Bleeding or oozing during pulmonary artery stapling in the era of minimally invasive lung surgery: a narrative review

Background and Objective: Pulmonary artery (PA) transection is a critical step in minimally invasive lung surgery. Due to PA wall fragility, bleeding or oozing during PA stapling remains a frequent intraoperative issue that obscures visualization and increases surgical difficulty. This narrative review elucidates bleeding incidence during PA stapling, identifies associated risk factors, and synthesizes the current status of PA stapling in thoracoscopic surgery.

Methods: A search for studies published in English between January 2000 and May 2026 was conducted using the PubMed database. This review focuses exclusively on “pure” stapling-phase bleeding, defined as bleeding or oozing occurring during or immediately after firing, and excludes injuries related to dissection or stapler insertion.

Key Content and Findings: Variability in definitions limits comparisons of stapling-phase bleeding rates across studies. Major bleeding events, defined as events requiring unplanned interventions, such as clipping, fibrin sealant patch application, or suturing, are uncommon (<2%). In contrast, minor bleeding, encompassing staple line (SL) bleeding or oozing that resolves spontaneously or with compression, occur in approximately 10.0–31.5% of transections. Notably, 0.6–5.9% of cases require adjunctive hemostatic measures. Most studies have reported no significant association between stapling-phase bleeding (particularly SL bleeding) and device selection (e.g., staple row number and cartridge color/staple height) or anatomical factors (e.g., vessel diameter and simultaneous transection of multiple vessels). In contrast, technical factors, particularly PA lifting and twisting during stapling, have consistently been identified as significant contributors. Additional port placement may reduce excessive tension. Continuous slow firing using Covidien’s Signia™ Stapling System has been reported to reduce SL bleeding.

Conclusions: Stapling-phase bleeding represents a routine intraoperative risk in PA transection. Given its multifactorial nature, future studies should prioritize multivariate analyses that account for confounding factors. Ongoing development and evaluation of new technologies, including slow-firing stapling systems, may further improve SL integrity and surgical outcomes.