The role of video-assisted thoracoscopic surgery in blunt and penetrating chest trauma

Video-assisted thoracoscopic surgery (VATS) has emerged as a valuable tool in the management of both blunt and penetrating chest trauma. Indications for VATS include retained haemothorax, persistent pneumothorax, and diagnostic clarification of suspected intrathoracic injuries. Compared to open thoracotomy, VATS offers reduced postoperative pain, shorter hospital stay, and decreased infection rates, particularly when performed early, ideally within 72 hours of injury. In cases of blunt trauma, early VATS enables effective evacuation of clotted blood, reduces ventilator days, and minimizes complications such as empyema or fibrothorax. In penetrating trauma, VATS allows for minimally invasive inspection and management of diaphragmatic, pulmonary, and pleural injuries in haemodynamically stable patients, with early intervention showing superior outcomes. The role of VATS in rib fracture stabilization is expanding, with data supporting its feasibility and effectiveness in anatomically challenging cases, such as posterior or subscapular fractures. Thoracoscopic-assisted fixation may offer comparable or superior outcomes to open techniques, particularly when novel devices like memory alloy plates are used. While early surgical stabilization of rib fractures (SSRF) is generally favoured, recent evidence suggests that delayed SSRF does not necessarily worsen clinical outcomes, allowing prioritization of other life-threatening injuries in polytrauma scenarios. Despite promising retrospective and cohort data, there remains a lack of randomized controlled trials (RCTs) to definitively guide timing and patient selection for VATS in trauma. Standardized protocols for integrating VATS into trauma algorithms are needed. This review synthesizes current evidence and proposes pragmatic recommendations for the timing and indications of VATS in modern thoracic trauma care.