The majority of the penetrating lung injuries are treated by simple procedures as tube thoracostomies. Thoracotomy is needed in 10% of the patients, and pneumorraphy is the most common operative technique. Pulmonary anatomic resections are frequently associated with high mortality, which ranges between 55 and 80%. This occurs as a consequence of the right side cardiac failure and pulmonary hypertention observed in these situations. So, in order to prevent this outcome, lung sparing techniques, as tractotomy, have been advocated in critical scenarios.

Authors report the case of a 25 year old man sustaining multiple gunshot wounds to the thorax. He was unconscious on admission, with absent respiratory sounds at the right side. He sustained profound shock and, supposedly, a large right hemothorax. After intubation, a right tube thoracostomy was performed, which was followed by the drainage of 1500 cc of blood from the right thorax. After starting the fluid infusion, the patient was transferred to the operation room. A right antero lateral thoracotomy was carried out. There were three transfixing injuries through the lung, one in each lobe, with active arterial bleeding. The operative technique of tractotomy is shown in the video, with comments on details of the procedure. Authors also discuss the role of tractotomy and anatomic resections, based on published papers on the subject.

Tractotomy has been demonstrated to be technically simple and rapid. Nevertheless, it is necessary in only 11% of the patients that undergo thoracotomy due to lung injuries. Recently, its efficacy has been questioned, as some studies showed a high incidence of complications. Other groups defended lung sparing techniques in the management of lung injuries, when feasible. There is no prospective data comparing both techniques. It seems that the complications associated with pulmonary tractotomies are considerably high, but the mortality of anatomic resections is prohibitive. Our opinion favors pulmonary tractotomy. It has been used in our institution for the last decade, with low morbidity and mortality rates. It is especially useful in critical cases when damage control techniques are deemed necessary. It also helps in cases with multiple pulmonary injuries, permitting rapid access to the bleeding vessel.