A case of using minimally invasive techniques in a gunshot wound to the chest with mediastinal injury

Abstract

Background. In modern military conflicts, the frequency of gunshot wounds to the chest is 8–12 %, of which 79.4 % are non-penetrating, and 20.4 % are penetrating with damage to intrathoracic organs. The most challenging task is to choose an approach to penetrating chest wounds due to the inability of verifying the anatomical and topographic nature of the chest wound by non-invasive methods before surgery. At present, there is a tendency to a widespread use of minimally invasive techniques in all areas of surgery. So, the aim of the study is to demonstrate the options of minimally invasive techniques in the diagnosis and treatment of gunshot wounds to the chest with mediastinal damage. Materials and ­methods. Patient G., 36 years old, was wounded to the chest and delivered an hour after the injury to the frontline surgical unit in the state of moderate severity, where he underwent left thoracentesis and pleural drainage. In 4 hours, he was taken to the Military Medical Clinical Center of the Northern Region of the Armed Forces of Ukraine and hospitalized to the emergency department. Diagnosis was made of gunshot shrapnel penetrating wound to the left chest with damage to the upper lobe of the left lung and mediastinum. A foreign body (metal fragment) in the mediastinum. Left-sided hemothorax (300 ml), post-traumatic pneumonitis. Surgery: left thoracentesis, drainage of the pleural cavity by Bülau. A chest and abdominal ultrasound were performed according to the FAST protocol. Laboratory tests were carried out: complete blood count, urinalysis, biochemical blood test, blood coagulogram. Multislice computed tomography of the head, chest, abdomen, and pelvis was performed, as well as video-assisted esophagogastroduodenoscopy and thoracoscopy. Surgical treatment consisted in video-assisted thoracoscopy, revision of the left pleural cavity, removal of a foreign body (metal fragment) from the mediastinum, sanitation and repeated drainage of the left pleural cavity according to Bülau. A foreign body (metal fragment) was removed using a magnetic instrument for endovideoscopic diagnosis and removal of metal ferromagnetic foreign bodies from the abdominal and pleural cavities. Results. Data of multislice computed tomography of the chest on admission were as follows: a 10 × 5 mm metal fragment near the pulmonary artery, post-traumatic pneumonitis along the wound channel. A video-assisted esophagogastroduodenoscopy was done, and esophageal damage was excluded. Surgery was performed: video-assisted thoracoscopy, revision of the left pleural cavity, removal of a foreign body (metal fragment) from the mediastinum, sanitation and repeated drainage of the left pleural cavity according to Bülau. The surgical intervention lasted 30 minutes. On the second day, the drain tube was removed from the pleural cavity. Subsequently, 2 weeks later, the sutures were removed, the wounded man was presented to the military medical commission and discharged to the unit. Conclusion. Gunshot wounds to the chest with mediastinal damage are rare. The use of a modern magnetic surgical instrument allows the removal of ferromagnetic foreign bodies in case of mediastinal injury. The use of minimally invasive surgical interventions for gunshot wounds to the chest with mediastinal injury reduces surgical trauma and can be applied at a specialized level of medical care.