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UNUSUAL CASE
Year : 2013  |  Volume : 9  |  Issue : 3  |  Page : 136-137
 

A case of complete transection of right main bronchus in a child: Role of thoracoscopy and bronchoscopy


1 Department of Surgery, S.N.M.C and H.S.K Hospital, Navanagar, Bagalkot, Karnataka, India
2 Department of Anaesthesia, S.N.M.C and H.S.K Hospital, Navanagar, Bagalkot, Karnataka, India
3 Department of Paediatrics, S.N.M.C and H.S.K Hospital, Navanagar, Bagalkot, Karnataka, India

Date of Submission14-Jun-2012
Date of Acceptance10-Nov-2012
Date of Web Publication22-Jul-2013

Correspondence Address:
Ramesh B Hatti
Department of Surgery, S.N.M.C and H.S.K Hospital, Navanagar, Bagalkot-587102, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.115379

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 ¤ Abstract 

Isolated tracheobronchial injuries are extremely rare in children and challenging due to life threatening complications. Blunt trauma to chest, especially in pediatric age group, is usually associated with multi-organ involvement and high mortality rate. These patients rarely reach a hospital. We have described here a case of complete transection of right main bronchus in a child, without hilar vascular injury, and its successful management, emphasizing the role of bronchoscopy and thoracoscopy.


Keywords: Bronchoscopy, chest trauma, tracheobronchial rupture, thoracoscopy


How to cite this article:
Hatti RB, Hosalli VB, Vanaki RN, Patil DH. A case of complete transection of right main bronchus in a child: Role of thoracoscopy and bronchoscopy. J Min Access Surg 2013;9:136-7

How to cite this URL:
Hatti RB, Hosalli VB, Vanaki RN, Patil DH. A case of complete transection of right main bronchus in a child: Role of thoracoscopy and bronchoscopy. J Min Access Surg [serial online] 2013 [cited 2019 Dec 9];9:136-7. Available from: http://www.journalofmas.com/text.asp?2013/9/3/136/115379



 ¤ Introduction Top


Blunt chest trauma resulting tracheobronchial (TB) rupture is rare, especially in children. These injuries are potentially life threatening and present with severe respiratory distress. TB rupture is usually the result of high velocity road traffic accidents, and it can also be caused by crushing or twisting injury or by a fall from a height. High index of clinical suspicion with prompt early diagnosis and treatment reduces mortality and morbidity.


 ¤ Case Report Top


We received a 5-year-old male child from a peripheral hospital to our emergency room, with a history of run over by a bullock cart. On arrival, the child was in severe respiratory distress with absence of peripheral pulses and air entry on the right side of chest as well as un-recordable blood pressure. The child was resuscitated with crystalloids and vasopressor support.

An immediate bedside chest X-ray showed massive tension pneumothorax on the right side and an intercostal drain (ICD) tube was inserted [Figure 1]a. The child was stabilized for the next 24 h, but ICD showed continuous massive air leak and the child had persistent tachypnoea. A computed tomography (CT) scan image showed a collapse lung and massive pneumothorax with a suspicion of right main bronchus injury.
Figure 1: (a) Preoperative X-ray showing right tension pneumothorax (b) Thoracoscopic view of bronchial transection and air leak (c) Introperative picture of right main bronchial transection

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The child was taken to the operating room. After intubation with single lumen endotracheal tube, a fiber optic bronchoscopy showed right mainstem bronchus obliteration by hematoma just 1.5 cm from carina, and the endotracheal tube was guided into left main bronchus. A diagnostic thoracoscopy was done to reveal complete transection of the right main bronchus and no associated mediastinal injuries [Figure 1]b.

A right postero-lateral thoracotomy showed bronchial transection about 1.5 cm from the carina [Figure 1]c. The distal end was dissected out from the hilar structures and bronchial continuity was established by an end-to-end anastomosis with 4-0 vicryl interrupted sutures. The child was extubated and was in intensive care unit (ICU) with oxygen support. Early postoperative chest X-ray showed features of pneumonitis, which resolved with intravenous (IV) antibiotics and chest physiotherapy, with complete lung expansion seen on chest X-ray [Figure 2].
Figure 2: Postoperative X-ray showing right lung expansion

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 ¤ Discussion Top


The incidence of TB injuries is about 0.7-2.8%, [1] and mortality relating to TB injuries is very high. The mechanism of TB injuries [2] are traction at the carina, rapid deceleration, or sudden increase of pressure in the TB tree.

The aorta lies anterior to the right main bronchus and arches posterior to the left main bronchus. Hence, the right main bronchus is more prone to injury as it lies directly over rachis, whereas left bronchus is protected posteriorly by aorta.

The patients with traumatic rupture of TB tree present with breathlessness, mediastinal and subcutaneous emphysema, hemoptysis, pneumothorax, atelectasis, persistent air leak, and failure to expand the lung with thoracostomy tube drainage. [3] Our patient presented with tension pneumothorax and shock following blunt chest trauma. Mortality is very high in these patients, unless it is diagnosed and intervened very early. A successful outcome depends on high index of clinical suspicion.
"Fallen lung sign" featuring a collapsed lung in dependant position, hanging on the hilum by its vascular attachments, is a more direct sign seen on CT scan. Flexible fiber optic bronchoscopy is the gold standard in establishing diagnosis and also can be used to guide endotracheal tube in to the main bronchus to isolate affected main bronchus. [4] Though CT scan in our case did not show the pathognomonic fallen lung sign, suspicious discontinuity of right main bronchus was identified.

With recent advances in pediatric thoracoscopic procedures, video assisted thoracic surgery (VATS) can be utilized for the initial diagnostic evaluation and surgical management of hemodynamically stable patients. [4],[5] In a study conducted by Lobe et al., [6] it was concluded that minimal access surgery (MAS) is becoming an accepted modality in the management of adults with trauma, but its use in children is rarely reported. MAS were used as a diagnostic and even as a therapeutic modality in repairing diaphragmatic lacerations.

We utilized the availability of VATS for confirmation of bronchial transection and also to rule out other mediastinal and diaphragmatic injuries, as the child was hemodynamically stable.

Primary treatment of TB injuries is thoracotomy and bronchial repair. Interrupted, absorbable sutures are used exclusively to allow growth and to avoid the troublesome granuloma problems associated with non-absorbable sutures.

 
 ¤ References Top

1.Gaebler C, Mueller M, Schramm W, Eckersberger F, Vecsei V. Tracheobronchial ruptures in children. Am J Emerg Med 1996;14:279-84.  Back to cited text no. 1
    
2.Barmada H, Gibbons JR. Tracheobronchial injury in blunt and penetrating chest trauma. Chest 1994;106:74-8.  Back to cited text no. 2
[PUBMED]    
3.Hancock BJ, Wiseman NE. Tracheobronchial injuries in children. J Pediatr Surg 1991;26:1316-9.  Back to cited text no. 3
[PUBMED]    
4.Ben-Nun A, Orlovsky M, Best LA. Video-assisted thoracoscopic surgery in the treatment of chest trauma: Long term benefit. Ann Thorac Surg 2007;83:383-7.  Back to cited text no. 4
[PUBMED]    
5.Abolhoda A, Livingston DH, Donahoo JS, Allen K. Diagnostic and therapeutic video assisted thoracic surgery (VATS) following chest trauma. Eur J Cardiothoracic Surg 1997;12:356-60  Back to cited text no. 5
    
6.Chen MK, Schropp KP, Lobe TE. The use of minimal access surgery in pediatric trauma: A preliminary report. J Laparoendosc Surg 1995;5:295-301.  Back to cited text no. 6
[PUBMED]    


    Figures

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