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Gharagozloo et al. Mini-invasive Surg 2020;4:57 I http://dx.doi.org/10.20517/2574-1225.2020.44 Page 5 of 9

Figure 4. At the first sign of a bleeding complication, the EVERREST Patch is prepared. The strip of EVERREST is tied onto the tightly
rolled sponge and introduced through the accessory port by the assistant

should be controlled with pressure technique, as outlined for the pulmonary artery.

It is important to emphasize that the experience of the surgeon with robotic procedures should dictate
the next steps following control of the bleeding. For the less experienced surgeons, the safest strategy is
to maintain pressure control of the bleeding and calmly convert to a thoracotomy. Using the accessory
port, the assistant can introduce a long metal “Yankauer” suction to place direct pressure on the rolled
sponge and/or sponge/EVERREST patch. With pressure control of the bleeding point, the robot arms are
removed, and the camera is disconnected from the robot arm and introduced freely through the camera
port in order to maintain full visualization of the pleural space and to confirm the control of the bleeding
under direct vision. The robot is then moved away from the operating table, and the table is unlocked and
turned to the normal position for a thoracotomy. The second assistant is tasked with pressure control of
the bleeding point while a scrub nurse holds the camera for visual confirmation. Although some surgeons
prefer to disconnect the left arm from the robot cart and use it for pressure control, if a second assistant is
available, we prefer the suction pressure technique. The posterolateral thoracotomy is performed calmly
and under control. The chest is entered through the 5th intercostal space directly over the oblique fissure
in order to have full access to the hilum and the proximal pulmonary artery. After the chest is open, the
Yankauer suction is replaced with a conventional kittner carrying a rolled sponge and the pressure control
is maintained by the second assistant while the surgeon and the first assistant gain proximal control.

Surgeons with greater experience can obtain proximal control and repair the vascular injury by robotic or
endoscopic techniques. However, it must be emphasized that conversion to a thoracotomy should be seen
as the safest technique and conversion should be performed in a timely fashion and not as a last resort.

Proximal control
Once the vessel is hemostatic, the surgeon should obtain proximal control by passing a vessel loop around
the pulmonary artery or vein proximally, double loop around it, and gently pull up to completely stop its
blood flow. At this point, the patch sponge composite should be removed. The injury can be seen because
the blood flow is stopped, and it can be sewn using 4-0 nonabsorbable suture or stapled if there is room
proximally.

In our experience, pulmonary artery injury should be categorized into two groups: Group I, injury to
pulmonary artery branch; and Group II, injury to a central portion of the pulmonary artery. In Group I,
the bleeding is usually controlled using the EVERREST technique. In these patients, once the bleeding