Abstract
Aim: 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) intraoperative massive bleeding. Patient characteristics and perioperative results were compared between the two groups. Patients with significant vessel injury and conversion to thoracotomy were analyzed in detail. 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. The most frequently injured vessel in group A was the pulmonary artery (75%). Emergent conversion was required in four cases (cases 7, 76, 128, and 133; 2.4%) due to intraoperative bleeding. No patient developed catastrophic bleeding or required an intraoperative transfusion. Conclusion: 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.
Highlights
The first wedge resection through a single skin incision was reported in 1998, and the first video-assisted thoracic surgery through a single port lung biopsy was reported in 2000[1,2]
(first 30 cases), to ensure the safety of the operation, the uniportal approach was limited to cT1N0 cases, pulmonary metastasis, or benign disease, a strategy that allowed the surgical team to become familiar with this less invasive procedure
Significant vessel injury was defined as the injury of intrathoracic major vessels including pulmonary artery, pulmonary vein, azygos vein, superior vena cava, aorta, subclavian artery, or subclavian vein, which had the possibility of causing intraoperative life-threatening bleeding
Summary
The first wedge resection through a single skin incision was reported in 1998 (not uniportal), and the first video-assisted thoracic surgery through a single port lung biopsy was reported in 2000[1,2]. Major pulmonary resection via a uniportal approach was introduced by Gonzalez et al.[3] in 2011. The use of this type of minimally invasive surgery has gradually increased worldwide. Our team started to use “uniportal thoracoscopic major pulmonary resection” in February 2019. The uniportal thoracoscopic approach is considered minimally invasive and has several advantages, including low postoperative pain, few morbidities, short-duration postoperative chest drainage, short hospitalization periods, rapid postoperative recovery, and relatively low medical costs[4,5,6,7]. Magouliotis et al.[8] demonstrated more favorable short-term oncological results of a uniportal compared to multiportal approach for thoracic malignancies in their review article, the long-term outcomes were unclear
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