Completely thoracoscopic surgical stabilization of rib fractures: can it be done and is it worth it?

Surgical stabilization of rib fractures (SSRF) is now a common operation at most high-volume trauma centers. Increased experience with the procedure has spawned a variety of technical modifications to minimize incision length, muscle division, scapular retraction, and general tissue trauma. The ultimate example of such a minimally invasive approach is completely thoracoscopic SSRF, which refers to using a video-assisted thoracoscopic surgery (VATS) technique to both reduce and fixate rib fractures in an intra-thoracic fashion. The benefits of thoracoscopic SSRF may be divided broadly into those that relate to the repair of the rib fractures themselves, and those that relate to adjuncts to rib fracture repair. With respect to the former, theoretical benefits include improved visualization of rib fractures (particularly in posterior and sub-scapular locations), minimization of trauma to overlying muscles and nerves, minimization of trauma to intra-thoracic structures, and elimination of palpable plates. With respect to the latter, theoretical advantages include evacuation of retained hemothorax, guided placement of loco-regional anesthesia and chest tubes, and identification and repair of associated, intra-thoracic injuries. A VATS may also aid in trainee education. Despite these theoretical benefits, early attempts at thoracoscopic SSRF have been limited by both user inexperience and inadequate instrumentation. Furthermore, there are currently no data comparing the efficacy of completely thoracoscopic SSRF to either contemporary, minimally-invasive, extra-thoracic SSRF or non-operative management.