Algorithm based Troubleshooting For Bleeding During Thoracoscopic Anatomic Pulmonary Resections
Tomohiro Yazawa, Hitoshi Igai, Fumi Ohsawa, Ryohei Yoshikawa, Mitsuhiro Kamiyoshihara.
Japanese Red Cross Maebashi Hospital, Maebashi, Japan.
BACKGROUND: Few studies have reported on the effects of intraoperative complications such as vessel injury during thoracoscopic anatomic pulmonary resection. We investigated intraoperative vessel injury and assessed troubleshooting methods during thoracoscopic anatomic pulmonary resection. METHODS: In total, 434 patients underwent thoracoscopic anatomic pulmonary resection between April 2012 and October 2018, and an intraoperative vessel injury was detected in 45. Significant vessel injury was defined as bleeding that needed compression for hemostasis of more than 30 s. In our department, we treat significant bleeding based on the algorithm shown in Figure 1. We analyzed the injured vessel and the hemostatic procedure employed, then compared the perioperative outcomes in patients with (n = 45) and without (n = 389) vessel injury. RESULTS: Surgical procedures with significant bleeding included 36 (80%) lobectomies and 9 segmentectomies (20%). Injured vessels were a branches of pulmonary arteries (55.6%), branches of pulmonary veins (28.9%), or other (15.5%). Nine bleeding cases required conversion to a thoracotomy to achieve hemostasis. Hemostasis was achieved by applying a thrombostatic sealant in 28 cases (62%), compression with a cotton stick or adjacent lung parenchyma in 11 cases (25%), and other in 6 (13%). Although patients without vessel injury had a shorter duration of surgery (205 vs. 241 min, p < 0.001), and less morbidity (17.2 vs. 36.3%, p = 0.037) than patients with vessel injury, no significant differences were observed in the duration of postoperative drainage (3 vs. 3.9 days, p = 0.104), postoperative hospital stay (7.9 vs. 15 days, p = 0.15), or blood loss (51 vs. 558 ml, p = 0.098). The occurrence rate of significant intraoperative bleeding during the last year was similar to that during the first year (11.1 vs. 7.4%, p = 0.52), although other perioperative results had significantly improved in that time. CONCLUSIONS: Thoracoscopic anatomic pulmonary resection is feasible and safe if the surgeon performs appropriate hemostasis. Applying a sealant or compression technique using a cotton stick or adjacent lung parenchyma is important to achieve hemostasis for a significant vessel injury during such resection. 
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