Video-assisted thoracoscopic surgery (VATS) lobectomy has been used since the early nineties (1) and is now considered the gold standard treatment for early-stage non-small cell lung cancer (NSCLC) (2). Conversion-related factors and learning curve impacts, are described in the literature in some recent papers (3-5). We recently reviewed reasons for conversion and factors related with conversion in our own series of VATS lobectomy (6). From 2009 to October 2017, 610 patients underwent a VATS lobectomy; 32 (5.25%) cases experienced conversion from VATS to thoracotomy. We classified conversions as follows:
- Emergency/safety: due to vascular injury and intraoperative bleeding or bronchial injury;
- Oncologic: due to positive mediastinal lymph node, unexpected tumor extension into the mediastinum, chest wall or adjacent lobe infiltration;
- Technical: including presence of dense adhesions or inability to proceed due to space restrictions in morbidly obese patients.
As experience grows, surgeons reach lower conversion rate (6) and can handle intraoperative complications as vascular or bronchial injuries by VATS.
Herein we present some videos showing cases where vascular injuries led to conversion and others where a minimally-invasive trouble shooting of intraoperative complications was achieved.
All VATS lobectomies were performed with an anterior triportal approach, as we previously described (6). In case of conversion, we performed an anterior thoracotomy extending the utility incision.
We herein describe the cases of six patients undergoing VATS lobectomy for suspected or ascertained NSCLC. In two cases conversion was necessary, while in four cases the complications were successfully managed through VATS.
Case number 1
The patient was scheduled to undergo left upper VATS lobectomy. Tear of the pulmonary artery occurred after stapling. It happened at the beginning of our experience, and the assistant surgeon handling the camera was not prepared to deal with a major vascular lesion. The first decision to retrieve the camera after the unexpected complication was wrong. Thereafter, safe conversion was carried out while the injury was controlled by compression with a swab (Figure 1). Postoperative course was uneventful.
Case number 2
The patient was scheduled to undergo left upper VATS lobectomy. Lesion of the pulmonary artery occurred during stapler positioning. Initial attempt to manage vascular injury by VATS failed. After safe conversion, while the injury was controlled by compression with a swab (Figure 2), vascular suture was performed and postoperative course was uneventful.
Case number 3
The patient was scheduled to undergo right upper VATS lobectomy. Tear of the A2 pulmonary artery occurred during preparation-sealing with a high energy device. Bleeding was safely controlled by single hemostatic sponge application (TachoSil) (Figure 3). Postoperative course was uneventful.
Case number 4
The patient was scheduled to undergo right upper VATS lobectomy. Injury of the anterior truncus occurred during smooth preparation and tunneling of the vessel. Bleeding was safely managed by peripheral compression with a swab, re-tunneling and central stapling (Figure 4). Postoperative course was uneventful.
Case number 5
The patient was scheduled to undergo left upper VATS lobectomy. Hemorrhage due to tearing of staple line on a fragile wall of the pulmonary artery (A1–3). Hemostasis was successfully obtained after double sealing with a hemostatic sponge (Veriset) and compression with a swab (Figure 5). Postoperative course was uneventful.
Case number 6
The patient was scheduled to undergo right lower VATS lobectomy. Tear of the middle lobe bronchus occurred. Air-sealing was successfully achieved by thoracoscopic suture of the fistula (Figure 6). Postoperative course was uneventful.
Conversion is not a failure, safety first. There is no increase in morbidity after conversion. As experience grows, surgeons reach lower conversion rates and more ability to manage intraoperative complications by VATS. During VATS lobectomies try to be aware and prepared for potentially dangerous situations; think in advance of strategies to handle intraoperative complications; share these strategies with your own staff (surgeons, anesthesiologist, scrub nurse).
Conflicts of Interest: The authors have no conflicts of interest to declare.
Informed Consent: The authors confirm that all videos are completely anonymized and in the text there is no personal information or data that could potentially be traced back to the patient.
- Kirby TJ, Mack MJ, Landreneau RJ, et al. Initial experience with video-assisted thoracoscopic lobectomy. Ann Thorac Surg 1993;56:1248-52; discussion 1252-3. [Crossref] [PubMed]
- Detterbeck FC, Lewis SZ, Diekemper R, et al. Executive summary: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:7S-37S.
- Smith DE, Dietrich A, Nicolas M, et al. Conversion during thoracoscopic lobectomy: related factors and learning curve impact. Updates Surg 2015;67:427-32. [Crossref] [PubMed]
- Amore D, Curcio C. Steps in the development of a VATS lobectomy program. J Vis Surg 2017;3:104. [Crossref] [PubMed]
- Cao C, Petersen RH, Yan TD. Learning curve for video- assisted thoracoscopic lobectomy. J Thorac Cardiovasc Surg 2014;147:1727. [Crossref] [PubMed]
- Augustin F, Maier HT, Weissenbacher A, et al. Causes, predictors and consequences of conversion from VATS to open lung lobectomy. Surg Endosc 2016;30:2415-21. [Crossref] [PubMed]
- Lucciarini P, Augustin F, Maier HT, et al. Left upper VATS lobectomy: tear of the pulmonary artery requiring conversion in the early experience. Asvide 2018;5:064. Available online: http://asvidett.amegroups.com/article/view/22752
- Lucciarini P, Augustin F, Maier HT, et al. Left upper VATS lobectomy: lesion of the pulmonary artery not manageable by VATS. Asvide 2018;5:065. Available online: http://asvidett.amegroups.com/article/view/22753
- Lucciarini P, Augustin F, Maier HT, et al. Right upper VATS lobectomy: injury of the A2 pulmonary artery safely controlled by VATS with TachoSil. Asvide 2018;5:066. Available online: http://asvidett.amegroups.com/article/view/22754
- Lucciarini P, Augustin F, Maier HT, et al. Right upper VATS lobectomy: tear of the anterior truncus safely managed by VATS with compression and stapling. Asvide 2018;5:067. Available online: http://asvidett.amegroups.com/article/view/22755
- Lucciarini P, Augustin F, Maier HT, et al. Left upper VATS lobectomy: tear of the pulmonary artery successfully managed by VATS with compression and double Veriset application. Asvide 2018;5:068. Available online: http://asvidett.amegroups.com/article/view/22756
- Lucciarini P, Augustin F, Maier HT, et al. Right lower VATS lobectomy: lesion of the middle lobe bronchus successfully treated by thoracoscopic suture. Asvide 2018;5:069. Available online: http://asvidett.amegroups.com/article/view/22757
Cite this article as: Lucciarini P, Augustin F, Maier HT, Zaraca F, Schmid T. Intraoperative complications during VATS lobectomies from conversion to minimally-invasive “trouble-shooting”. J Vis Surg 2018;4:28.