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Page 2 of 9 Gharagozloo et al. Mini-invasive Surg 2020;4:57 I http://dx.doi.org/10.20517/2574-1225.2020.44

The overall incidence of major vascular injury during elective robotic thoracic operations was reported to
[1]
be 1.2% (16 of 1,304 operations) by Cerfolio et al. . These authors reported the incidence of major vascular
[2]
injury during robotic lobectomy as 2.6% and for robotic segmentectomy as 1.5%. Novellis et al. reported
an overall conversion rate of 6.2% (21/338) for major robotic lung resections, of which 1.1% (4/338) were
due to bleeding. Other authors have reported overall conversion rates of 1.5%-9% with pulmonary artery
[3-7]
or pulmonary vein injury resulting in conversion in 0.5%-2.6% . In a retrospective multi-institutional
[4]
study of 1,810 patients who underwent robotic anatomic pulmonary resections, Cao et al. reported
intraoperative catastrophic events in 1.9% of patients Catastrophic events were associated with higher
proportion of patients who underwent preoperative radiotherapy, higher perioperative mortality, longer
operative times, and higher estimated blood loss. In this study, intraoperative hemorrhage from the
pulmonary artery was the most common catastrophic event.

[3]
Gharagozloo et al. reported their experience with 638 consecutive robotic lobectomies for early stage lung
cancer. Conversion to a thoracotomy occurred in 11 (1.7%) patients. Six of eleven (54%) conversions were
for bleeding (0.9% of robotic lobectomies).

The most common intraoperative bleeding complication during robotic lung resection is from an injury to
[4]
the pulmonary artery. Most commonly, pulmonary artery injury occurs during dissection of the artery .
These injuries are easier to see as they occur directly at the point of dissection. Injury to the pulmonary
[5,6]
artery can also occur at the time of encirclement of the artery branch and passage of the stapling device .
In these instances, the pulmonary artery is usually torn at the branch point resulting in a more central
injury. Most commonly, a central pulmonary artery injury occurs during left upper lobectomy and is
associated with dissection, isolation, and division of the truncus branch. The risk factors for pulmonary
artery injury with robotic lung resection are similar to open or conventional video-assisted (VATS)
procedures. The risk of pulmonary artery injury is increased in patients who have received induction
chemo- and/or radiation therapy, have larger tumors, and in the presence of calcified lymph nodes .
[6-8]
[4]
Pulmonary vein injury is much less common than pulmonary arterial injury . Pulmonary vein injuries
can be more easily repaired using minimally invasive techniques such as stapling or over sewing. The most
important technical aspect of managing a pulmonary vein injury is to prevent air embolism by resisting
vigorous suction at the bleeding point. Control of the pulmonary vein bleeding by “pressure” is preferred
and is similar to what is outlined for the artery below.

This paper outlines a proven strategy for control of bleeding complications during robotic lung resections.

[1]
Strategy for the Control of Major Vascular Injury: Cerfolio et al. described the 4 “P”’s as the technique for
the control of major vascular injury: Poise, Pressure, Preparedness, and Proximal Control. Preparedness
can be further expanded to Prevention of the injury and Preparedness of the team to respond to the
catastrophic event.

THE 5 “P”’S
Prevention
First and foremost is Prevention. Prevention of major vascular injury dictates a different approach to the
dissection of the vascular structures during robotic lung resection. Unlike the technique of open and
VATS lobectomy where the artery branches are dissected and divided in a sequential manner, robotic
lung surgery requires a wider dissection of the mediastinum, the proximal and distal portions of the
artery and vein. The strategy of robotic lung resection starts with a wide mediastinal nodal dissection
with identification of the proximal broncho-vascular structures. This is followed by dissection of the
smaller vascular branches. As a general rule, the dissection of the smaller vascular branch should only be