LAUSR

We read with great interest the recent article published by Rabiou et al. about the management of penetrating thoracic injuries with video thoracoscopy, but on critically reviewing it, we found several aspects that should be mentioned to enhance the discussion. The authors included patients with injuries below the nipple line or the tip of the scapula; technically, these injuries should be referred to as thoracoabdominal penetrating injuries (TPI), since both the thorax and the abdomen are at risk of having a visceral injury. By using the term ‘thoracic injuries’, the authors may unintentionally mislead readers, and disregard the need for a high index of suspicion for abdominal injuries in such patients – studies show that more than 60% of these patients may present an intrabdominal injury, and it is for that reason that TPI are among the most challenging situations for the trauma surgeons. Stable patients with TPI may present an asymptomatic diaphragmatic injury in up to 67% of the cases. Early identification of such injuries is important because of the risk of diaphragmatic hernia and its associated morbidity. The optimal route of surgical exploration in such patients is controversial, especially when considering minimally invasive surgery and one aspect that should be noted is the time from admission to operation. Patients undergoing minimally invasive surgery within a few hours of admission should be considered for laparoscopy. Those with no abdominal complaints after several hours or a few days from admission may be considered as having low risk of abdominal injury; hence, surgical exploration may focus primarily on the thorax. Rabiou et al. approached all patients by video thoracoscopy, but as the timespan from admission to surgery is not mentioned, it is unclear what drove the authors to perform the surgical exploration through the thoracic cavity, and how they excluded intrabdominal injuries in some patients. The affected side is also relevant for surgical planning. Injuries to the right diaphragm are more challenging to manage by laparoscopy, especially when posterior, due to the presence of the liver. Although controversial, the need to repair right-sided injuries has been contested in animal studies showing spontaneous diaphragmatic healing. Rabiou et al. describe 58 patients with stab and firearm wounds, 95% of them on the left side. Thoracoscopic exploration may be sufficient in cases of right diaphragmatic injury with isolated liver injury detected by pre-operative imaging following a strict non-operative management of abdominal penetrating injuries. On the other hand, when a left diaphragmatic injury is noted during video thoracoscopy, there should be a high index of suspicion of intraabdominal injury, especially to the stomach, spleen and large bowel, and we believe laparoscopy should be performed. Rabiou et al. subjected all the patients to chest radiographs, but in line with the opinion of other authors, in our institution, the imaging of choice for stable patients with TPI is contrast-enhanced computerized tomography (CT) because of the possible identification of the injury tract, of retroperitoneal lesions, and of other signs such as hemoand pneumothorax. In general, preoperative imaging demonstrates poor accuracy for diaphragmatic lesions; nevertheless, CT has a higher accuracy when compared to radiographs, and we advocate for that option whenever possible. The benefits of endoscopic and video-assisted surgery in selected trauma patients are now well established in the literature. We congratulate the authors for pursuing better outcomes by using thoracoscopy with both diagnostic and therapeutic intent (video-assisted thoracotomy). However, we do not completely agree