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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 3 of 9

undertaken after the more proximal portion of the artery or vein has been fully dissected. This strategy
results in less tension on the branch points, ready access to the proximal portion of the artery or vein in
the case of injury, and a more controlled approach to the bleeding complication, which, in turns, increases
the odds of mitigation of bleeding without resorting to conversion to a thoracotomy. Prevention of major
vascular injury requires complete and methodical dissection of the perivascular structures, as outlined in
Technique of Robotic Lobectomy I and II. The completion of the mediastinal nodal dissection allows for
mobilization of the bronchial and vascular structures. Dissection and removal of perivascular N1 nodes
allows for full visualization of the PA branches and allows for a safer approach to the isolation and division
of the vessel. The use of vessel loops for elevation of the vascular branch and the use of staplers with guide
catheters further decreases the chance of vascular injury. As a rule, the branch of the pulmonary artery and
the proximal portion of the artery which gives rise to the branch should be completely dissected before any
attempt is made to encircle the branch. Decreasing tension on the branch point is an excellent technique
for avoiding injury to the artery. In general, greater dissection leads to safer control of the pulmonary
artery branches and prevention of catastrophic bleeding. Furthermore, following these principles facilitates
proximal control and control of bleeding in the event of injury to the pulmonary artery. In our view, all the
steps of robotic lobectomy should be designed to build a foundation of safety for prevention of vascular
injury. The “P” for prevention is the most important of the 5 “P”’s.

Preparedness
Anesthesia and the surgical team need to prepare by running drills such that each team member is totally
ready for their function in the event of vascular injury. This requires a dedicated anesthesia and nursing
team. Thoracotomy trays must be in the room, and possibly opened and counted depending on the
experience of the surgeon. Blood needs to be available, dictating the need to routinely type and cross match
blood for the patients who undergo robotic lobectomy and segmentectomy.

Poise
Poise is the first and most critical aspect of the response to a catastrophic injury. The primary surgeon
must remain as relaxed as possible in order to create a calm and methodical approach to the problem. The
primary surgeon needs to impart an attitude of confidence and calmness to all members of the surgical and
anesthesia teams. This is only possible when there is a specific anesthesia and OR team, and if the team has
prepared for the emergency by running regular disaster readiness drills.

Pressure
By virtue of being a low pressure and high flow vessel, pulmonary artery bleeding can be controlled with
pressure. Attempts at grabbing the artery should be discouraged as this maneuver which works best for
high pressure vessels will tend to enlarge the tear. The best approach is to have a tightly rolled sponge in
the field. In the event of bleeding, the rolled sponge is placed over the bleeding point with the left robotic
instrument (usually Cadiere forceps) and pressure is maintained [Figure 1]. Next, the assistant introduces
a tightly rolled sponge which is covered with “EVARREST” fibrin sealant patch (Ethicon, Inc. Somerville,
NJ, USA) [Figures 2 and 3]. The patch attached to a tightly rolled sponge is grasped by the right robotic
instrument (usually a curved bipolar). In a swift motion, the sponge in the left hand is removed and
replaced with the sponge carrying the EVERREST patch [Figure 4]. The patch is held over the bleeding
point for exactly 3 min. Following this, the patch should be left in place and the fourth arm should be used
to continue pressure on the sponge/patch composite. The tendency to assess the state of the tear should be
absolutely avoided. The patch should be left in place until proximal control is obtained.

Pulmonary vein injury usually occurs during dissection and encirclement maneuvers. Most commonly, the
upper lobe veins are injured. Usually, the injury is on the underside of the vein. In the case of pulmonary
vein injury, suction of blood should be avoided as this may lead to air (CO ) embolism. The bleeding
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