fig. 4c) and three with non-transmural lacerations. While plate fixation was performed after reduction of the fracture sites, VATS revealed occasional protrusion of drills and depth gauges into the thoracic cavity during the procedure (Fig. 4d). In addition to preoperative intrathoracic hematoma, bleeding during rib fixation procedures resulted in intrathoracic hematoma accumulation in most cases (Fig. 4e). These outcomes and injuries were managed through VATS-guided procedures including intrathoracic hematoma evacuation, pulmorrhaphy, and diaphragm repair with direct sutures.

Table 3.

Intraoperative findings, missed injuries, and additional VATS procedures

Intraoperative findings and missed injury	n (%)	Additional procedure
Intrathoracic hematoma	41 (97)	Evacuation of intrathoracic hemorrhage
Sharp bone fragments entering the thoracic cavity	8 (16)	Release of entrapped lung
Lung entrapment at the fracture site
Lung injury	7 (12)	Pulmorrhaphy
Diaphragm injury	4 (8)	Diaphragm repair with direct suture
Transmural laceration	1 (2)
Non-transluminal laceration	3 (7)

VATS video-assisted thoracoscopic surgery

Fig. 4.

Intraoperative findings and missed injuries discovered during surgical stabilization of rib fractures with video-assisted thoracoscopic surgery. a Sharp bone fragments ejected into the chest cavity, b Trapped lung at the fracture site, c Transmural diaphragm injury, d Protrusion of the drill into the thoracic cavity (yellow arrow), e Intrathoracic hematoma after rib fixation

Discussion

Our study demonstrated that VATS could be performed in approximately 80% of SSRF cases. Using VATS, we were able to identify protruding sharp bone fragments, drill protrusion into the thoracic cavity during the surgical procedure, intrathoracic hematoma accumulation, and injuries not detected in preoperative imaging studies. These missed injuries, including lung entrapment and injury, as well as diaphragm injury, were identified and repaired under VATS assistance during the same surgery in some cases.

In treating traumatic rib fractures, the possibility of missing injuries such as delayed hemopneumothorax, recurrent pneumothorax, and diaphragm injury should be considered. Lung entrapment at rib fracture sites and sharp fracture edges cause lung and diaphragm injuries, with the risk of developing delayed hemopneumothorax or recurrent pneumothorax [19–21]. Additionally, diaphragm injuries occur in 5% of blunt chest trauma cases and approximately 10% of multiple rib fracture cases [22, 23]. These injuries are difficult to identify even on computed tomography (CT) scans [24, 25]. There are cases where missed injuries in the acute phase have led to emergency surgery to treat incarceration of abdominal organs caused by delayed diaphragmatic injury, hernia, or delayed hemothorax [26, 27]. Although our study was limited to patients undergoing SSRF, VATS enabled the identification and repair of lung entrapment and diaphragm injuries (Fig. 4-b and c) such as those that were not detected on preoperative imaging in approximately 10% of cases, potentially contributing to the prevention of mid- to long-term complications such as delayed hemopneumothorax and diaphragmatic hernia. Perioperative complications of surgical fixation include hemothorax, empyema, and pneumothorax, including tension pneumothorax from intraoperative lung injury [28]. In our study, VATS observation of plate fixation procedures for rib fractures revealed protrusion of drill bits and screw tips into the thoracic cavity (Fig. 4-d). We identified cases in the without-VATS group where postoperative air leaks were observed despite being absent preoperatively, suggesting that lung injury occurred intraoperatively. While recent plate and screw systems are equipped with stopper mechanisms to prevent excessive drill protrusion into the thoracic cavity and improve safety, lung injury occurring during plate and screw fixation with the lung entrapped at the fracture site remains a concern (Fig. 4-b). Furthermore, intrathoracic hematoma accumulation after fracture reduction and fixation was more extensive than anticipated (Fig. 4-e). We believe that VATS observation helped prevent lung injury and pneumothorax by releasing lung entrapment at fracture sites, creating space behind the fracture site, and monitoring fixation procedures. In addition, postoperative thoracic irrigation and hematoma evacuation helped prevent postoperative hemothorax and empyema.

While some studies on SSRF with VATS include > 100 cases [15], most reports only describe a few dozen [12–14, 16, 17]. These studies have reported frequencies of intrathoracic hematoma accumulation at 20–70%, that of sharp bone fragment protrusion into the thoracic cavity at approximately 20%, that of lung entrapment at fracture sites and lung injury at 10%, and that of diaphragm injury at 2% [12–17]. In our study, the frequency of intrathoracic hematoma accumulation was higher than that previously reported because it was evaluated following rib fixation procedures; however, frequencies of other intraoperative findings and missed injuries were comparable to those previously reported.

Another advantage of VATS assistance is its contribution to minimally invasive plate osteosynthesis (MIPO) procedures by enabling precise fracture site identification and optimizing and minimizing skin incision to reduce chest wall destruction [11]. Complete thoracoscopic surgery has also been described [14, 29], and this approach is expected to be useful not only for MIPO but also for fractures in locations difficult to approach from the surface of the body, such as the posterior aspect of the scapula.

Regarding disadvantages of VATS, our study showed trends toward longer operation times and increased intraoperative bleeding, although the differences between the two groups were not statistically significant. However, the increased intraoperative bleeding likely reflects more thorough intrathoracic drainage with VATS rather than increased bleeding from surgical manipulation. Although the median operation time was approximately 50 min longer due to intrathoracic observation and manipulation, it was considered acceptable as there was no increase in perioperative complications, postoperative intubation period, or length of ICU or hospital stay; therefore, suggesting no clear disadvantages associated with VATS. Although there was no statistically significant difference, the VATS group had fewer postoperative days on a ventilator and shorter ICU stays, hospital stays, and total hospital stays. In the without-VATS group, 90% patients had multiple injuries, and chest AIS and ISS were significantly higher than those in the with-VATS group. This suggests that the without-VATS group had more multiple injuries and more severe cases, resulting in a longer treatment period, including treatment for injuries outside the chest.

The major limitation of this study is that it was a single-center study with a small sample size. Previous studies also had small sample sizes, and there are limited prospective comparative trials between with-VATS and without-VATS groups. Additionally, the without-VATS group had more cases of multiple traumatic injuries with greater severity, and more positional limitations due to respiratory failure and associated injuries, suggesting that VATS may not be feasible in such cases. Although there is a possibility of missed injuries in more severe cases wherein VATS could not be performed, our strategy did not involve thoracotomy to search for missed injury in such cases. Furthermore, it is possible that there are cases in the without-VATS group wherein missed injuries could have been identified if a thoracotomy had been performed and if the thoracic cavity had been explored. Whether a search for missed injury should be performed by thoracotomy in cases wherein VATS cannot be performed remains to be determined. Furthermore, for most patients with traumatic rib fractures who did not undergo surgery, thoracoscopic intrathoracic examination was not performed, leading to potentially missed injuries in these cases. Further studies to evaluate the effectiveness of VATS are needed, including prospective comparative studies with large sample sizes, to determine its indications, including whether it may be beneficial for patients with traumatic rib fractures not requiring SSRF

Conclusion

In this study, we conducted a single-center, medical record-based, retrospective cohort study to clarify the feasibility and efficacy of combining VATS with SSRF. The use of VATS for SSRF was found to be safe and feasible, may be applicable in detecting and repairing missed injuries, and may contribute to reducing perioperative complications by removing hematomas accumulated in the thoracic cavity after surgery.

Author contributions

All authors contributed to the study conception and design. Material preparation, H. K performed data collection and analysis. The first draft of the manuscript was written by H. K and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

No funding was received for this study.

Data availability

Data sets generated during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical approval

The study was approved by the appropriate ethics committee/institutional review board (IRB) of Sakai City Medical Center [approval date, 2024/07/03; approval number, 24–442] and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Informed consent

The need for informed consent was waived due to the retrospective nature of the study.

Competing interests

The authors declare no competing interests.