Uniportal video-assisted thoracoscopic surgery: bleeding control with additional port surgical technique

Introduction

Since the first thoracic lung wedge resection through a single skin incision in 1998 and the first uniportal lobectomy for lung cancer in 2010 (1,2), uniportal video-assisted thoracoscopic surgery (VATS) has evolved as an alternative to other minimally invasive thoracic surgical approaches including multiportal VATS and robotic-assisted thoracic surgery. There is a large body of literature comparing the uniportal VATS (UVATS) approach with multiportal VATS and robotic-assisted thoracic surgery that confirms that UVATS is not inferior to other approaches as measured by surgical and oncological outcomes (3-5). With the widespread dissemination and adoption of UVATS, primarily in Asia and Europe, thoracic surgeons have been able to not only perform standard lung resections using UVATS but also approach complex surgeries, such as bronchial sleeve lobectomy and bronchovascular double-sleeve lobectomy, with UVATS (6-8). During complex resection, increased rates of intraoperative complications are expected, and bleeding is the most frequent reason for conversion to open thoracotomy (9).

Yamashita and colleagues reported vascular injuries in 4.7% of VATS resections (26 cases). Most frequently, lesions were in a pulmonary artery (PA) branch (17 patients) or the main PA or trunk (4 patients). There were 19 patients in whom conversion to open surgery was necessary to resolve the bleeding. The devices most frequently involved in vascular accidents were staplers and ultrasonic coagulation shears (10). Decaluwe and colleagues reported vascular injury in 2.9% of VATS anatomic resections in a large multi-institution series (11). In our series, Drevet and Ugalde Figueroa reported UVATS safety, efficacy and our learning curve during adoption of the approach. During the first 10 months of adoption of the UVATS technique, we encountered 4 (2.2%) major vascular accidents that required multiple blood transfusions and conversion to open surgery to stop the bleeding. However, with time and experience, we developed strategies to safely manage vascular accidents minimally invasively (12). In a retrospective analysis by Igai and colleagues of 240 patients who underwent VATS anatomic lung resection, 26 patients had massive bleeding intraoperatively. In 21 patients (80.8%), the bleeding was resolved using a minimally invasive approach, but 5 patients (19.2%) needed conversion to thoracotomy (13).

As a part of VATS special series on Advanced Uniportal VATS, this article overviews UVATS and discusses the importance of bleeding control during lung resection. The manuscript previews the surgical technique of bleeding control with an additional port that can be used to manage vascular accidents during UVATS procedures. By providing insights into the strategies for safely managing complications during UVATS, this article is an important tool for thoracic surgeons and surgical residents who want to learn more about this minimally invasive surgical approach. We present this article in accordance with the SUPER reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-23-12/rc).

Classification of bleeding

The classification and grading of bleeding varies among surgeons. Gonzalez-Rivas and colleagues classified intraoperative bleeding into three main types: oozing, minor, and major (14). In contrast, Demmy and colleagues classified bleeding as mild and more serious (15). Oozing refers to bleeding from adhesions released by blunt dissection in the thoracic wall or lung. Minor or mild bleeding originates from small tears and injuries to the vascular stumps in vessels smaller than 3–4 mm, typically in the distal lobar arteries. Major bleeding refers to bleeding from proximal pulmonary arteries or veins, and more serious bleeding from the pulmonary vessels exceeds 500 mL (14,15).

Preoperative preparations and requirements

Prevention is the best strategy to avoid major complications during VATS procedures. Patients with a history of infectious or inflammatory diseases, such as tuberculosis or pneumoconiosis, have a higher risk of vascular accidents and bleeding because the scar tissue or inflammation surrounding the vascular structures makes dissection more laborious. Preoperative computerized tomography (CT) imaging with reconstructions can help the surgeon anticipate potential technical difficulties, such as vascular anomalies or calcified lymph nodes around the vessels. Patients must be advised of the risk for intraoperative complications and conversion to thoracotomy (14,16). Preventive techniques have been described, mainly for complex procedures (17-19). For example, Kamiyoshihara and colleagues reported two cases where they inserted vascular clamps through an access incision to clamp the main PA during a VATS arterioplasty and thereby avoided bleeding and conversion to thoracotomy. The authors call this maneuver “the outside-field vascular clamping technique” (17). Watanabe described a PA clamping using a silk suture due to dense pleural adhesions and bleeding from PA during a VATS, avoiding bleeding and conversion to thoracotomy (20).

The study was conducted in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from the patient for the publication of this manuscript, the accompanying images, and the videos. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step managing perioperative bleeding

Direct compression and hemostatic materials

When a vascular accident happens, the first measure taken to resolve the bleeding is direct compression. If immediately available, long thoracoscopic forceps mounted with a sponge stick enable constant compression, which is then followed by cleaning up the field. Overcompression can enlarge a laceration and the PA has relatively low pressure to begin with, so in many patients, light-to-moderate pressure is sufficient to stop the bleeding. Once the bleeding is entirely under control and the field is clean, the surgeon must remain calm, address the issue with the operating room team, understand the extent of the laceration, and decide on a strategy for definitive repair in conjunction with the operating room (OR) team (16). Hemostatic materials (collagen sponge or patch) can be used to close minor injuries (<6 mm). In cases where the PA injuries can be managed only with direct compression, a hemostatic patch can be applied to prevent the reopening (19).

The four Ps

Cerfolio and colleagues reported the “four Ps” to manage bleeding during minimally invasive robotic thoracic surgery, starting with remaining calm (Poise). After a vascular injury, the surgeon should remain calm and perpetuate an attitude of confidence in the team. The second step is to compress the bleeding vessel (Pressure) using a sponge. During compression, the surgeon has to prepare a plan to resolve the bleeding and give the anesthesia and nursing team time to prepare after the injury (Preparedness), and finally, he or she must establish proximal control of the bleeding (Proximal) (21).

Ligation with titanium clips or locking clips

In minor bleeding, mainly when an incidental clip displacement occurs, it is possible to try to place a clip on a bleeding vessel. However, the surgeon must be sure that there is enough area to clip the vessel. It is imperative not to perform a blind clipping because it could worsen the damage and generate fatal consequences (14).

Direct repair

When bleeding continues despite the above measures, the surgeon must repair the injured vessel by direct suturing. Mei and colleagues described a suction-compressing angiorrhaphy technique for troubleshooting this problem without conversion. The concept for this technique is to compress the injury and remove the blood from the field simultaneously to allow a vascular suture. In their study, 414 VATS lung resections were performed, with 17 vascular injuries. They managed 15 of the injuries without conversion to open surgery, showing that, in their hands, the procedure was effective for managing vascular injury during VATS (22).

Alternatively, clamping the proximal end of the blood vessel with a vessel loop, endoscopic bulldog clamp, or another vascular clamp can limit massive blood loss and offer better exposure to the site injury (19).

Bleeding control with additional port

To illustrate our approach of bleeding control with additional port, we present a case of a 72-year-old woman with prior anatomic segmentectomy in the right upper and right lower lobes to remove early-stage adenocarcinomas who developed a new neoplastic lesion in the lingula (Figure 1). An uniportal lingulectomy was indicated. The patient had an incomplete oblique fissure. The first step of the surgery was to divide the fissure to expose the interlobar PA and lingular branches. We divided the fissure using an endoscopic stapler. When the fissure was almost completely stapled, we decided to use an energy-sealing device for the last, small portion of fissure. Unfortunately, before applying the device, it got hooked over the PA causing laceration of the interlobar PA, and major bleeding occurred.

Figure 1 Early-stage adenocarcinoma in the lingula (arrow).

As described previously, the first steps to follow in patients with bleeding due to vascular injury during uniportal lung resections are always: keep calm, compress the bleeding site with a sponge stick, and communicate with the anesthesia and nursing team. Prompt compression with a sponge stick was applied, and the bleeding stopped (Video 1 and Figure 2). We suctioned the field to have good exposure of the area where the accident happened.

Figure 2 Sponge-stick compression after vascular injury and bleeding.

After communicating with the anesthesia and nursing teams to ensure everyone in the OR was aware we had a major vascular accident, we reassessed the zone of the bleeding. We concluded that the bleeding was caused by a laceration in the interlobar PA and that due to its size, the laceration would require a primary repair with suture. Based on the patient’s hemodynamic stability, the fact that the bleeding was under control, and the surgeon’s confidence and experience in minimally invasive thoracoscopic procedures, we elected to perform the repair using VATS. An additional port was placed in the 9^th intercostal space, and the sponge stick compressing the laceration was removed from the working incision and reapplied through the new, additional port (Figure 3A,3B). This not only allowed the surgeon to have more space, and therefore more comfort, to perform the lung resection and the vascular repair, but also placed the assistant surgeon and the instrument used for compression across the field and away from the surgeon’s working space. A thoracoscopic instrument, placed through a 10 mm port, was used to maintain soft compression by the assistant. In this patient, we proceeded first with the lingulectomy and lymph node dissection, which opened space to have proximal and distal control of the laceration (Video 2). Once proximal and distal PA control was achieved with clamps (alternatively, vessel loops, tourniquets or bulldogs could be used for a central control), the sponge stick was removed. The assistant was able to use suction and other instruments through the additional port to improve exposure. Finally, the injury was repaired using 4-0 prolene (Video 3 and Figure 4). In this case, the postoperative period was uneventful and no blood transfusion was required.

Figure 3 Managing vascular injury using an additional port. (A) Additional port placed in the 9^th left intercostal space (arrow). (B) Sponge-stick compression by an assistant through the additional port.

Figure 4 Final result of pulmonary artery injury repair.

Discussion

This case exemplifies why an additional port is a useful tool for controlling major bleeding during uniportal VATS. This maneuver allows the surgeon to reassess the vascular accident in a more controlled setting, and he or she can then decide if the repair can be performed minimally invasively or if conversion to thoracotomy is required. Either way, the bleeding is under control, and the decisions are made in a safe setting.

In cases where hemodynamic stability is not assured, bleeding is not controlled despite direct compression, and the surgeon does not have experience repairing a vessel through a minimally invasive approach, the conversion to open surgery should not be postponed.

Patient safety and surgical/oncological outcomes are of paramount importance during a lung resection and the surgeon should not hesitate to convert to thoracotomy in case of any complications or surgical difficulties.

We believe that watching surgical videos, reading articles on technical aspects of minimally invasive surgery, and attending hand-on courses either wet labs or simulation are very helpful in building mindset on how to manage surgical complications.

Tips and pearls

The potential benefits of this approach are listed below:

• Steady compression of the bleeding site by an assistant outside the surgical field.
• Freedom in the working incision to continue with lung resection or vascular control with case-by-case decision-making.
• Use of secondary instruments by the assistant.
• Maintenance of a clear surgical field for a safe and comfortable repair.
• Thoracotomy, if needed, will be non-urgent.

Conclusions

An additional port allows the surgeon to reappraise the bleeding in a controlled scenario and decide whether the repair can be performed minimally invasively or conversion to open surgery is required. The decisions made in a safe setting enhance the surgeon’s ability to make better decisions aiming for safety and the best surgical/oncological outcomes.

Acknowledgments

We thank Shannon Wyszomierski, PhD for editing a draft of the article.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery for the series “Advanced Uniportal VATS”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-23-12/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-23-12/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-23-12/coif). The series “Advanced Uniportal VATS” was commissioned by the editorial office without any funding or sponsorship. P.U.F. served as the unpaid Guest Editor of the series and she received payment for lectures and other educational activities from AstraZeneca, Bristol Myers Squibb (BMS), and Medtronic. R.O. received payment from AstraZeneca. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from the patient for the publication of this manuscript, the accompanying images, and the videos. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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