Incidence, Results, and Our Current Intraoperative Technique to Control Major Vascular Injuries During Minimally Invasive Robotic Thoracic Surgery.

Background: Our objective is to report our incidence, results, and technique for the control of major vascular injuries during minimally invasive robotic thoracic surgery.

Methods: This is a consecutive series of patients who underwent a planned robotic thoracic operation by one surgeon.

Results: Between February 2009 and September 2015, 1,304 consecutive patients underwent a robotic operation (lobectomy, n = 502; segmentectomy, n = 130; mediastinal resection, n = 115; Ivor Lewis, n = 103; thymectomy, n = 97; and others, n = 357) by one surgeon. Conversion to thoracotomy occurred in 61 patients (4.7%) and in 14 patients (1.1%) for bleeding (pulmonary artery, n = 13). The incidence of major vascular injury during anatomic pulmonary resection was 2.4% (15 of 632). Of these, 13 patients required thoracotomy performed in a nonurgent manner while the injury was displayed on a monitor, 2 had the vessel repaired minimally invasively, 2 required blood transfusion (0.15%), and 1 patient had 30-day mortality (0.16%). Techniques used to minimize morbidity include having a sponge available during vessel dissection and stapling, applying immediate pressure, delaying the opening until the bleeding is controlled without external pressure, and ensuring there is no bleeding while the chest is opened.

Conclusions: Major vascular injuries can be safely managed during minimally invasive robotic surgery. Our evolving technique features initial packing of the bleeding for several minutes, maintaining calmness to provide time to prepare for thoracotomy, and reexamination of the injured vessel. If repair is not possible minimally invasively, the vessel is repacked and a nonhurried, elective thoracotomy is performed while the injury is displayed on a monitor to ensure active bleeding is not occurring.