Controlling bleeding during uniportal thoracoscopic major pulmonary resection

Abstract

Aim: In uniportal thoracoscopic major pulmonary resection, it is important to appropriately manage significant vessel injury, to ensure patient safety and minimize conversion to thoracotomy. We analyzed cases of significant vessel injury and investigated efficacy of an algorithm to manage bleeding during thoracoscopic uniportal major pulmonary resection.

Methods: A total of 169 patients underwent “uniportal thoracoscopic major pulmonary resection” (lobectomy or segmentectomy) at our department between February 2019 and April 2021. These patients were classified into groups with (group A, n = 8) and without (group B, n = 161) intraoperative massive bleeding. Patient characteristics and perioperative results were compared between the two groups. Patients with significant vessel injury and conversion to thoracotomy were analyzed in detail.

Results: Group B had significantly less blood loss (A: 197 ± 173 g; B: 42 ± 74 g, P < 0.0001) and shorter-duration postoperative drainage (A: 2.6 ± 1.8 days; B: 1.6 ± 1.3 days, P = 0.036). There were no group differences in any other factors. The most frequently injured vessel in group A was the pulmonary artery (75%). Emergent conversion was required in four cases (cases 7, 76, 128, and 133; 2.4%) due to intraoperative bleeding. No patient developed catastrophic bleeding or required an intraoperative transfusion.

Conclusion: We managed significant vessel injury appropriately during uniportal thoracoscopic major pulmonary resection using the troubleshooting algorithm. The algorithm for the uniportal approach was considered effective and easy to apply even by less-experienced surgeons.

Keywords

Troubleshooting / intraoperative bleeding / uniportal approach

References

[1] Yamamoto H,Takada M,Sakata K.Video-assisted thoracic surgery through a single skin incision.Arch Surg1998;133:145-7

[2] Migliore M,Deodato G. Video assisted thoracic surgery through a single port. Proceedings of Thoracic Surgery and Interdisciplinary Symposium on the Threshold of the Third Millennium, Naples, Italy. 2000. p. 29-30.

[3] Gonzalez-Rivas D,Fieira E.Single-port video-assisted thoracoscopic lobectomy with pulmonary artery reconstruction.Interact Cardiovasc Thorac Surg2013;17:889-91 PMCID:PMC3805214

[4] Bourdages-Pageau E,Lacasse Y.Outcomes of uniportal vs multiportal video-assisted thoracoscopic lobectomy.Semin Thorac Cardiovasc Surg2020;32:145-51

[5] Zhu Y,Wu W.Preliminary results of single-port versus triple-port complete thoracoscopic lobectomy for non-small cell lung cancer.Ann Transl Med2015;3:92 PMCID:PMC4430732

[6] Hirai K,Usuda J.Single-incision thoracoscopic surgery and conventional video-assisted thoracoscopic surgery: a retrospective comparative study of perioperative clinical outcomes†.Eur J Cardiothorac Surg2016;49 Suppl 1:i37-41

[7] Al-Ameri M,Sartipy U.Uniportal versus multiportal video-assisted thoracic surgery for lung cancer.J Thorac Dis2019;11:5152-61 PMCID:PMC6987997

[8] Magouliotis DE,Spiliopoulos K.Uniportal versus multiportal video-assisted thoracoscopic lobectomy for lung cancer: an updated meta-analysis.Lung2021;199:43-53 PMCID:PMC7929953

[9] Igai H,Yoshikawa R,Yazawa T.Algorithm-based troubleshooting to manage bleeding during thoracoscopic anatomic pulmonary resection.J Thorac Dis2019;11:4544-50 PMCID:PMC6940248

[10] Yamashita S,Moroga T.Totally thoracoscopic surgery and troubleshooting for bleeding in non-small cell lung cancer.Ann Thorac Surg2013;95:994-9

[11] Puri V,Majumder K.Intraoperative conversion from video-assisted thoracoscopic surgery lobectomy to open thoracotomy: a study of causes and implications.J Thorac Cardiovasc Surg2015;149:55-61, 62.e1 PMCID:PMC4272658

[12] Amore D,Scaramuzzi R.Reasons for conversion during VATS lobectomy: what happens with increased experience.J Vis Surg2018;4:53 PMCID:PMC5897696

[13] Fourdrain A,Iquille J.Intraoperative conversion during video-assisted thoracoscopy does not constitute a treatment failure†.Eur J Cardiothorac Surg2019;55:660-5

[14] Scarci M,Schmidt J.Management of intraoperative difficulties during uniportal video-assisted thoracoscopic surgery.Thorac Surg Clin2017;27:339-46

[15] Tentzeris V.Uniportal video-assisted thoracic surgery treatment of intra-operative complications.J Vis Surg2018;4:74 PMCID:PMC5945664

[16] Xiao ZL,Pu Q.Technical strategy for dealing with bleeding during thoracoscopic lung surgery.Ann Cardiothorac Surg2014;3:213-5 PMCID:PMC3988308

[17] Flores RM,Dycoco J.Video-assisted thoracoscopic surgery (VATS) lobectomy: catastrophic intraoperative complications.J Thorac Cardiovasc Surg2011;142:1412-7

[18] Fournel L,Grigoroiu M,Gossot D.Totally thoracoscopic major pulmonary resections: an analysis of perioperative complications.Ann Thorac Surg2014;97:419-24

[19] Igai H,Ibe T,Osawa F.Troubleshooting for bleeding in thoracoscopic anatomic pulmonary resection.Asian Cardiovasc Thorac Ann2017;25:35-40

[20] Gonzalez-Rivas D.Important technical details during uniportal video-assisted thoracoscopic major resections.Thorac Surg Clin2017;27:357-72

[21] Igai H,Kamiyoshihara M.Uniportal thoracoscopic upper division segmentectomy of left upper lobe using a unidirectional anterior approach.Multimed Man Cardiothorac Surg2020;2020

[22] Igai H.Uniportal thoracoscopic fissureless right lower lobectomy using the suction device trick.Multimed Man Cardiothorac Surg2019;2019

[23] Igai H,Ohsawa F,Matsuura N.Application of "suction-guided stapling" during uniportal thoracoscopic major lung resection.Gen Thorac Cardiovasc Surg2021;