Awake Emergency Department Thoracoscopic Investigation of Penetrating Diaphragmatic Injuries: A Novel Minimally Invasive Technique of Diagnosis

Background: The diagnosis of occult penetrating diaphragmatic trauma remains challenging, with conventional imaging offering inadequate accuracy for diagnosis. Minimally invasive surgical options for evaluating the diaphragm conventionally require general anesthesia. We propose a technique for evaluating the diaphragm via awake thoracoscopy in the emergency department. Methods: A prospective interventional study was conducted to investigate the safety and accuracy of emergency department awake thoracoscopy for diagnosing diaphragmatic injuries in penetrating thoracoabdominal trauma. All adult patients who presented to the trauma unit with penetrating thoracoabdominal trauma who were hemodynamically stable were enrolled. The patients underwent emergency department awake thoracoscopy with a rigid endoscope through a previously inserted intercostal drain. Only local anesthesia and conscious sedation were provided. Results: Forty patients were enrolled. All 40 (100%) were men, and the median age was 34 years. Thirty-four had stab wounds (85%), 5 had gunshot wounds (12.5%), and 1 had a suspected iatrogenic diaphragm injury during intercostal drain insertion (2.5%). In 32 (80%), the diaphragm was well visualized, of whom 7 (17.5%) had diaphragm injuries. In the remaining 8 patients in whom the diaphragm was not well visualized, only 1 (2.5%) had a diaphragmatic injury. The diaphragmatic injuries that were identified were confirmed and repaired during a subsequent explorative laparoscopy. There were no procedure-related complications in any of the patients during short-Term follow-up. Conclusions: Awake thoracoscopy is safe, feasible, and accurate for the diagnosis of occult diaphragm injuries and may offer a modality for assessment that does not require general anesthesia.