Management of Retained Hemothorax When VATS Visualization is Poor

Primary Alternative: Conversion to Open Thoracotomy

The American Thoracic Society recommends conversion to open thoracotomy when VATS visualization is inadequate, as it allows for direct visualization despite adhesions, extensive decortication, and definitive control of bleeding 1, 2, 3
Conversion to open thoracotomy is the standard approach when adhesions prevent safe thoracoscopic examination or when the pleural space cannot be adequately visualized, according to the American College of Chest Physicians 3, 4

The surgeon must be prepared to convert to thoracotomy at the start of any VATS procedure for retained hemothorax, as adhesions are often only appreciated intraoperatively, with a reported incidence of approximately 20% 1, 2, 3
Open thoracotomy allows for direct visualization, extensive decortication, and definitive control of bleeding, with the European Respiratory Society recommending this approach for cases with poor VATS visualization 3, 5

The European Respiratory Society recommends performing muscle-sparing thoracotomy through an intercostal space, with or without partial rib resection, when converting from VATS to open thoracotomy 5
Multiple chest tubes are often required for chronic drainage when extensive decortication is performed, according to the American Thoracic Society 1, 2
Complete decortication should be performed to allow maximal lung re-expansion, even if cavity resection is not technically feasible, as recommended by the American College of Chest Physicians 1, 2

The American College of Chest Physicians advises against persisting with VATS when visualization is inadequate, as this risks incomplete evacuation, missed bleeding sources, and prolonged operative time 3
Delaying conversion to open thoracotomy is not recommended, as the presence of adhesions preventing safe thoracoscopic examination is an absolute indication for open approach, according to the American Thoracic Society 3, 4