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Controlling Bleeding During Uniportal Thoracoscopic Major Pulmonary Resection
Hitoshi Igai, Mitsuhiro Kamiyoshihara, Kazuki Numajiri, Fumi Ohsawa, Natsumi Matsuura.
Japanese Red Cross Maebashi Hospital, Maebashi, Japan.

BACKGROUND: In uniportal thoracoscopic major pulmonary resection, it is important to appropriately manage significant vessel injury, to ensure patient safety and minimize conversion to thoracotomy. We analyzed cases of significant vessel injury and investigated efficacy of an algorithm to manage bleeding during thoracoscopic uniportal major pulmonary resection.
METHODS: A total of 169 patients underwent “uniportal thoracoscopic major pulmonary resection” (lobectomy or segmentectomy) at our department between February 2019 and April 2021. These patients were classified into groups with (group A, n = 8) and without (group B, n = 161) significant vessel injuries. Patient characteristics and perioperative results were compared between the two groups. Moreover, Patients with significant vessel injury and conversion to thoracotomy were analyzed in detail.Significant vessel injury was defined as the injury of intrathoracic major vessels which had the possibility of causing intraoperative life-threatening bleeding.The algorithm to manage significant vessel injury during thoracoscopic uniportal major pulmonary resection was shown in Figure 1.
RESULTS: Group B had significantly less blood loss (A: 197 ± 173 g; B: 42 ± 74 g, p < 0.0001) and shorter-duration postoperative drainage (A: 2.6 ± 1.8 days; B: 1.6 ± 1.3 days, p = 0.036). There were no group differences in any other factors including operative time, postoperative hospitalization time, Clavien-Dindo grade > III morbidity, readmission within 30 days after the operation, or 30-day mortality.The most frequently injured vessel in group A was the pulmonary artery (75%). The hemostatic procedure involved compression with the adjacent lung or a cotton stick in five cases (62.5%), proximal clamp after conversion to thoracotomy in two (25%), and grasping by forceps in one (12.5%). Four cases (50%) required emergent conversion to thoracotomy. Except for the four cases, nonemergent conversion was performed in six among all cases.
No patient developed catastrophic bleeding or required an intraoperative transfusion.
CONCLUSIONS: We managed significant vessel injury appropriately during uniportal thoracoscopic major pulmonary resection using the troubleshooting algorithm. The algorithm for the uniportal approach was considered effective and easy to apply even by less-experienced surgeons. LEGEND: Algorithm used in our department to manage bleeding during uniportal thoracoscopic major pulmonary resection.

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