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Ann Thorac Surg 1995;59:736-737
© 1995 The Society of Thoracic Surgeons

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Case Reports

Potential Complications of Vascular Stapling in Thoracoscopic Pulmonary Resection

Department of Thoracic Surgery, City Hospital, Edinburgh, United Kingdom

Accepted for publication July 18, 1994.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment References

 
In a series of 57 patients undergoing thoracoscopic pulmonary lobectomy, 2 required expeditious conversion to open thoracotomy when a stapling device (Endo-GIA 30 V3; Autosuture, Ascot, UK) used on the main right lower pulmonary artery in 1 case and on the left superior pulmonary vein in the other cut but failed to staple the vessel involved. In both instances the vessel was successfully controlled while a thoracotomy was performed and the involved vessel was oversewn. Both patients made an uncomplicated postoperative recovery. As the number of thoracoscopic pulmonary resections increases, it is likely that similar episodes will occur in the future. These cases strongly emphasize the fact that patients undergoing this procedure should do so in a center specializing in thoracic surgery where there is the necessary surgical expertise and equipment to deal with such potentially life-threatening vascular complications.

	Introduction

Top Footnotes Abstract Introduction Case Reports Comment References

 
See also page 737.

Video-assisted thoracoscopic pulmonary resection has progressed substantially over the last few years, allowing surgeons to perform a pneumonectomy or standard dissectional lobectomy with lobar lymph node clearance equal to that obtained with a standard open thoracotomy [1–5]. Thoracoscopic operation offers the patient significant benefits such as reduced postoperative pain and discomfort, resulting in a shorter high-dependency unit stay [2].

In performing thoracoscopic pulmonary resection, the main vascular structures are divided with endovascular stapling devices, which simultaneously cut and staple the vessel. This combined action raises the possibility that the endostapling device may cut the vessel and fail to staple it, resulting in massive hemorrhage, given the nature of the vessels involved. We report 2 cases of this potentially life-threatening complication.

	Case Reports

Top Footnotes Abstract Introduction Case Reports Comment References

 
The surgical technique employed for thoracoscopic pulmonary lobectomy at the City Hospital, Edinburgh, has been described previously [2, 3]. The patient is prepared, anesthetized, and positioned as for a standard posterolateral thoracotomy with the necessary instruments for this beside the operating table. Before any endovascular stapler is used, both the scrub nurse and surgeon ensure that the stapling cartridge is correctly inserted into the stapling device with no residual staples left from previous firings that could cause the stapling device to misfire.

Patient 1
A 71-year-old woman was referred to the thoracic surgical unit with a 3-cm peripheral opacity in her right lower lobe that was noted on a chest radiograph performed during preoperative work-up for an elective sinus operation. She had no respiratory symptoms, and physical examination and routine hematologic and biochemical profiles were unremarkable. A thoracic computed tomographic scan was performed, confirming the presence of a peripheral opacity in the right lower lobe with no associated mediastinal lymphadenopathy. The liver and adrenal glands were normal. Rigid bronchoscopy was performed and no endobronchial abnormality was noted. Mediastinoscopy revealed anthrocotic nodes in the subcarinal, right tracheobronchial, and right paratracheal regions; biopsy of these nodes confirmed that they were free of metastatic disease.

The patient was scheduled for a thoracoscopic right lower lobectomy; however, when the main stem lower pulmonary artery was stapled (Endo-GIA 30 V3; Autosuture, Ascot, UK) a sudden rush of blood was noted when the jaws of the stapler were partially opened. The staple jaws were closed again, arresting the flow of blood. A standard posterolateral thoracotomy was performed and the proximal end of the pulmonary artery was controlled and oversewn with Prolene (Ethicon Ltd, Edinburgh, UK). The remaining part of the operation proceeded without incident, and the patient made an uncomplicated postoperative recovery. Total blood loss was estimated at 130 mL. Histologic examination of the resected lobe revealed a T2 N0 bronchoalveolar carcinoma.

Patient 2
A 69-year-old man was referred to the thoracic surgical unit with a 3-cm peripheral opacity in his left upper lobe that was noted on a chest radiograph taken for an episode of pleuritic chest pain. At the time of referral he was asymptomatic and physical examination was unremarkable. Routine hematologic and biochemical profiles were normal. A thoracic computed tomographic scan revealed a 3 cm peripheral lesion in the left upper lobe with no mediastinal lymphadenopathy. The liver and adrenal glands were normal.

Rigid bronchoscopy was performed and no endobronchial abnormality was noted. Mediastinoscopy revealed anthrocotic nodes in the subcarinal and left paratracheal regions, biopsy of these nodes confirmed that they were free of metastatic disease.

The patient was scheduled for a thoracoscopic left upper lobectomy and the operation proceeded well until the left superior pulmonary vein was stapled (Endo-GIA 30 V3). When the jaws of the stapler were opened there was a rush of blood from the pulmonary vein and it was apparent that the staple line was incomplete and, in addition, the staple head could not be separated from the staple line. The central end of the vein was grasped with a vascular clamp introduced with ease through the submammary incision, and the hemorrhage was arrested while a thoracotomy was performed. The patient made an uncomplicated postoperative recovery. Total blood loss was estimated at 730 mL and no blood transfusion was required. Histologic examination of the resected lobe revealed a T1 N0 non–small cell undifferentiated carcinoma.

	Comment

Top Footnotes Abstract Introduction Case Reports Comment References

 
Bleeding from the main pulmonary artery or one of its branches or from the pulmonary veins is a potential hazard during any thoracoscopic pulmonary resection. In our experience, the most common source of troublesome hemorrhage has occurred while attempting to staple branches of the main pulmonary artery, particularly during the early ``learning curve'' [3]. In this situation, applying the stapler to the vessel often involves traction along the branch, which can lead to its avulsion. Traction damage to the vessel was not an issue in our 2 cases; however, it is certain that further development of endoscopic instruments, in particular roticulating instruments, will make their use easier and safer [6].

In both of the reported cases, problems arose due to failure of the stapling action that accompanies vessel division. We have performed 62 video-assisted thoracoscopic pulmonary resections to date (57 lobectomies and 5 pneumonectomies), which required approximately 243 firings of the Endo-GIA 30 V3 stapler. The 2 patients in our series therefore resulted in a 0.82% failure rate for endovascular stapling.

When a large branch of the pulmonary artery or a lobar vein is to be stapled, we suggest that a sufficient length of vessel is dissected to allow a vascular clamp to be placed on the proximal end before firing of the staple gun. If it is not possible to use a vascular clamp then the jaws of the staple gun should be partially opened and active bleeding sought. If active bleeding occurs, the staple jaws should be closed again, which will arrest the hemorrhage until a thoracotomy can be performed. Other groups have used an endovascular stapler with the knife blade removed so that correct firing of the staples can be ensured before division of the vessel [7]. This may, however, compromise the product license and would not have helped in our second case, when the staple head could not be separated from the staple line on the pulmonary vein. The submammary incision also allows insertion of mounted swabs, which also can be used to tamponade bleeding temporarily and allow easy insertion of vascular clamps.

The two Endo-GIA 30 V3 stapling devices were returned to Autosuture, UK, for evaluation. In both cases, Autosuture reported that the stapling cartridge had been correctly inserted into the staple gun; however, the anvil was incorrectly aligned on manufacture so that on firing the staples were forced into an open, rather than closed (B shaped) position, rendering them ineffective. It is extremely important that the endostapler cannot be fired if the cartridge is not properly inserted or if the anvil is not correctly aligned. The Endo-GIA 30 V3 stapler has since been modified. It is, however, unlikely that any mechanical device ever can be guaranteed completely safe. Any potential problem can occur given enough use, and any single failing can result in the death of a patient. It is therefore vital to operate in a manner that incorporates strategies to counter this possibility. Despite these failures, the risk of which should be diminished by the endostaple design change, we have not lost our enthusiasm for video-assisted thoracoscopic pulmonary resection.

The operating surgeon must be capable of dealing expeditiously with any unexpected hemorrhage and must also be aware of the complex and variable anatomic relationships of the main structures. For this reason, both in the United States and Great Britain, professional societies recommend that thoracoscopic pulmonary resection should only be undertaken by surgeons trained in thoracic surgery [8]. These cases illustrate the validity of this view and are presented as a reminder that thoracoscopic pulmonary resection, although minimal access, is not a minimally invasive operation.

	Footnotes

Top Footnotes Abstract Introduction Case Reports Comment References

 
Address reprint requests to Mr Walker, Department of Thoracic Surgery, City Hospital, GreenbankDr, Edinburgh EH10 5SB, UK.

	References

Top Footnotes Abstract Introduction Case Reports Comment References

 

1. Walker WS, Carnochan FM, Mattar S. Video-assisted thoracoscopic pneumonectomy. Br J Surg 1994;81:81–2.[Medline]
2. Walker WS, Carnochan FM, Pugh GC. Thoracoscopic pulmonary lobectomy. J Thorac Cardiovasc Surg 1993;106:1111–7.[Abstract]
3. Walker WS, Carnochan FM, Tin M. Thoracoscopy-assisted pulmonary lobectomy. Thorax 1993;48:921–4.[Abstract/Free Full Text]
4. Roviaro G, Varoli F, Rebuffat C, et al. Major pulmonary resections: pneumonectomies and lobectomies. Ann Thorac Surg 1993;56:779–83.[Abstract]
5. Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Initial experience with video-assisted thoracoscopic lobectomy. Ann Thorac Surg 1993;56:1248–53.[Abstract]
6. Acuff TE, Mack MJ, Landreneau RJ, Hazelrigg SR. Role of mechanical stapling devices in thoracoscopic pulmonary resection. Ann Thorac Surg 1993;56:749–51.[Abstract]
7. Kirby TJ, Rice TW. Thoracoscopic lobectomy. Ann Thorac Surg 1993;56:784–6.[Abstract]
8. Statement of the AATS/STS Joint Committee on Thoracoscopy and Video Assisted Thoracic Surgery. Ann Thorac Surg 1992;54:1.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stewart R. Craig William S. Walker Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Craig, S. R. Articles by Walker, W. S. Search for Related Content PubMed PubMed Citation Articles by Craig, S. R. Articles by Walker, W. S. Related Collections Related Article