Retrospective Review of Surgical Management of Flail Chest Injury using Routine Thoracoscopy and a Minimally Invasive Surgical Approach
Ledford Powell, Nicholas Mannering, Almaas Shaikh
St Joseph, Mission Hospital, Mission Viejo, CA
Background: Flail Chest Injury is described as an incompetent chest wall segment, comprised of three or more consecutive ribs that are fractured in at least two places. Flail Chests injuries are present in 6-15% of patients that have sustained blunt chest trauma. Surgical stabilization of a flail chest injury has been shown in multiple studies to decrease length of stay (LOS), ventilator days, mortality, ICU days, rate of pneumonia and tracheostomy rate. Traditional surgical approach to rib fixation of flail chest injuries often required a large incision along the chest wall with violation of muscle fibers. Current reports on surgical management of flail chest injuries report LOS in days between 10-18 days, ICU days of 6-16.5, ventilator days of 3.1-15days, mortality rates of 8-22% with pneumonia rates of 22%. We developed what we describe as a Minimally Invasive Muscle Sparing (MIMS) Rib fixation technique. All patients in our facility have rib fixations performed using this approach. Methods An IRB approved retrospective review of medical records was performed on all patients admitted to our facility with rib fractures. We looked at our experience with rib fractures between the dates of January 2015 to June 2017. Potential patients were identified by performing a query of the trauma database and medical records for codes specific to rib fractures. We isolated patients with flail chests that were treated with surgical fixation. We excluded those with a severe closed head injury, severe spinal cord injury or death within 24 hours of admission. Flail chest stabilization was performed through a MIMS technique. Patient recovery was documented by assessment of post-operative pain management, duration of mechanical ventilation, ICU stay, length of hospitalization, chest tube days and by the incidence of pneumonia, need for tracheostomy, disposition after discharge and need for re-admission within 6 weeks. RESULTS. 35 patients were identified during the course of the review that met criteria. Average chest AIS score was 4.14. LOS, 8 days, chest tube days 2.3, ventilator days 1.85 days and ICU days 3.76 days. Immediate postoperative extubation in 78% of patients. Only 2.8 percent of patients required a tracheostomy. 77% of patients were discharged directly to home while others went to physical Rehabilitation facilities or skilled nursing. Readmission rate 0%, Mortality rate 0%. Conclusion: We observed improved outcomes in our patient population when compared to published studies. We concluded that using a minimally invasive surgical approach with routine use of thoracoscopy may yield better outcomes from surgical fixation of flail chest injuries as compared to traditional open operation.
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