Cardiothoracic Surgery

Case summary
A 71-year-old man underwent a diagnostic left upper lobe resection. A three-port video-assisted thoracoscopic surgery (VATS) technique was used, with the working port in the fourth intercostal space. The frozen section of the initial segmentectomy was revealed as an adenocarcinoma. The operation proceeded to completion lobectomy. During the last stages of lung division, the pulmonary artery (PA) was inadvertently injured. This caused significant blood loss and eventually led to a cardiac arrest. The patient could not be salvaged and was declared dead following resuscitation.

There is no specific description of a thoracotomy.

Discussion
Pulmonary vascular injury is a known complication during lung surgery (1–3%) and haemorrhage is described as one of the most common fatal causes of conversion from VATS to an open thoracotomy.¹ The incidence of significant bleeding during VATS for major pulmonary resection varies by region, population characteristics, disease severity and surgical centre capacity. In 2016, Ghosh et al retrospectively analysed 8563 cases of VATS anatomic lung resection based on a USA national database (Premier Perspective Database) and found that 9.2% of patients required a blood transfusion due to intraoperative bleeding.² These data were collected from more than 600 USA hospitals, reflecting a broad-based national incidence sample of clinically significant bleeding during VATS.

A recent study of the Italian VATS lobectomy registry, which enrolled 1679 cases from 10 high-volume centres, found that the bleeding-related conversion rate was 2.6%.³ Besides major vascular lacerations, intraoperative VATS haemorrhage arises from bronchial arterial injury; partial pulmonary arterial or venous stump dehiscence; and lower capacity vessels dissected from the bronchial stump, lung parenchyma, lymph nodes, chest wall and subcutaneous incisions.

Most patients with PA injuries had severe anthracofibrosis around the bronchus or vessels, as well as dense hilar adhesions. PA injuries often occurred during sharp dissection with scissors, energy devices (ultrasound scalpel or electrocautery hook), forceps or suction instruments. An unclear plane, inadequate dissection of the PA branches and improper endo-stapler angulation adjustments may also lead to PA lacerations. Lack of awareness of small PA branches that cannot be detected by computed tomography scanning can also lead to tearing and cause bleeding while dissecting the PA.

Of the options in response to massive bleeding during VATS lung surgery, urgent conversion to thoracotomy is most common. Surprisingly, it is unclear how this patient was managed.

Clinical lesson
Controlling bleeding is the priority. Compression is the most common and direct method for haemostasis, during which suction, gauze, gauze balls, adjacent lung tissues or surgical instruments may be used.

References
1. Louie BE. Catastrophes and complicated intraoperative events during robotic lung resection. J Vis Surg. 2017; 3:52. Published 10 April 2017. Doi:10.21037/jovs.2017.02.05.
2. Ghosh SK, Roy S, Daskiran M, Yoo A, Li G, Fegelman EJ. The clinical and economic burden of significant bleeding during lung resection surgery: a retrospective matched cohort analysis of real-world data. J Med Econ. 2016; 19(11), 1081–1086. https://doi.org/10.1080/13696998.2016.1199431
3. Liu L, Mei J, He J, et al. International expert consensus on the management of bleeding during VATS lung surgery. Ann Transl Med. 2019;7(23):712. Doi:10.21037/atm.2019.11.142.