ADVANCED SURGICAL TRAINING COURSES – WARTIME EVOLUTION: PERSONAL PERSPECTIVE (a review of thoracic trauma component)

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Yaroslav TELUSHKO

Major of the Medical Service, Candidate of Medical Sciences, Associate Professor

Head of the Department of Thoracic Surgery Zaporizhzhia Military Hospital

Yurii MIKHEIEV

Major of the Medical Service, DrSci(Med),

Leading Surgeon of Zaporizhzhia Military Hospital

Roman KUZIV

Lieutenant Colonel of the Medical Service

Commander of the Military Medical Clinical Center of the Eastern Region

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A full-scale invasion of Ukraine has led to an epidemic of battle trauma affecting both military personnel and civilians. An absence of such a specialty in Ukraine as Trauma Surgery, as well as the urgent need to rapidly train young surgeons in providing surgical care close to combat zones, primarily within Forward Surgical Teams (Role 2), has created a high demand for training programs such as ATLS (Advanced Trauma Life Support), ASSET (Advanced Surgical Skills in Exposure in Trauma), and HEST (Hostile Environment Surgical Training). A number of surgeons, both young and experienced, have completed these courses in Ukraine and abroad. Moreover, we now have certified instructors among our domestic surgeons who are able to mentor such courses independently.

Therefore, we really appreciate the creators of these courses. However, as the full-scale war is now in its fourth year, we gain our own experience in combat trauma surgery, multiplied by human suffering. We begin to notice some specific aspects and mismatches when compared to our conditions, as well as mindless replication of "postulates."

This is particularly relevant to thoracic trauma management. We would like to focus on several aspects and introduce our own perspective.

TUBE THORACOSTOMY

It is well known that the primary procedure (intervention) for thoracic trauma management is a Chest Drainage (thoracostomy).

PRO

The typical site for tube insertion is the 5th intercostal space within the “safe triangle” (TCCC, ATLS).

The “safe triangle”:

·        Anterior border - the lateral edge of the m. pectoralis major

·        Posterior border - the anterior edge of the m. latissimus dorsi

·        Inferior border - the level of the 5th intercostal space

·        Apex - the axilla

The tube should be inserted over the superior border of the rib to avoid neurovascular bundle injury. 

CONTRA

The selected site in the 5th intercostal space corresponds to the skin surface of the interlobar fissure.  Consequently, the tube frequently becomes compressed by lung parenchyma on both sides, thereby losing its function. The degree of lung collapse determines the drain position when it is setting (insertion at a 90° angle to the skin). According to our experience, the reduction in lung volume in cases of pneumothorax is ¼ - 1/3, and therefore the fissure remains close to its normal anatomical position.

In addition, air in the pleural cavity accumulates superiorly (or anteriorly in the supine position), while blood collects inferiorly (posteriorly). Loss of the drain function within the fissure leads to residual volumes of air or blood and compromises the ability to monitor air leaks. These issues cannot be resolved by increasing the tube diameter or applying active suction.

In thoracic surgical practice, there is a well-known method for identifying the intercostal space that serves as the surface «projection» of the interlobar fissure onto the chest wall. First, this fissure is located near the 5th intercostal space. The width of these specific intercostal spaces in adults (4, 5, or 6) is several millimeters greater. This can be easily verified by palpating along each intercostal space in the lateral chest region. Alternatively, an ultrasound probe can be used to measure this width.

A clinical decision should be made before chest tube insertion: is the drainage required for pneumothorax or hemothorax? In cases of severe pneumothorax, it is better to set the tube above the fissure "projection", directing it retrosternally and upwards. If there is a need for drainage of hemothorax or non-tension hemopneumothorax, intercostal space below the "projection" should be selected. After advancing the tube to 3-6 cm (depending on the thickness of the subcutaneous tissue) and feeling a "loss of resistance", the drain should be directed inferiorly towards the back. In any case, the depth of the tube insertion should not exceed 10-12 cm.

BILATERAL СLAMSHELL THORACOTOMY: WHAT IS WRONG WITH IT?

Essentially, the main aim of medical care is about saving lives. However, Non nocere is a principle that has endured for millennia. Is the outcome worth the exertion? Is it possible to restore one function by destroying another one?

PRO

Access to both pleural cavities and the mediastinum allows simultaneous exposure to all major vessels and lungs. 

CONTRA

It is difficult to imagine a casualty with bilateral lung injury who truly requires two thoracotomies and mediastinal access with major vessels or anterior heart trauma (as the posterior aspect of the heart cannot be visualized this way). It is highly likely that this patient would die within minutes. Do such highly traumatic procedures require anything more than the just a surgeon’s hands, a scalpel, and mechanical ventilation? Does performing such highly traumatic procedures require more than just a surgeon’s hands, a scalpel, and mechanical ventilation? The fields of surgery in which this approach is routinely used are thoracic oncology and transplantation. In cardiac surgery, a median sternotomy is usually sufficient. The technological and anesthetic support required for these operations is among the most complex, and the practical skills of specialists take years to master. Furthermore, such patients remain in the hospital rather than being immediately evacuated by ground transport. Military surgery is always characterized by overload, uncertainty, limited resources, and extensiveness.

What is being proposed instead, is the most non-physiological (function disruption of both lungs, the heart, and the major vessels), and traumatic approach (transection of the sternum and ribs), which is often performed by a surgeon who may be uncertain about its necessity, the potential findings, and the possibility of repair. No guideline provides detailed recommendations for closure of such a chest wall, and within the relevant specialties there is a cautious attitude toward this approach, as subsequent complications create significant challenges. Furthermore, the tactical situation does not allow for resource expenditure required for such patients.

Our experience demonstrates a small number of such casualties, a lack of indications for opening the second pleural cavity at the Role 2 level, and significant metabolic shifts in the casualty that cannot be managed under current evacuation conditions. These issues are often linked to the loss of chest wall integrity due to inadequate closure (including the level of sternal incision and the methods used for sternal and rib fixation). Higher levels of medical care facilities are better equipped to manage such patients, where advanced diagnostic capabilities simplify understanding of the situation and allows for optimal decision-making. Unfortunately, the desire of young surgeons to perform a Clamshell Thoracotomy (especially at Role 2) often far exceeds the actual clinical necessity.

It is essential to recognize the boundary where surgical trauma outweighs the combat injury, and where clinical experience is more valuable than the ability to see what has hidden by the nature.

!!! Content Warning !!!

The following content may contain descriptions of traumatic injuries, medical procedures, or battlefield-related events that may be disturbing or sensitive for some viewers. Viewer discretion is advised.

METHODS OF HEMORRHAGE CONTROL FROM LUNG PARENCHYMA

TRACTOTOMY

PRO

By inserting a stapling device into the lung wound, the parenchyma is transected along the entire length of the tract in order to control bleeding within the wound channel of the lung parenchyma.

CONTRA

The vast majority (over 95%) of injuries are fragmentation wounds caused by small foreign bodies (up to 1 cm). In such cases, lung injuries have a narrow-wound tract which size does not allow insertion of the stapling jaw.

Smaller wounds may not even require suturing, as the formation of a blood clot ensures safe healing. Non-anatomical parenchymal dissection results in impaired blood supply to the remaining tissue. Additionally, only 50% of the wound tract wall is secured by stapling, while the remainder still requires hemostasis and aerostasis.

As an alternative, it is proposed the closure of deep wound tracts by horizontal U-shaped sutures placed circumferentially, with figure-of-eight sutures to close the entry and exit points. U-shaped sutures close the parenchymal wound tract, creating small, narrow cavities filled with blood clots that eventually lead to scarring. If necessary, bipolar coagulation of vessels can be used in the depth of the wound; bronchi, which are smaller than segmental, typically heal once sealed by a blood clot, without prolonged air leakage. Larger parenchymal lacerations are better managed step-by-step from within the wound, with coagulation or ligation of vessels and bronchi, followed by layered closure of the laceration from the depth.

LUNG TORSION AROUND THE HILAR STRUCTURES

PRO 

Rapid dissection of the inferior pulmonary ligament and the mediastinal pleura around the hilum allows the lung to be rotated, which helps control hemorrhage from its vessels by compressing their lumen.

CONTRA

The dissection of the inferior pulmonary ligament should accompany any lung suturing involving a parenchymal hematoma and/or resection. This is essential for the complete filling of the hemithorax, accounting for the reduced elastic properties of the lung when an intrapulmonary hematoma of any size is present.

Torsion of the hilar structures may lead to their rupture (particularly affecting the distally located inferior pulmonary veins) as well as the rupture of anomalous vessels (given the high variability of pulmonary anatomy), which would significantly complicate the situation. The condition of the main bronchus and the anatomical alignment of its layers after a such manipulation is unlikely to be optimal for a subsequent pneumonectomy (damaged bronchial rings often lead to bronchial stump failure). Rotation of the lung distorts the surgeon’s anatomy perception and complicates orientation. In general, wounded have a hard time to tolerate pneumonectomy and lobectomy amid hemorrhage; therefore, preservation of lung parenchyma is very important.

Instead, it is proposed a limited drainage (a short-term tidal volume (TV) reduction up to 15–20% during mechanical ventilation) with tight packing of the pleural cavity with gauze around the hilum. The lung is gently folded anteriorly around this packing while simultaneously compressing the parenchyma. This involves folding the lung anteriorly over the packing while simultaneously compressing the parenchyma. The absence of ventilation decreases pulmonary blood flow, while the external pressure prevents vascular filling. A systematic, step-by-step examination of the injured area allows for the identification of the bleeding source and control of hemorrhage while preserving the organ.

Ultimately, the choice is up on the operating surgeon; but in the most critical scenarios, a graduated approach is necessary in order to find an optimal solution with minimal losses.

!!! IMPORTANT !!!

*all drawings give a schematic idea of ​​the manipulations and states