Vascular injuries during VATS lobectomies: keep calm, compress and have a plan

“Everything is unprecedented until it happens for the first time.”—Chesley ‘Sully’ Sullenberger

Nowadays video-assisted thoracic surgery (VATS) lobectomy is the standard surgical modality for early-stage non-small cell lung cancer (NSCLC) and has been gradually applied also to more advanced stages of lung cancer. A lobectomy requires the interruption of significant structures, including branches of the pulmonary artery, pulmonary vein, and bronchus. As for the thoracotomy, this technique had not changed since 1940 when individual hilar dissection was first performed (1). The pivotal role of VATS lobectomy has been extensively explored evidencing the decreased morbidity, the better quality of life and the reduced hospital length of stay, with similar survival rates (2). The penetrance of this technique has been somewhat slow in the last 25 years in the thoracic surgeon community, due to many reasons and including the fear of major intraoperative complications (3). The vascular injury was an obstruction to the acceptance of VATS in lung surgery. Injuries to vascular structures might be uncontrollable and call for an emergency and unplanned conversion or, worse, might necessitate major pulmonary resections (4). However, there was no adequate solution, and the information reported afterwards is still rare, except the conversion to open thoracotomy. Intraoperative management for bleeding from a significant pulmonary arterial branch injury referred to the Cerfolio’s rule of the four “P”: poise; pressure to apply immediately to the bleeding vessel; preoperatively preparedness of a disaster plan (not rush preparation of thoracotomy after the injury); proximal control of the vessel bleeding (5).

In their recently published paper, Chenglin Guo et al. from the West China Hospital, Sichuan University of Chengdu (CN), presented the details of suction—compressing angiography technique for vascular injury repair during VATS lobectomies. After the control of the bleeding with the compression of the injured site with the suction tip, the vascular repair could be divided into three different approaches according to the location and size of the vascular injury (6). Nevertheless, this technique is not suitable for the injuries of the main pulmonary artery when there is not enough space to block the proximal artery (6).

Despite pulmonary artery bleeding is considered among the most feared situations during hilar VATS dissection, the related risk factors and the direct consequences of these vascular injuries are challenging to study. On the other hand, this issue is not widely covered in the medical literature. The incidence of vascular damages reported by large volume centres and by skilled surgeons is slight (7), and reports of intra-operative catastrophes, including death, caused by uncontrolled bleeding in high-volume centres are also negligible. However, the incidence of vascular injuries across the spectrum of surgical experience is likely to be higher. The occurrence of vascular incidents (or complications that result from vascular injuries during VATS lobectomy) is possible under-reported (8). An analysis of the vascular injuries among a vast population coming from the European Society of Thoracic Surgeons (ESTS) database found an incidence of 2.9% (9); other authors reported a range of unplanned thoracotomy due to bleeding from 0.5% to 5.2% (8), or from 4.1% (10) to 8.2% (11). It might be noted otherwise that while most of the vascular injuries are related to a challenging and hazardous vessel dissection, stapler failure is only anecdotic, and most of the stapler malfunctions could be related to human mistakes in handling and appropriately manipulating vessels (12). Therefore, the literature evidence is not homogeneous, and the comparison of different surgical approaches is difficult. For example, it is well accepted that hilar adhesions due to lymphadenopathy are responsible for most of the vascular injuries requiring an unplanned thoracotomy (10,13-15) and that skilled surgeons could move beyond the boundaries to a more aggressive lymph nodes dissection (13). Nevertheless, only a minority of potential conversion due to complicated hilar preparation are predictable preoperatively on a preoperative chest computed tomography (2). The primary concerns for vascular injuries are the possible increased risk of morbidity and mortality due to longer operating time, further lung manipulation, an increased risk of damage to adjacent tissues and an increased blood loss.

Patient safety must remain the primary focus and conversion should be discussed at any time when patient safety is not guaranteed. Conversion should be considered more a resource to preserve patient’s safety rather than the failure of the VATS approach. Therefore, the correct assessment of any bleeding is of paramount importance during every VATS procedure (16). Delayed conversion and an unsuccessful attempt to manage complications with minimally invasive techniques increase the risk of unfortunate intraoperative events (17).

In conclusion, the occurrence of vascular injury is inevitable, but a well-trained surgical team can treat it appropriately. The decision regarding repair by VATS or the conversion to thoracotomy depends on many factors as the severity of the vascular injury, the surgeons’ experience, the anesthesiologist and nursing staff’s cooperation and so on (18). However, one strategy should guide us: keep calm, compress the bleeding site directly and have an organised disaster plan.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

References

1. Sumitomo R, Fukui T, Marumo S, et al. Effects of vessel interruption sequence during thoracoscopic lobectomy for non-small cell lung cancer. Gen Thorac Cardiovasc Surg 2018;66:464-70. [Crossref] [PubMed]
2. Hanna JM, Berry MF, D'Amico TA. Contraindications of video-assisted thoracoscopic surgical lobectomy and determinants of conversion to open. J Thorac Dis 2013;5 Suppl 3:S182-9. [PubMed]
3. Jawitz OK, Wang Z, Boffa DJ, et al. The differential impact of preoperative comorbidity on perioperative outcomes following thoracoscopic and open lobectomies. Eur J Cardiothorac Surg 2017;51:169-74. [Crossref] [PubMed]
4. Flores RM, Ihekweazu U, Dycoco J, et al. Video-assisted thoracoscopic surgery (VATS) lobectomy: catastrophic intraoperative complications. J Thorac Cardiovasc Surg 2011;142:1412-7. [Crossref] [PubMed]
5. Cerfolio RJ, Bess KM, Wei B, et al. Incidence, Results, and Our Current Intraoperative Technique to Control Major Vascular Injuries During Minimally Invasive Robotic Thoracic Surgery. Ann Thorac Surg 2016;102:394-9. [Crossref] [PubMed]
6. Guo C, Mei J, Ma L, et al. Handling vascular bleeding without conversion during video-assisted thoracoscopic surgery major pulmonary resection. Ann Transl Med 2018;6:363. [Crossref] [PubMed]
7. Fernandez Prado R, Fieira Costa E, Delgado Roel M, et al. Management of complications by uniportal video-assisted thoracoscopic surgery. J Thorac Dis 2014;6:S669-73. [PubMed]
8. Berry MF. Pulmonary Artery Bleeding During Video-Assisted Thoracoscopic Surgery: Intraoperative Bleeding and Control. Thorac Surg Clin 2015;25:239-47. [Crossref] [PubMed]
9. Decaluwe H, Petersen RH, Hansen H, et al. Major intraoperative complications during video-assisted thoracoscopic anatomical lung resections: an intention-to-treat analysis. Eur J Cardiothorac Surg 2015;48:588-98; discussion 599. [Crossref] [PubMed]
10. Mei J, Pu Q, Liao H, et al. A novel method for troubleshooting vascular injury during anatomic thoracoscopic pulmonary resection without conversion to thoracotomy. Surg Endosc 2013;27:530-7. [Crossref] [PubMed]
11. Kawachi R, Tsukada H, Nakazato Y, et al. Morbidity in video-assisted thoracoscopic lobectomy for clinical stage I non-small cell lung cancer: is VATS lobectomy really safe? Thorac Cardiovasc Surg 2009;57:156-9. [Crossref] [PubMed]
12. Miyazaki T, Yamasaki N, Tsuchiya T, et al. Management of unexpected intraoperative bleeding during thoracoscopic pulmonary resection: a single institutional experience. Surg Today 2016;46:901-7. [Crossref] [PubMed]
13. Sawada S, Komori E, Yamashita M. Evaluation of video-assisted thoracoscopic surgery lobectomy requiring emergency conversion to thoracotomy. Eur J Cardiothorac Surg 2009;36:487-90. [Crossref] [PubMed]
14. Samson P, Guitron J, Reed MF, et al. Predictors of conversion to thoracotomy for video-assisted thoracoscopic lobectomy: a retrospective analysis and the influence of computed tomography-based calcification assessment. J Thorac Cardiovasc Surg 2013;145:1512-8. [Crossref] [PubMed]
15. Vallance A, Tcherveniakov P, Bogdan C, et al. The evolution of intraoperative conversion in video assisted thoracoscopic lobectomy. Ann R Coll Surg Engl 2017;99:129-33. [Crossref] [PubMed]
16. Gonzalez-Rivas D, Stupnik T, Fernandez R, et al. Intraoperative bleeding control by uniportal video-assisted thoracoscopic surgery. Eur J Cardiothorac Surg 2016;49 Suppl 1:i17-24. [PubMed]
17. 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]
18. Wu CF, de la Mercedes T, Fernandez R, et al. Management of intra-operative major bleeding during single-port video-assisted thoracoscopic anatomic resection: two-center experience. Surg Endosc 2018. [Epub ahead of print]. [Crossref] [PubMed]