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. 2013 Feb;27(2):530-7.
doi: 10.1007/s00464-012-2475-1. Epub 2012 Jul 18.

A novel method for troubleshooting vascular injury during anatomic thoracoscopic pulmonary resection without conversion to thoracotomy

Jiandong Mei  1 , Qiang Pu, Hu Liao, Lin Ma, Yunke Zhu, Lunxu Liu
Affiliations

A novel method for troubleshooting vascular injury during anatomic thoracoscopic pulmonary resection without conversion to thoracotomy

Jiandong Mei et al. Surg Endosc. 2013 Feb.

Abstract

Background: Massive bleeding caused by vascular injury is considered the most troublesome and dangerous complication during video-assisted thoracoscopic surgery (VATS) pulmonary resection and is an important reason for emergency conversion to thoracotomy. The purpose of this paper was to show the suction-compressing angiorrhaphy technique (SCAT) for troubleshooting this problem without conversion.

Methods: A total of 414 consecutive VATS anatomic pulmonary resections were performed between May 2006 and July 2011, among which 17 operations (4.11 %) encountered unexpected vascular injury. The procedure for troubleshooting vascular injury included bleeding control and angiorrhaphy. Bleeding was first controlled through side compression of the injured site with an endoscopic suction. Angiorrhaphy was then performed with running 5-0 Prolene suture using different procedures according to the size and location of the injuries, including direct suture upon suction compression, suture after substituting suction compression with clamping of the injured site, or suture after attaining proximal cross-clamping of the main pulmonary artery. Detailed information of these patients was carefully reviewed. The reasons for conversion to thoracotomy also were revealed.

Results: Fifteen cases (15/17, 88.24 %) were successfully managed without conversion. Two cases of left main pulmonary artery injury were converted to thoracotomy due to difficulties in proximal cross-clamping of the injured vessel. Blood loss of the 17 patients ranged from 60-935 (median, 350) ml. Two patients were administered with allogeneic blood. The postoperative chest CT scan showed normal blood flow on the injured vessels. The total conversion rate was 2.66 % (11/414). The most common reason for conversion was hilar lymphadenopathy.

Conclusions: The SCAT is an effective procedure for managing vascular injury during VATS anatomic pulmonary resection. In most cases, bleeding control and angiorrhaphy could be achieved using this method with acceptable blood loss, thereby avoiding emergency conversion to thoracotomy.

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Figures

Fig. 1
Fig. 1
Typical placement of the ports and instruments. A Direct suture upon suction compression of the injured site. B Suture after substituting suction compression with clamping of the injured site. The suction was removed (arrow) after side clamping the wound with Allis forceps. ICS intercostal space
Fig. 2
Fig. 2
A Vascular injury. B Bleeding control via side compression of the injured site with the suction
Fig. 3
Fig. 3
Situation 1 Direct suture upon suction compression of the injured site. A Controlling bleeding with the suction. B and C Sewing the wound site by moving the suction in opposite directions. D Tightening the stitches
Fig. 4
Fig. 4
Situation 2 Suture after substituting suction compression with clamping of the injured site. A Controlling bleeding with the suction. B Side clamping the wound with long Allis forceps and removing the suction. C Performing angiorrhaphy with running 5-0 Prolene suture on one side of the Allis. D Removing the Allis and making an additional suture. E and F Sewing the wound using the other needle of the same Prolene stitches and knotting
Fig. 5
Fig. 5
Situation 3 Suture after substituting suction compression with proximal cross-clamping of the main pulmonary artery. A Controlling bleeding with the suction. B Side clamping the wound with long Allis forceps and removing the suction. C Clamping the proximal artery with an atraumatic vascular clamp and removing the Allis. D and E Performing angiorrhaphy with running 5-0 Prolene suture. F and G Sewing the wound using the other needle of the same Prolene stitches. H Removing the vascular clamp
Fig. 6
Fig. 6
Demonstration of managing left pulmonary artery laceration using the method described in Fig. 5. A Blunt dissection of lingular artery with a long right angle clamp and suction. B Bleeding (arrow). C Controlling bleeding with the suction. D Clamping the laceration with Allis forceps and removing the suction. E Cross-clamping left main pulmonary artery with endoscopic atraumatic vascular clamp. F Reevaluating the laceration (arrowhead). G Sewing the laceration using running 5-0 Prolene suture. H Removal of the vascular clamp. AVC atraumatic vascular clamp, BS bronchial stump, LA lingular artery, LPA left pulmonary artery
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