Thoracoscopic lobectomy is now considered the standard of care for surgical management of early stage pulmonary malignancy, offering many advantages over thoracotomy (1-5). Among the varied reasons for increased rates of complications, conversion to open surgery or planned conventional open surgery is the presence of difficult hilar or interlobar lymphadenopathy (6-8). This difficult to manage lymphadenopathy can be seen in the post induction setting, leading to a potentially increased risk of pulmonary arterial injury (7,9,10). While many thoracic surgeons advocate prompt conversion to thoracotomy in the setting of pulmonary arterial injury, with experience a minimally invasive approach to repair can be safe and effective. We present a case of pulmonary arterial injury during a thoracoscopic left upper lobectomy in the post induction setting, demonstrating tamponade of the injury, with subsequent proximal control and suture repair of the defect.
Figure 1 is a video presenting a two incision thoracoscopic left upper lobectomy complicated by a pulmonary arterial injury incurred while dissecting post induction adherent lymphadenopathy off of the ongoing pulmonary artery distal to the take off of the truncus anterior. At the outset of the video, a sponge ball has been placed overlying the injury to achieve tamponade. We then address the fissure, performing blunt dissection using a thoracoscopic suction and lymph node grasper to raise the pulmonary parenchyma off of the underlying pulmonary arterial branches. The lingular and ascending branches of the pulmonary artery are then divided using a curved tip vascular load of the endoscopic stapler. The truncus anterior branch of the pulmonary artery is dissected out with a thoracoscopic right angle and lymph node grasper and is divided using a curved tip vascular load of the endoscopic stapler as is another ascending branch of the pulmonary artery. The left upper lobe bronchus is then divided with a regular load of the endoscopic stapler. The left upper lobe is then placed in a retrieval bag and removed from the chest cavity. The sponge ball is then lifted to check for hemostasis and ongoing bleeding is encountered. It is easily controlled with repeated tamponade. We then employ the thoracoscopic suction and lymph node grasper to dissect proximally on the left pulmonary artery allowing placement of a thoracoscopic vascular clamp proximal to the pulmonary arterial injury. Hemostasis is then adequate to allow a suture repair of the defect.
This video is illustrative of several tips for management of difficult pulmonary arterial injury encountered during thoracoscopic lobectomy. First, if a pulmonary arterial injury is encountered control can usually be obtained with gentle pressure. The surgeon can then assess the degree of injury, their degree of confidence with techniques of vascular control and repair, and thus the safety of proceeding in a minimally invasive fashion. The need for proximal control should be weighed. Here we demonstrate an injury in a difficult location with significant bleeding after an extended period of tamponade. Proximal control in this case significantly improves visualization and provides an added layer of safety. We also demonstrate that in the setting of pulmonary arterial injury, moving away from the area of difficulty to complete dissection elsewhere can lead to good exposure in an indirect manner. We then demonstrate the feasibility of performing a thoracoscopic sutured repair of the pulmonary arterial injury.
Conflicts of Interest: Dr. D’Amico is a consultant for Scanlan Instruments.
Ethical Statement: The study was approved by the institutional ethical committee. Written informed consent was obtained from the patient for publication. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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Cite this article as: Edwards JP, Balderson SS, D’Amico TA. Management of pulmonary arterial bleeding in the post induction setting. J Vis Surg 2016;2:53.