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Page 8 of 9 Gharagozloo et al. Mini-invasive Surg 2020;4:57 I http://dx.doi.org/10.20517/2574-1225.2020.44

Figure 11. Injury to the proximal pulmonary artery during robotic left upper lobectomy. Thoracotomy is completed in preparation of
proximal control and safe repair of the pulmonary artery injury

is controlled, proximal pulmonary artery control is obtained, and bleeding is mitigated using robotic
techniques. The most common scenario is to staple the more proximal portion of the pulmonary artery
branch [Figures 5 and 6].

In Group II, the injury to the pulmonary artery is more central and requires control of the main pulmonary
artery. This group is illustrated by injury to the proximal pulmonary artery during a robotic upper
lobectomy procedure. In this group, the EVERREST technique allows for better but not perfect control
of the bleeding. In these patients, the pressure needs to be maintained, the robotic procedure needs to be
converted to a thoracotomy, and the vascular injury needs to be repaired in a safe manner.

If conversion to thoracotomy is chosen, the robotic instruments need to be completely removed, the robot
undocked and moved completely away from the operative field, and the bleeding stopped by the sponges
and the pressure maintained on the sponge by an external suction manned by the assistant. Robotic
instruments should not be used to hold pressure. In our view, it is best to avoid leaving one arm of the
robot in to compress a vessel. It is critical to completely remove the robot from the operative field. If a
vessel is still bleeding, pressure needs to be held by means of a nonrobotic instrument through the access
port by a bedside assistant while the chest is safely and calmly opened [Figures 7-11].

With greater experience, the minimally invasive technique can be used to control pulmonary artery
bleeding. However, until greater experience is gained, and even then, under certain circumstances, an
orderly conversion to a thoracotomy should remain the procedure of choice.

CONCLUSION
Intraoperative bleeding complications and catastrophes during pulmonary resection are rare. In fact,
due to the uncommon nature of these complications, the surgical team is usually unprepared to manage
the catastrophic bleeding and therefore these complications can result in significant consequences for
the patient. Robotic surgical teams must have a well-rehearsed reproducible “fire drill” plan so that the
team members understand their roles during these uncommon yet potentially catastrophic events. The
application of the 5 “P”’s to robotic lung resection will increase patent safety and surgeon adoption of these
procedures.