Traumatic retained hemothorax: is it time for video assisted thoracoscopic surgery


  • Mayank Badkur Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan India
  • Suruthi Baskaran Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan India
  • Satya Prakash Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan India
  • Lalit Kishore Department of General Surgery, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
  • Mahendra Lodha Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan India
  • Mahaveer Rodha Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan India
  • Ramkaran Chaudhary Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan India
  • Ashok Puranik Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan India



Hemothorax, Retained hemothorax, Video assisted thoracoscopic surgery, Thoracostomy, Thoracic trauma


Thoracic trauma is a significant cause of morbidity and mortality, if not treated promptly. 80% to 85% of chest injuries can be treated with chest tube insertion alone. However, in about four to 20% of population, there is incomplete clearance of hemothorax following tube insertion and can lead to a condition called retained hemothorax. The purpose of this review is to establish the role and effectiveness of Video assisted thoracoscopic surgery (VATS) in successful evacuation of retained hemothorax following blunt thoracic trauma. Relevant articles from databases like Pubmed, Google scholar, Medline and Cochrane library were included. A retained hemothorax is defined as the persistence of residual clots in the pleural cavity, which is radiologically evident, 72 hours following initial tube thoracostomy. The various options to manage this condition include observation, insertion of second thoracostomy tube, intrapleural fibrinolytic, VATS or thoracotomy. Based on review of existing studies, VATS evacuation was found to have shorter hospital stay, lesser costs and shorter duration of tube drainage. There was also lesser rate of conversion to thoracotomy as compared to other methods and fewer complications like fibrothorax and empyema. In hemodynamically unstable patients, which is a contraindication to VATS, use of intrapleural fibrinolytics like streptokinase may be considered as an alternative option to provide clearance of the retained hemothorax. Retained hemothorax, when encountered following thoracic trauma, can be effectively managed by VATS. The decision to use VATS for hemothorax evacuation should be made promptly for maximum results, especially within three to seven days following trauma.

Author Biography

Mayank Badkur, Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan India

Assistant Professor, Department of General Surgery, All India Institute of Medical Sciences Jodhpur Rajasthan India.


Henry S. ATLS advanced trauma life support, student course manual, 10th edition. American college of surgeo. 2018.

Chou YP, Lin HL, Wu TC. Video-assisted thoracoscopic surgery for retained hemothorax in blunt chest trauma. Curr Opin Pulm Med. 2015;21(4):393-8.

Billeter AT, Druen D, Franklin GA, Smith JW, Wrightson W, Richardson JD. Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review. Langenbecks Arch Surg. 2013;398(4):515-23.

Bozzay JD, Bradley MJ. Management of post-traumatic retained hemothorax. Trauma. 2019;21(1):14-20.

Meyer DM, Jessen ME, Wait MA, Estrera AS. Early Evacuation of Traumatic Retained Hemothoraces Using Thoracoscopy: A Prospective, Randomized Trial. Ann Thorac Surg. 1997;64(5):1396-401.

Oğuzkaya F, Akçalı Y, Bilgin M. Videothoracoscopy versus intrapleural streptokinase for management of post traumatic retained haemothorax: a retrospective study of 65 cases. Injury. 2005;36(4):526-9.

Casós SR, Richardson JD. Role of thoracoscopy in acute management of chest injury: Curr Opin Crit Care. 2006;12(6):584-9.

Sinha P, Sarkar P. Late clotted haemothorax after blunt chest trauma. Emerg Med J. 1998;15(3):189-91.

Scott MF, Khodaverdian RA, Shaheen JL, Ney AL, Nygaard RM. Predictors of retained hemothorax after trauma and impact on patient outcomes. Eur J Trauma Emerg Surg. 2017;43(2):179-84.

Benns MV, Egger ME, Harbrecht BG, Franklin GA, Smith JW, Miller KR, et al. Does chest tube location matter? An analysis of chest tube position and the need for secondary interventions: J Trauma Acute Care Surg. 2015;78(2):386-90.

Kugler NW, Carver TW, Milia D, Paul JS. Thoracic irrigation prevents retained hemothorax: A prospective propensity scored analysis. J Trauma Acute Care Surg. 2017;83(6):1136-41.

Bilello JF, Davis JW, Lemaster DM. Occult traumatic hemothorax: when can sleeping dogs lie? Am J Surg. 2005;190(6):844-8.

DuBose J, Inaba K, Okoye O, Demetriades D, Scalea T, O’Connor J, et al. Development of posttraumatic empyema in patients with retained hemothorax: Results of a prospective, observational AAST study. J Trauma Acute Care Surg. 2012;73(3):752-7.

Chardoli M. Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma. Chin J Traumatol. 2013;16(6):351-4.

Kea B, Gamarallage R, Vairamuthu, H, Fortman J, Lunney K, Hendey GW, et al. What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma? Am J Emerg Med. 2013;31(8):1268-73.

Morrison CA, Lee TC, Wall MJ, Carrick MM. Use of a Trauma Service Clinical Pathway to Improve Patient Outcomes for Retained Traumatic Hemothorax. World J Surg. 2009;33(9):1851-6.

Elkhayat H, Ayyad S, Mohamed AK, Emad M, Farhgaly A. Thoracoscopic evacuation compared with reinsertion of thoracostomy tube in persistent traumatic hemothorax. J Curr Med Res Pract. 2018;3(2):81.

Hendriksen BS, Kuroki MT, Armen SB, Reed MF, Taylor MD, Hollenbeak CS. Lytic Therapy for Retained Traumatic Hemothorax. Chest. 2019;155(4):805-15.

Holsen MR, Tameron AM, Evans DC, Thompson M. Intrapleural Tissue Plasminogen Activator for Traumatic Retained Hemothorax. Ann Pharmacother. 2019;53(10):1060-6.

Lodhia JV, Konstantinidis K, Papagiannopoulos K. Video-assisted thoracoscopic surgery in trauma: pros and cons. J Thorac Dis. 2019;11(4):1662-7.

Sanna S, Bertolaccini L, Brandolini J, Argnani D, Mengozzi M, Pardolesi A, et al. Uniportal video-assisted thoracoscopic surgery in hemothorax. J Vis Surg. 2017;3:126.

Ziapour B, Mostafidi E, Sadeghi-Bazargani H, Kabir A, Okereke I. Timing to perform VATS for traumatic-retained hemothorax (a systematic review and meta-analysis). Eur J Trauma Emerg Surg. 2020;46(2):337-46.

Abolhoda A. Diagnostic and therapeutic video assisted thoracic surgery (VATS) following chest trauma. Eur J Cardiothorac Surg. 1997;12(3):356-60.

Fabbrucci P, Nocentini L, Secci S, Manzoli D, Bruscino A, Fedi M, et al. Video-assisted thoracoscopy in the early diagnosis and management of post-traumatic pneumothorax and hemothorax. Surg Endosc. 2008;22(5):1227-31.

Smith JW, Franklin GA, Harbrecht BG, Richardson JD. Early VATS For Blunt Chest Trauma: A Management Technique Underutilized By Acute Care Surgeons: J Trauma Inj Infect Crit Care. 2011;71(1):102-7.

Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg. 2004;78(1):282-5.

Lin HL, Huang WY, Yang C, Chou SM, Chiang HI, Kuo LC, et al. How early should VATS be performed for retained haemothorax in blunt chest trauma? Injury. 2014;45(9):1359-64.

Huang FD, Yeh WB, Chen SS, Liu YY, Lu IY, Chou YP, et al. Early Management of Retained Hemothorax in Blunt Head and Chest Trauma. World J Surg. 2018;42(7):2061-6.

Chou YP, Kuo LC, Soo KM, Tarng YW, Chiang HI, Huang FD, et al. The role of repairing lung lacerations during video-assisted thoracoscopic surgery evacuations for retained haemothorax caused by blunt chest trauma. Eur J Cardiothorac Surg. 2014;46(1):107-11.

Lin HL, Tarng YW, Wu TH, Huang FD, Huang WY, Chou YP. The advantages of adding rib fixations during VATS for retained hemothorax in serious blunt chest trauma – A prospective cohort study. Int J Surg. 2019;65:13-8.

Yanık F. The role of VATS in the diagnosis and treatment of diaphragmatic injuries after penetrating thoracic traumas. Turk J Trauma Emerg Surg. 2019. Available from: Last accessed on 10 July 2020.

Manlulu A, Lee T, Thung K, Wong R, Yim A. Current indications and results of VATS in the evaluation and management of hemodynamically stable thoracic injuries. Eur J Cardiothorac Surg. 2004;25(6):1048-53.






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