Ann Thorac Surg 2009;87:e51-e53. doi:10.1016/j.athoracsur.2009.03.004
© 2009 The Society of Thoracic Surgeons
Case Reports
Primary Repair of an Iatrogenic Bronchial Rupture Under Video Mediastinoscopy
Young-Du Kim, MD,
Chan-Beom Park, MD, PhD,
Jae-Jun Kim, MD,
Chi-Kyung Kim, MD, PhD,
Seok-Whan Moon, MD, PhD*
Department of Thoracic and Cardiovascular Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
Accepted for publication March 2, 2009.
* Address correspondence to Dr Moon, Department of Thoracic and Cardiovascular Surgery, College of Medicine, The Catholic University of Korea, St. Paul's Hospital, 620-56, Jeonnong-Dong, Dongdaemun-Gu, Seoul, 130-709, Korea (Email: swmoon{at}catholic.ac.kr).
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Abstract
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Complications after performing mediastinoscopy are uncommon, but they may occur even for an experienced surgeon. The major complications have the potential to be life-threatening injuries, such as major vascular or airway injury. A 51-year-old man presented to our hospital due to mediastinal node enlargement on follow-up after he had undergone gastric cancer surgery 2 years previously. An iatrogenic bronchial rupture occurred while performing mediastinoscopic biopsy, and this injury was primarily repaired with multiple direct interrupted sutures, along with the aid of a homemade knot pusher under video mediastinoscopy, and we did not have to convert to an open thoracotomy.
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Introduction
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Mediastinoscopy is the gold standard for performing mediastinal lymph node staging, and it is a safe procedure with acceptable low perioperative mortality and morbidity [1]. Although uncommon, the complications of mediastinoscopy can be severe and life threatening due to major bleeding or airway injury [2, 3]. Tracheobronchial injury that requires repair is extremely rare, and there has not been much written in the literature regarding its management. We present here a case of iatrogenic bronchial injury that was caused by a biopsy device, and this injury was primarily repaired under video mediastinoscopy without converting to open thoracotomy. We believe that this is the first such case reported in the English literature.
A 51-year-old man with a history of total gastrectomy due to gastric cancer 2 years ago was referred to our hospital for his mediastinal lymph node enlargement. A computed tomographic scan of the chest demonstrated an enlarged lymph node in the right lower paratracheal area (Fig 1). We performed video mediastinoscopy to rule out any lymph node metastasis.
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Fig 1. The (A) preoperative and (B) 1-month postoperative computed tomographic scans demonstrate the enlarged lymph node (arrowhead) in the right lower paratracheal area and bronchial breaking (arrow) after the repair.
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Under single-lumen endotracheal administered general anesthesia, the mediastinoscope was introduced, which was then advanced to the carina, and the target node was identified between the carina and the right main bronchus. After aspirating the node by using a long needle, we confirmed there was no bleeding and no air leakage, and the node was dissected with a blunt suction instrument and electrocautery. Then the node was biopsied using a cup-type biopsy device multiple times. Immediately after the node was thoroughly retrieved, there was vigorous air leakage from the biopsy site, and the anesthesiologist complained that he could not fill the lung sufficiently. We believed that a bronchial rupture had occurred. The single-lumen endotracheal tube was directed into the left main bronchus under fiberoptic bronchoscopic guidance, which was a life-saving decision, because this enabled us to recognize what had happened with the limited view of the mediastinoscopy. After reintroducing the mediastinoscope into the wound, the rupture of the anterior wall of the right main bronchus was identified; the defect was 0.5 cm in size, and it was just distal to the carina and parallel to the bronchial cartilage (Fig 2). Endoscopic repair was attempted first, which was successful, as the bronchial defect was repaired primarily with three interrupted nonabsorbable sutures and an extracorporeal knot that was tied under the video mediastinoscope. Our knot pusher was made of plastic, and we slid it down against the slipknot through the instrument channel of the video mediastinoscope by using the operator's dominant hand, while both ends of the suture were maintained with the operator's nondominant hand and the assistant's hand (Fig 3). After the completion of the endoscopic suture, a saline immersion test confirmed there was no air leakage. The patient tolerated the procedure well. He was extubated in the operating room.
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Fig 2. The mediastinoscopic view shows the rupture of (A) the right main bronchus and (B) after repairing the bronchial defect, which was primarily done under video mediastinoscopy. (C = carina; R = right main bronchus.)
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Fig 3. Schematic view of the extracorporeal knot tying with the aid of a homemade knot pusher. Note the suture needle, which was reformed into the shape of a hockey stick to facilitate its introduction through the instrument channel of the video mediastinoscope together with the endoscopic needle holder. Inset: Cross-sectional view of the head of the knot pusher.
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Pathologic examination of the node revealed only reactive hyperplasia and the patient recovered uneventfully. He was still doing well at the 2-year follow-up after the bronchial repair.
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Comment
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Mediastinoscopy has been shown to be a safe procedure, and the morbidity and mortality rate is 0.6% to 3.7% and zero to 0.3%, respectively [1]. The complications of mediastinoscopy include hemorrhage, pneumothorax, vocal cord dysfunction, airway injury, and wound infection. The hemorrhagic complications of mediastinoscopy are considered to be the most severe and life threatening. There are several reports on the hemorrhagic complications of mediastinoscopy and its management [2, 4], but there is little written in the literature regarding the management of airway injury that requires repair.
When the airway injury is minimal, it may be controlled by cellulose sheet tamponade without thoracotomy [5], but when the injury is large enough to cause vigorous air leakage, a prompt open thoracotomy should be considered to save the patient. Schubach and Landreneau [3] reported a laceration of the right intermedius bronchus while performing a mediastinoscopic procedure, which was managed by in-continuity bronchial flap repair through a right lateral thoracotomy. They mentioned that primary repair was impossible due to the size (1.5 cm x 1.0 cm) and irregular margins of the bronchial defect. For our case the bronchial defect was relatively small (0.5 cm x 0.2 cm), so we first tried a primary repair and the bronchial defect was successfully closed under video mediastinoscopy with the aid of a homemade knot pusher.
We routinely use the aspiration needle before performing a biopsy to confirm that there is no bleeding or air leak, and we used electrocautery as little as possible in our consecutive series of more than 100 cases. Nevertheless, repeated use of the cup-type biopsy device might have been the direct cause of bronchial rupture in our case. We recommend that the node should be bluntly dissected with the cautious use of electrocautery, and the node should be dissected in all directions before performing a biopsy to prevent a possible vascular or airway injury.
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References
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- Lemaire A, Nikolic I, Pertersen T, et al. Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate Ann Thorac Surg 2006;82:1185-1190.[Abstract/Free Full Text]
- Hung JJ, Wu YC, Hsu HS, Wang KM, Hsu WH. Major hemorrhage and subsequent cardiac tamponade during mediastinoscopy J Thorac Cardiovasc Surg 2007;133:269-270.[Free Full Text]
- Schubach SL, Landreneau RJ. Mediastinoscopic injury to the bronchus: use of in-continuity bronchial flap repair Ann Thorac Surg 1992;53:1101-1103.[Abstract/Free Full Text]
- Park BJ, Flores R, Downey RJ, Bains MS, Rusch VW. Management of major hemorrhage during mediastinoscopy J Thorac Cardiovasc Surg 2003;126:726-731.[Abstract/Free Full Text]
- Puhakka HJ. Complications of mediastinoscopy J Laryngol Otol 1989;103:312-315.[Medline]
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Abstract
Introduction
