Feasibility and Efficacy of Video-Assisted Thoracoscopic Surgery for the Surgical Stabilization of Rib Fractures: A Single-center Retrospective Cohort Study

Feasibility and Efficacy of Video-Assisted Thoracoscopic Surgery for the Surgical Stabilization of Rib Fractures: A Single-center Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Feasibility and Efficacy of Video-Assisted Thoracoscopic Surgery for the Surgical Stabilization of Rib Fractures: A Single-center Retrospective Cohort Study Hiroyuki Kayata, Akihiro Usui, Koki Terakawa, Koichi Inukai, Yu Hashimoto, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6573428/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Aug, 2025 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Surgical fixation of traumatic multiple rib fractures is becoming more common; video-assisted thoracoscopic surgery (VATS) is reportedly useful in such cases. Therefore, we aimed to explore the feasibility and effectiveness of VATS for surgical stabilization of rib fractures (SSRF). Methods We conducted a single-center, medical record-based retrospective cohort study including 52 patients with traumatic multiple rib fractures who underwent SSRF with or without VATS. All patients were admitted to our hospital between January 2017 and March 2024. Patient characteristics and perioperative outcomes were compared between the groups, and the frequencies of relevant VATS outcomes were investigated. Results VATS was performed in 42 patients. The with-VATS group had significantly more isolated thoracic trauma ( p = .04) and lower thoracic Abbreviated Injury Scale and Injury Severity Score ( p = .015, p = .017) than the without-VATS group, albeit no differences in perioperative outcomes were found. In the VATS group, common intraoperative findings included sharp bone fragments protruding into the thoracic cavity, lung entrapment at fracture site, lung and diaphragm injuries, and intrathoracic hematomas. These injuries were managed through repair, as well as hematoma irrigation and evacuation. Conclusions VATS was feasible in 80% of cases and was not associated with adverse outcomes. The addition of VATS to SSRF facilitated injury identification and repair, enhanced intrathoracic visualization during fixation, and enabled hematoma evacuation, potentially reducing perioperative complications. Traumatic Rib Fracture Surgical Rib Fixation Missed Injury Complications Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Rib fractures are observed in 10% of blunt trauma cases and approximately 6% of trauma inpatients [ 1 , 2 ]. In the short term, they are associated with increased mortality, pneumonia, prolonged mechanical ventilation, intensive care unit (ICU) stay, and hospital length of stay. Long term complications include increased hospital readmissions, decreased activities of daily living, and increased treatment costs [ 3 – 7 ]. Surgical stabilization of rib fractures (SSRF) for traumatic rib fractures, once primarily reserved for flail chest, has shown benefits even in patients without flail chest [ 8 , 9 ], leading to broader indications and widespread use [ 10 ]. Video-assisted thoracoscopic surgery (VATS) has been reported to aid in detecting missed injuries, preventing perioperative complications, and minimizing invasiveness [ 11 ]. However, current literature included few case reports with small sample sizes; further, there are few reports on the feasibility of SSRF combined with VATS for traumatic rib fractures and on comparing a VATS and a non-VATS combination group [ 12 – 17 ]. Therefore, we aimed to evaluate the feasibility and effectiveness of VATS for SSRF by comparing patient characteristics and treatment outcomes in those undergoing SSRF for traumatic rib fractures assigned to with-VATS and without-VATS groups, and by eliciting the frequency of relevant VATS outcomes. Methods Study design and Data Collection This was a single-center, medical record-based retrospective cohort study. Among 506 patients with traumatic rib fractures admitted to Sakai City Medical Center (referred to as “our hospital” from here on) between January 2017 and March 2024, 52 patients who underwent SSRF were included. From medical records, data was obtained regrading patient characteristics, including age, sex, comorbidities, detailed mechanism of injury, isolated thoracic trauma versus multiple trauma, thoracic trauma severity using the Abbreviated Injury Scale (AIS), and overall trauma severity using the Injury Severity Score (ISS). Surgical parameters (use of thoracoscopy, time from injury to surgery, operation time, and intraoperative blood loss), and treatment outcomes (postoperative complications, mortality, duration of postoperative mechanical ventilation, postoperative ICU stay, postoperative hospital stay, total hospital stay, and discharge destination [home versus transfer]) were assessed. Additionally, we analyzed intraoperative findings and associated injuries identified using thoracoscopy, as well as the incidence and frequency of additional surgical procedures performed. Statistical Analyses Categorical variables are presented as numbers and percentages. Group comparisons were performed using chi-square tests and Fisher's exact tests when more than 20% of expected frequencies were below five. Continuous variables are presented as medians and interquartile ranges; group comparisons were performed using U tests. Statistical significance was set at p < .05 for group comparisons, and analyses were performed using IBM® SPSS Statistics version 26 (New York, NY, USA). Surgical Indications and Treatment Strategies Surgical indications and treatment strategies for traumatic rib fractures at our hospital were based on the guidelines of the Chest Wall Injury Society[18] (Fig. 1 ). Morphological evaluation of traumatic rib fractures was performed using computed tomography (CT), while pain control, mobilization status, and respiratory function were assessed through physical therapy in conjunction with appropriate analgesic administration. In patients with hemodynamic instability due to severe trauma, initial resuscitation is prioritized; surgical evaluation is deferred until after the patient is stabilized. As access to the first and second ribs is challenging due to their localization near major blood vessels and nerves, they are excluded from fixation. The eleventh and twelfth ribs were also excluded because they are floating ribs. Anatomical surgical indications included flail chest, severe displacement, and injury to surrounding organs (the lung, diaphragm, major blood vessel). Clinical surgical indications included three or more consecutive rib fractures with ≥ 50% displacement, persistent respiratory failure despite adequate analgesic administration and physical therapy intervention preventing ventilator weaning, inability to mobilize or expectorate, or poor progression in mobilization. The exclusion criteria included poor general condition such as being originally bedridden, or inability to tolerate general anesthesia due to severe cardiac, pulmonary, or hepatic comorbidities. Furthermore, in cases with injuries requiring priority treatment such as pelvic fractures, vertebral fractures, aortic injury, or injury to abdominal solid organs or hollow viscera, treatment of these injuries took precedence, and were subsequently re-evaluated for SSRF indications. The surgical approach involves VATS under general anesthesia with one-lung ventilation, with the patient’s position adjusted from supine to lateral, depending on the fracture location. VATS was used to identify fracture sites, detect and repair associated intrathoracic injuries, verify fracture locations, observe fixation procedures from within the thoracic cavity, and perform intrathoracic irrigation and hematoma evacuation following fixation (Fig. 2 ). Results Patient Cohort and Group Allocation Among the 506 patients with traumatic rib fractures treated at our hospital during the observation period, SSRF was performed in 52 patients(10.2%). Of these, 42 patients (80.7%) were assigned to the with-VATS group and 10 (19.2%) to the without-VATS group. The decision to not perform VATS was based on specific clinical constraints, including difficulty in achieving one-lung ventilation due to respiratory failure, positional limitations, and poor visualization due to intrathoracic adhesions (Fig. 3 ). Clinical Characteristics and Perioperative Outcomes Tables 1 and 2 summarize the baseline characteristics and perioperative outcomes for all 52 patients, with a comparison between the with-VATS and without-VATS groups. The median age of the cohort was 70.5 years, with males accounting for more than 70% of the study population. Regarding trauma characteristics, the with-VATS group had a significantly higher incidence of isolated thoracic trauma ( p = .04), and significantly lower thoracic AIS and ISS ( p = .015, p = .017), compared to the without-VATS group. Although differences did not reach statistical significance, there was a trend toward longer operation times and greater intraoperative blood loss in the with-VATS group ( p = 0.078 and 0.094). However, no significant differences between the two groups in terms of perioperative complications, duration of postoperative hospital stay, mechanical ventilation, ICU stay, or final discharge outcomes . Intraoperative Thoracoscopic Findings and Additional Procedures Detailed intraoperative outcomes and missed injuries identified during VATS are shown in Table 3 and Fig. 4 . Among the 42 patients in the VATS group, eight (16%) exhibited sharp bone fragments penetrating the thoracic cavity or lung entrapment at fracture sites. Lung injuries were observed in seven patients (12%), and diaphragmatic injuries were detected in four patients (8%), including one with a transmural laceration and three with non-transmural lacerations. While plate fixation was performed after reduction of the fracture sites, VATS revealed occasional protrusion of drills and depth gauges into the thoracic cavity during the procedure. In addition to preoperative intrathoracic hematoma, bleeding during rib fixation procedures resulted in intrathoracic hematoma accumulation in most cases. These outcomes and injuries were managed through VATS-guided procedures including intrathoracic hematoma evacuation, pulmorrhaphy, and diaphragm repair with direct sutures. Discussion Our study demonstrated that VATS could be performed in approximately 80% of SSRF cases. Using VATS, we were able to identify protruding sharp bone fragments, drill protrusion into the thoracic cavity during the surgical procedure, intrathoracic hematoma accumulation, and injuries not detected in preoperative imaging studies. These missed injuries, including lung entrapment and injury, as well as diaphragm injury, were identified and repaired under VATS assistance during the same surgery in some cases. In treating traumatic rib fractures, the possibility of missing injuries such as delayed hemopneumothorax, recurrent pneumothorax, and diaphragm injury should be considered. Lung entrapment at rib fracture sites and sharp fracture edges cause lung and diaphragm injuries, with the risk of developing delayed hemopneumothorax or recurrent pneumothorax [ 19 – 21 ]. Additionally, diaphragm injuries occur in 5% of blunt chest trauma cases and approximately 10% of multiple rib fracture cases [ 22 , 23 ]. These injuries are difficult to identify even on computed tomography (CT) scans [ 24 , 25 ]. There are cases where missed injuries in the acute phase have led to emergency surgery to treat incarceration of abdominal organs caused by delayed diaphragmatic injury, hernia, or delayed hemothorax [ 26 , 27 ]. Although our study was limited to patients undergoing SSRF, VATS enabled the identification and repair of lung entrapment and diaphragm injuries (Fig. 4 -b and c) such as those that were not detected on preoperative imaging in approximately 10% of cases, potentially contributing to the prevention of mid- to long-term complications such as delayed hemopneumothorax and diaphragmatic hernia. Perioperative complications of surgical fixation include hemothorax, empyema, and pneumothorax, including tension pneumothorax from intraoperative lung injury [ 28 ]. In our study, VATS observation of plate fixation procedures for rib fractures revealed protrusion of drill bits and screw tips into the thoracic cavity (Fig. 4 -d). We identified cases in the without-VATS group where postoperative air leaks were observed despite being absent preoperatively, suggesting that lung injury occurred intraoperatively. While recent plate and screw systems are equipped with stopper mechanisms to prevent excessive drill protrusion into the thoracic cavity and improve safety, lung injury occurring during plate and screw fixation with the lung entrapped at the fracture site remains a concern (Fig. 4 -b). Furthermore, intrathoracic hematoma accumulation after fracture reduction and fixation was more extensive than anticipated (Fig. 4 -e). We believe that VATS observation helped prevent lung injury and pneumothorax by releasing lung entrapment at fracture sites, creating space behind the fracture site, and monitoring fixation procedures. In addition, postoperative thoracic irrigation and hematoma evacuation helped prevent postoperative hemothorax and empyema. While some studies on SSRF with VATS include > 100 cases [ 15 ], the majority of the papers only describe a few dozen [ 12 – 14 , 16 , 17 ]. These studies have reported frequencies of intrathoracic hematoma accumulation at 20–70%, sharp bone fragment protrusion into the thoracic cavity at approximately 20%, lung entrapment at fracture sites and lung injury at 10%, and diaphragm injury at 2%. [ 12 – 17 ] In our study, the frequency of intrathoracic hematoma accumulation was higher than previously reported because it was evaluated following rib fixation procedures; however, the frequencies of other intraoperative findings and missed injuries were comparable to previously reported. Another advantage of VATS assistance is its contribution to minimally invasive plate osteosynthesis (MIPO) procedures by enabling precise fracture site identification and optimizing and minimizing skin incision to reduce chest wall destruction [ 11 ]. Complete thoracoscopic surgery has also been described [ 14 , 29 ], and this approach is expected to be useful not only for MIPO but also for fractures in locations difficult to approach from the surface of the body, such as the posterior aspect of the scapula. Regarding disadvantages of VATS, our study showed trends toward longer operation times and increased intraoperative bleeding, although the differences between the two groups were not statistically significant. However, the increased intraoperative bleeding likely reflects more thorough intrathoracic drainage with VATS rather than increased bleeding from surgical manipulation. Although the median operation time was approximately 50 minutes longer due to intrathoracic observation and manipulation, it was considered acceptable as there was no increase in perioperative complications, postoperative intubation period, or length of ICU or hospital stay; therefore, suggesting no clear disadvantages associated with VATS. The major limitation of this study is that it was a single-center study with a small sample size. Previous studies also had small sample sizes, and there are limited prospective comparative trials between with-VATS and without-VATS groups. Additionally, the without-VATS group had more cases of multiple traumatic injuries with greater severity, and more positional limitations due to respiratory failure and associated injuries, suggesting that VATS may not be feasible in such cases. Furthermore, for most patients with traumatic rib fractures who did not undergo surgery, thoracoscopic intrathoracic examination was not performed, leading to potentially missed associated injuries in these cases. Further studies to evaluate the effectiveness of VATS are needed, including prospective comparative studies with large sample sizes, to determine its indications and optimal number of cases, including whether it may be beneficial for patients with traumatic rib fractures not requiring SSRF. Conclusion In this study, we conducted a single-center, medical record-based, retrospective cohort study to clarify the feasibility and efficacy of combining VATS with SSRF. The use of VATS for SSRF is feasible, safe, and advantageous for the detection and repair of missed injuries and for the reduction of perioperative complications through intrathoracic observation of fixation procedures and hematoma evacuation. Declarations Ethical Approval The study was approved by the appropriate ethics committee/institutional review board (IRB) of Sakai City Medical Center [approval date, 2024/07/03; approval number, 24–442] and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Informed Consent The need for informed consent was waived due to the retrospective nature of the study. Conflict of interest statement The authors declare no conflict of interest associated with this manuscript. Funding No funding was received for this study. Author Contribution All authors contributed to the study conception and design. Material preparation, H. K performed data collection and analysis. The first draft of the manuscript was written by H. K and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgement We would like to thank Editage (www.editage.com) for English language editing. Data Availability Data sets generated during the current study are available from the corresponding author on reasonable request. References Peek J‍‍, Ochen Y, Saillant N, Groenwold RHH, Leenen LPH, Uribe-Leitz T, Houwert RM, Heng M. Traumatic rib fractures: a marker of severe injury. A nationwide study using the National Trauma Data Bank. Trauma Surg Acute Care Open. 2020;5:e000441. Peek J, Beks RB, Hietbrink F, De Jong MB, Heng M, Beeres FJP, IJpma FFA, Leenen LPH, Groenwold RHH, Houwert RM. 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Med (Baltim). 2016;95:e4362. Peek J, Beks RB, Hietbrink F, Heng M, Jong MBD, Beeres FJP, Leenen LPH, Groenwold RHH, Houwert RM. Complications and outcome after rib fracture fixation: A systematic review. J Trauma Acute Care Surg. 2020;89:411–8. Fredric M, Pieracci. Completely thoracoscopic surgical stabilization of rib fractures: can it be done and is it worth it? J Thorac Dis. 2019;11:S1061–9. Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files table.1.docx table.2.docx table.3.docx Cite Share Download PDF Status: Published Journal Publication published 22 Aug, 2025 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted Editorial decision: Revision requested 10 Jun, 2025 Reviews received at journal 09 Jun, 2025 Reviewers agreed at journal 05 May, 2025 Reviewers invited by journal 04 May, 2025 Editor assigned by journal 04 May, 2025 Submission checks completed at journal 02 May, 2025 First submitted to journal 01 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6573428","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":452222291,"identity":"e71e286a-b75c-456e-a23c-c1042a9be966","order_by":0,"name":"Hiroyuki 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17:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6573428/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6573428/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00068-025-02955-y","type":"published","date":"2025-08-22T16:29:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82355304,"identity":"fa214433-b50c-4f14-858b-fa24ef0842aa","added_by":"auto","created_at":"2025-05-09 11:13:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":258890,"visible":true,"origin":"","legend":"\u003cp\u003eTreatment strategy for traumatic rib fractures at our hospital\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*1\u003c/sup\u003eCT: Computed tomography\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*2\u003c/sup\u003eOther-organ injury: lung parenchyma, diaphragm, and aortic injuries\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*3\u003c/sup\u003e3+ \u0026gt;50% displaced rib fractures: three ipsilateral consecutive or non-consecutive ribs, each with a 50% fracture displacement of the rib width on axial CT.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*4\u003c/sup\u003eSSRF: Surgical stabilization of rib fractures\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*5\u003c/sup\u003eVATS: Video-assisted thoracoscopic surgery\u003c/p\u003e","description":"","filename":"Fig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-6573428/v1/f37c0fe971b7ff64d7d36b89.png"},{"id":82351548,"identity":"580ed890-aff3-4421-8bb4-80d50a4003ef","added_by":"auto","created_at":"2025-05-09 10:57:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":954176,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical position and approach\u003c/p\u003e\n\u003cp\u003ePosition of the patient adjusted from lateral to supine depending on the location of the fracture.\u003c/p\u003e\n\u003cp\u003eSurgery performed with video-assisted thoracoscopic surgery under one-lung ventilation and performed jointly with an orthopedic surgeon.\u003c/p\u003e","description":"","filename":"Fig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-6573428/v1/3e7a805705e8e516ecc14aac.png"},{"id":82353168,"identity":"4e1cf895-ca42-4317-944d-6bcfeaf89a42","added_by":"auto","created_at":"2025-05-09 11:05:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":151558,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical stabilization of rib fractures with or without video-assisted thoracoscopic surgery in patients with traumatic rib fractures\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*1\u003c/sup\u003eSSRF: Surgical stabilization of rib fractures\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*2\u003c/sup\u003eVATS: Video-assisted thoracoscopic surgery\u003c/p\u003e","description":"","filename":"Fig.3.png","url":"https://assets-eu.researchsquare.com/files/rs-6573428/v1/9b776c9ac161bf88ac46cbb0.png"},{"id":82351560,"identity":"35d61d1a-1d9a-40ee-ab1f-d8fa4ff2f726","added_by":"auto","created_at":"2025-05-09 10:57:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":841619,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative findings and missed injuries discovered during video-assisted thoracoscopic surgery\u003c/p\u003e\n\u003cp\u003eFigure 4-a Sharp bone fragments ejected into the chest cavity\u003c/p\u003e\n\u003cp\u003eFigure 4-b Trapped lung at the fracture site\u003c/p\u003e\n\u003cp\u003eFigure 4-c Transmural diaphragm injury\u003c/p\u003e\n\u003cp\u003eFigure 4-d Protrusion of the drill into the thoracic cavity (yellow arrow)\u003c/p\u003e\n\u003cp\u003eFigure 4-e Intrathoracic hematoma\u003c/p\u003e","description":"","filename":"Fig.4.png","url":"https://assets-eu.researchsquare.com/files/rs-6573428/v1/6cfc687cc46d34314c9e82d5.png"},{"id":89847197,"identity":"b114221c-f076-4844-a198-f59e8e641d4f","added_by":"auto","created_at":"2025-08-25 16:41:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3830981,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6573428/v1/30f441de-3d8d-451e-8ced-20371d89f57b.pdf"},{"id":82351551,"identity":"6c14cf9f-20c2-4790-a633-adb186e99470","added_by":"auto","created_at":"2025-05-09 10:57:48","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27423,"visible":true,"origin":"","legend":"","description":"","filename":"table.1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6573428/v1/3ea5ce6dc0020dc3c47ef7f2.docx"},{"id":82353167,"identity":"2d069fbf-8c10-4ce2-ba0d-198821655adf","added_by":"auto","created_at":"2025-05-09 11:05:48","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":31445,"visible":true,"origin":"","legend":"","description":"","filename":"table.2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6573428/v1/2a038fa1ff613fc22a9fc8b5.docx"},{"id":82355306,"identity":"634f02e2-79b4-4ffd-b6f1-7851fe1156c7","added_by":"auto","created_at":"2025-05-09 11:13:49","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":28210,"visible":true,"origin":"","legend":"","description":"","filename":"table.3.docx","url":"https://assets-eu.researchsquare.com/files/rs-6573428/v1/d81fa1c39bd0d40c016c0076.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Feasibility and Efficacy of Video-Assisted Thoracoscopic Surgery for the Surgical Stabilization of Rib Fractures: A Single-center Retrospective Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRib fractures are observed in 10% of blunt trauma cases and approximately 6% of trauma inpatients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In the short term, they are associated with increased mortality, pneumonia, prolonged mechanical ventilation, intensive care unit (ICU) stay, and hospital length of stay. Long term complications include increased hospital readmissions, decreased activities of daily living, and increased treatment costs [\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Surgical stabilization of rib fractures (SSRF) for traumatic rib fractures, once primarily reserved for flail chest, has shown benefits even in patients without flail chest [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], leading to broader indications and widespread use [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVideo-assisted thoracoscopic surgery (VATS) has been reported to aid in detecting missed injuries, preventing perioperative complications, and minimizing invasiveness [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, current literature included few case reports with small sample sizes; further, there are few reports on the feasibility of SSRF combined with VATS for traumatic rib fractures and on comparing a VATS and a non-VATS combination group [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, we aimed to evaluate the feasibility and effectiveness of VATS for SSRF by comparing patient characteristics and treatment outcomes in those undergoing SSRF for traumatic rib fractures assigned to with-VATS and without-VATS groups, and by eliciting the frequency of relevant VATS outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and Data Collection\u003c/h2\u003e \u003cp\u003eThis was a single-center, medical record-based retrospective cohort study. Among 506 patients with traumatic rib fractures admitted to Sakai City Medical Center (referred to as \u0026ldquo;our hospital\u0026rdquo; from here on) between January 2017 and March 2024, 52 patients who underwent SSRF were included.\u003c/p\u003e \u003cp\u003eFrom medical records, data was obtained regrading patient characteristics, including age, sex, comorbidities, detailed mechanism of injury, isolated thoracic trauma versus multiple trauma, thoracic trauma severity using the Abbreviated Injury Scale (AIS), and overall trauma severity using the Injury Severity Score (ISS).\u003c/p\u003e \u003cp\u003eSurgical parameters (use of thoracoscopy, time from injury to surgery, operation time, and intraoperative blood loss), and treatment outcomes (postoperative complications, mortality, duration of postoperative mechanical ventilation, postoperative ICU stay, postoperative hospital stay, total hospital stay, and discharge destination [home versus transfer]) were assessed.\u003c/p\u003e \u003cp\u003eAdditionally, we analyzed intraoperative findings and associated injuries identified using thoracoscopy, as well as the incidence and frequency of additional surgical procedures performed.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStatistical Analyses\u003c/h3\u003e\n\u003cp\u003eCategorical variables are presented as numbers and percentages. Group comparisons were performed using chi-square tests and Fisher's exact tests when more than 20% of expected frequencies were below five. Continuous variables are presented as medians and interquartile ranges; group comparisons were performed using U tests. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05 for group comparisons, and analyses were performed using IBM\u0026reg; SPSS Statistics version 26 (New York, NY, USA).\u003c/p\u003e\n\u003ch3\u003e\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cem\u003eSurgical Indications and Treatment Strategies\u003c/em\u003e\u003c/div\u003e \u003cp\u003e Surgical indications and treatment strategies for traumatic rib fractures at our hospital were based on the guidelines of the Chest Wall Injury Society[18] (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Morphological evaluation of traumatic rib fractures was performed using computed tomography (CT), while pain control, mobilization status, and respiratory function were assessed through physical therapy in conjunction with appropriate analgesic administration. In patients with hemodynamic instability due to severe trauma, initial resuscitation is prioritized; surgical evaluation is deferred until after the patient is stabilized. As access to the first and second ribs is challenging due to their localization near major blood vessels and nerves, they are excluded from fixation. The eleventh and twelfth ribs were also excluded because they are floating ribs. Anatomical surgical indications included flail chest, severe displacement, and injury to surrounding organs (the lung, diaphragm, major blood vessel).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eClinical surgical indications included three or more consecutive rib fractures with \u0026ge;\u0026thinsp;50% displacement, persistent respiratory failure despite adequate analgesic administration and physical therapy intervention preventing ventilator weaning, inability to mobilize or expectorate, or poor progression in mobilization.\u003c/p\u003e \u003cp\u003eThe exclusion criteria included poor general condition such as being originally bedridden, or inability to tolerate general anesthesia due to severe cardiac, pulmonary, or hepatic comorbidities. Furthermore, in cases with injuries requiring priority treatment such as pelvic fractures, vertebral fractures, aortic injury, or injury to abdominal solid organs or hollow viscera, treatment of these injuries took precedence, and were subsequently re-evaluated for SSRF indications.\u003c/p\u003e \u003cp\u003eThe surgical approach involves VATS under general anesthesia with one-lung ventilation, with the patient\u0026rsquo;s position adjusted from supine to lateral, depending on the fracture location. VATS was used to identify fracture sites, detect and repair associated intrathoracic injuries, verify fracture locations, observe fixation procedures from within the thoracic cavity, and perform intrathoracic irrigation and hematoma evacuation following fixation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003ePatient Cohort and Group Allocation\u003c/h2\u003e\n \u003cp\u003eAmong the 506 patients with traumatic rib fractures treated at our hospital during the observation period, SSRF was performed in 52 patients(10.2%). Of these, 42 patients (80.7%) were assigned to the with-VATS group and 10 (19.2%) to the without-VATS group. The decision to not perform VATS was based on specific clinical constraints, including difficulty in achieving one-lung ventilation due to respiratory failure, positional limitations, and poor visualization due to intrathoracic adhesions (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eClinical Characteristics and Perioperative Outcomes\u003c/h2\u003e\n \u003cp\u003eTables \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e summarize the baseline characteristics and perioperative outcomes for all 52 patients, with a comparison between the with-VATS and without-VATS groups. The median age of the cohort was 70.5 years, with males accounting for more than 70% of the study population. Regarding trauma characteristics, the with-VATS group had a significantly higher incidence of isolated thoracic trauma (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.04), and significantly lower thoracic AIS and ISS (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.015, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.017), compared to the without-VATS group. Although differences did not reach statistical significance, there was a trend toward longer operation times and greater intraoperative blood loss in the with-VATS group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.078 and 0.094). However, no significant differences between the two groups in terms of perioperative complications, duration of postoperative hospital stay, mechanical ventilation, ICU stay, or final discharge outcomes .\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eIntraoperative Thoracoscopic Findings and Additional Procedures\u003c/h3\u003e\n\u003cp\u003eDetailed intraoperative outcomes and missed injuries identified during VATS are shown in Table 3 and Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. Among the 42 patients in the VATS group, eight (16%) exhibited sharp bone fragments penetrating the thoracic cavity or lung entrapment at fracture sites. Lung injuries were observed in seven patients (12%), and diaphragmatic injuries were detected in four patients (8%), including one with a transmural laceration and three with non-transmural lacerations. While plate fixation was performed after reduction of the fracture sites, VATS revealed occasional protrusion of drills and depth gauges into the thoracic cavity during the procedure. In addition to preoperative intrathoracic hematoma, bleeding during rib fixation procedures resulted in intrathoracic hematoma accumulation in most cases. These outcomes and injuries were managed through VATS-guided procedures including intrathoracic hematoma evacuation, pulmorrhaphy, and diaphragm repair with direct sutures.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study demonstrated that VATS could be performed in approximately 80% of SSRF cases. Using VATS, we were able to identify protruding sharp bone fragments, drill protrusion into the thoracic cavity during the surgical procedure, intrathoracic hematoma accumulation, and injuries not detected in preoperative imaging studies. These missed injuries, including lung entrapment and injury, as well as diaphragm injury, were identified and repaired under VATS assistance during the same surgery in some cases.\u003c/p\u003e \u003cp\u003eIn treating traumatic rib fractures, the possibility of missing injuries such as delayed hemopneumothorax, recurrent pneumothorax, and diaphragm injury should be considered. Lung entrapment at rib fracture sites and sharp fracture edges cause lung and diaphragm injuries, with the risk of developing delayed hemopneumothorax or recurrent pneumothorax [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Additionally, diaphragm injuries occur in 5% of blunt chest trauma cases and approximately 10% of multiple rib fracture cases [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These injuries are difficult to identify even on computed tomography (CT) scans [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. There are cases where missed injuries in the acute phase have led to emergency surgery to treat incarceration of abdominal organs caused by delayed diaphragmatic injury, hernia, or delayed hemothorax [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Although our study was limited to patients undergoing SSRF, VATS enabled the identification and repair of lung entrapment and diaphragm injuries (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e4\u003c/span\u003e-b and c) such as those that were not detected on preoperative imaging in approximately 10% of cases, potentially contributing to the prevention of mid- to long-term complications such as delayed hemopneumothorax and diaphragmatic hernia. Perioperative complications of surgical fixation include hemothorax, empyema, and pneumothorax, including tension pneumothorax from intraoperative lung injury [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In our study, VATS observation of plate fixation procedures for rib fractures revealed protrusion of drill bits and screw tips into the thoracic cavity (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e4\u003c/span\u003e-d). We identified cases in the without-VATS group where postoperative air leaks were observed despite being absent preoperatively, suggesting that lung injury occurred intraoperatively. While recent plate and screw systems are equipped with stopper mechanisms to prevent excessive drill protrusion into the thoracic cavity and improve safety, lung injury occurring during plate and screw fixation with the lung entrapped at the fracture site remains a concern (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e4\u003c/span\u003e-b). Furthermore, intrathoracic hematoma accumulation after fracture reduction and fixation was more extensive than anticipated (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e4\u003c/span\u003e-e). We believe that VATS observation helped prevent lung injury and pneumothorax by releasing lung entrapment at fracture sites, creating space behind the fracture site, and monitoring fixation procedures. In addition, postoperative thoracic irrigation and hematoma evacuation helped prevent postoperative hemothorax and empyema.\u003c/p\u003e \u003cp\u003eWhile some studies on SSRF with VATS include\u0026thinsp;\u0026gt;\u0026thinsp;100 cases [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], the majority of the papers only describe a few dozen [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These studies have reported frequencies of intrathoracic hematoma accumulation at 20\u0026ndash;70%, sharp bone fragment protrusion into the thoracic cavity at approximately 20%, lung entrapment at fracture sites and lung injury at 10%, and diaphragm injury at 2%. [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] In our study, the frequency of intrathoracic hematoma accumulation was higher than previously reported because it was evaluated following rib fixation procedures; however, the frequencies of other intraoperative findings and missed injuries were comparable to previously reported.\u003c/p\u003e \u003cp\u003eAnother advantage of VATS assistance is its contribution to minimally invasive plate osteosynthesis (MIPO) procedures by enabling precise fracture site identification and optimizing and minimizing skin incision to reduce chest wall destruction [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Complete thoracoscopic surgery has also been described [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e29\u003c/span\u003e], and this approach is expected to be useful not only for MIPO but also for fractures in locations difficult to approach from the surface of the body, such as the posterior aspect of the scapula.\u003c/p\u003e \u003cp\u003eRegarding disadvantages of VATS, our study showed trends toward longer operation times and increased intraoperative bleeding, although the differences between the two groups were not statistically significant. However, the increased intraoperative bleeding likely reflects more thorough intrathoracic drainage with VATS rather than increased bleeding from surgical manipulation. Although the median operation time was approximately 50 minutes longer due to intrathoracic observation and manipulation, it was considered acceptable as there was no increase in perioperative complications, postoperative intubation period, or length of ICU or hospital stay; therefore, suggesting no clear disadvantages associated with VATS.\u003c/p\u003e \u003cp\u003eThe major limitation of this study is that it was a single-center study with a small sample size. Previous studies also had small sample sizes, and there are limited prospective comparative trials between with-VATS and without-VATS groups. Additionally, the without-VATS group had more cases of multiple traumatic injuries with greater severity, and more positional limitations due to respiratory failure and associated injuries, suggesting that VATS may not be feasible in such cases. Furthermore, for most patients with traumatic rib fractures who did not undergo surgery, thoracoscopic intrathoracic examination was not performed, leading to potentially missed associated injuries in these cases. Further studies to evaluate the effectiveness of VATS are needed, including prospective comparative studies with large sample sizes, to determine its indications and optimal number of cases, including whether it may be beneficial for patients with traumatic rib fractures not requiring SSRF.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, we conducted a single-center, medical record-based, retrospective cohort study to clarify the feasibility and efficacy of combining VATS with SSRF. The use of VATS for SSRF is feasible, safe, and advantageous for the detection and repair of missed injuries and for the reduction of perioperative complications through intrathoracic observation of fixation procedures and hematoma evacuation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthical Approval\u003c/h2\u003e \u003cp\u003e The study was approved by the appropriate ethics committee/institutional review board (IRB) of Sakai City Medical Center [approval date, 2024/07/03; approval number, 24\u0026ndash;442] and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed Consent\u003c/strong\u003e \u003cp\u003e The need for informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflict of interest statement\u003c/strong\u003e \u003cp\u003eThe authors declare no conflict of interest associated with this manuscript.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, H. K performed data collection and analysis. The first draft of the manuscript was written by H. K and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to thank Editage (www.editage.com) for English language editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData sets generated during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePeek J\u0026zwj;\u0026zwj;, Ochen Y, Saillant N, Groenwold RHH, Leenen LPH, Uribe-Leitz T, Houwert RM, Heng M. Traumatic rib fractures: a marker of severe injury. A nationwide study using the National Trauma Data Bank. 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A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL). J Trauma Acute Care Surg. 2020;88:249\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe W, Yang Y, Salonga R, Powell L, Greiffenstein P, Prins JTH, et al. Surgical stabilization of multiple rib fractures in an Asian population: a systematic review and meta-analysis. J Thorac Dis. 2023;15:4961\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKane ED, Jeremitsky E, Pieracci FM, Majercik S, Doben AR. Quantifying and exploring the recent national increase in surgical stabilization of rib fractures. 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World J Emerg Surg. 2024;19:33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSu YH, Yang SM, Ko HJ. Diagnosis and management of a trapped lung or diaphragm by fractured ribs: analysis of patients undergoing rib fracture repair. BMC Surg. 2019;19:123.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBui JT, Browder SE, Wilson HK, Kindell DG, Ra JH, Haithcock BE, Long JM. Does routine uniportal thoracoscopy during rib fixation identify more injuries and impact outcomes? J Thorac Dis. 2020;12:5281\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang J, Hong Q, Mo X, Ma C. Complete Video-assisted Thoracoscopic Surgery for Rib Fractures: Series of 35 Cases. Ann Thorac Surg. 2022;113:452\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Gool MH, Roozendaal LM, Vissers YLJ, van den Broek R, van Vugt R, Meesters B, Pijnenburg AM, Hulsew\u0026eacute; KWE, de Loos ER. VATS\u0026ndash;assisted surgical stabilization of rib fractures in flail chest: 1\u0026ndash;year follow\u0026ndash;up of 105 cases. Gen Thorac Cardiovasc Surg. 2022;70:985\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBae CM, Son SA, Lee YJ, Lee SC. Clinical Outcomes of Minimally Invasive Surgical Stabilization of Rib Fractures Using Video-Assisted Thoracoscopic Surgery. J Chest Surg. 2023;56:120\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchots JPM, Vissers YLJ, Hulsew\u0026eacute; KWE, Meesters B, Hustinx PA, Pijnenburg A, Siebenga J, de Loos ER. Addition of Video-Assisted Thoracoscopic Surgery to the Treatment of Flail Chest. Ann Thorac Surg. 2017; 103:940\u0026ndash;4. Chest Wall Injury Society: Chest Wall Injury Society Guideline for SSRF. Indications, Contraindications, and Timing [Internet]. Salt Lake City; Chest Wall Injury Society. 2025. https:// cwisociety. org / wp-content /\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003euploads/2020/05/CWIS-SSRF-Guideline-01102020.pdf\u003c/span\u003e\u003cspan address=\"http://uploads/2020/05/CWIS-SSRF-Guideline-01102020.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 08 Feb 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu MS, Huang YK, Liu YH, Liu HP, Kao CL. Delayed pneumothorax complicating minor rib fracture after chest trauma. Am J Emerg Med. 2008;26:551\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMisthos P, Kakaris S, Sepsas E, Athanassiadi K, Skottis I. A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma. 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The Current Status of Traumatic Diaphragmatic Injury: Lessons Learned From 105 Patients Over 13 Years. Ann Thorac Surg. 2008;85:1044\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLawson CM, Daley BJ, Ormsby CB, Enderson B. Missed Injuries in the Era of the Trauma Scan. J Trauma. 2011;70:452\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKesavaramanujam S, Morell MC, Harigovind D, Bhimmanapalli C, Cassaro S. Total thoracic herniation of the liver: a case of delayed right-sided diaphragmatic hernia after blunt trauma. Surg Case Rep. 2020;6:178.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu J, Wang B, Che X, Li X, Qiu G, He S, Fan L. Delayed traumatic diaphragmatic hernia: A case-series report and literature review. Med (Baltim). 2016;95:e4362.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeek J, Beks RB, Hietbrink F, Heng M, Jong MBD, Beeres FJP, Leenen LPH, Groenwold RHH, Houwert RM. Complications and outcome after rib fracture fixation: A systematic review. J Trauma Acute Care Surg. 2020;89:411\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFredric M, Pieracci. Completely thoracoscopic surgical stabilization of rib fractures: can it be done and is it worth it? J Thorac Dis. 2019;11:S1061\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Traumatic Rib Fracture, Surgical Rib Fixation, Missed Injury, Complications","lastPublishedDoi":"10.21203/rs.3.rs-6573428/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6573428/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eSurgical fixation of traumatic multiple rib fractures is becoming more common; video-assisted thoracoscopic surgery (VATS) is reportedly useful in such cases. Therefore, we aimed to explore the feasibility and effectiveness of VATS for surgical stabilization of rib fractures (SSRF).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a single-center, medical record-based retrospective cohort study including 52 patients with traumatic multiple rib fractures who underwent SSRF with or without VATS. All patients were admitted to our hospital between January 2017 and March 2024. Patient characteristics and perioperative outcomes were compared between the groups, and the frequencies of relevant VATS outcomes were investigated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eVATS was performed in 42 patients. The with-VATS group had significantly more isolated thoracic trauma (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.04) and lower thoracic Abbreviated Injury Scale and Injury Severity Score (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.015, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.017) than the without-VATS group, albeit no differences in perioperative outcomes were found. In the VATS group, common intraoperative findings included sharp bone fragments protruding into the thoracic cavity, lung entrapment at fracture site, lung and diaphragm injuries, and intrathoracic hematomas. These injuries were managed through repair, as well as hematoma irrigation and evacuation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eVATS was feasible in 80% of cases and was not associated with adverse outcomes. The addition of VATS to SSRF facilitated injury identification and repair, enhanced intrathoracic visualization during fixation, and enabled hematoma evacuation, potentially reducing perioperative complications.\u003c/p\u003e","manuscriptTitle":"Feasibility and Efficacy of Video-Assisted Thoracoscopic Surgery for the Surgical Stabilization of Rib Fractures: A Single-center Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 10:57:44","doi":"10.21203/rs.3.rs-6573428/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-10T20:12:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-09T12:28:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48229379249248019411927954541612797408","date":"2025-05-05T17:04:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-04T20:32:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-04T20:31:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-02T06:17:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2025-05-01T17:05:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4b25de3a-0233-420e-bf7b-b48fbf55af11","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-25T16:33:17+00:00","versionOfRecord":{"articleIdentity":"rs-6573428","link":"https://doi.org/10.1007/s00068-025-02955-y","journal":{"identity":"european-journal-of-trauma-and-emergency-surgery","isVorOnly":false,"title":"European Journal of Trauma and Emergency Surgery"},"publishedOn":"2025-08-22 16:29:11","publishedOnDateReadable":"August 22nd, 2025"},"versionCreatedAt":"2025-05-09 10:57:44","video":"","vorDoi":"10.1007/s00068-025-02955-y","vorDoiUrl":"https://doi.org/10.1007/s00068-025-02955-y","workflowStages":[]},"version":"v1","identity":"rs-6573428","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6573428","identity":"rs-6573428","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}