VATS Lobectomy: Prevention and Management of Intraoperative Events

The objectives of this video are to review potentially dangerous situations that may occur during thoracoscopic lobectomy, and how to manage them (see Table 1). Multiple events and responses are discussed.

Important Considerations for Performing VATS Lobectomy

• When building a practice or training a surgeon to perform VATS (video-assisted thoracoscopic lobectomy), it is important to be transparent with both the patient and the team that the surgeon is near the beginning of their learning curve.
• One may find a simple transition from a posterior to an anterior approach increases safety and allows the surgeon to stay oriented, with the comfort of still having an open chest. The next step in transitioning may be to insert the camera into the field to allow the surgeon to begin to look at the screen, rather than inside the chest.
• Team training is important. Every member of the operating team should be aware of potential complications that can occur, and how they may be managed differently than if the chest were open.
• Always keep a sponge on a clamp on the back table. This is the simplest and most obvious safety tip when doing any minimally invasive work. 
• Conversion is not a sign of failure. Surgeons should always convert if they are not able to offer the patient the same surgery they would perform in an open manner.
• The surgical team should practice for events in the operating room, and the surgeon should set a timer for how long they will work at a task to ensure progress is made.
• The best way to manage an event is prevention. Studies have shown that a skilled and experienced surgeon will begin to predict injuries before they happen, and will more often electively convert, rather than emergently convert, as they gain experience and train themselves to recognize potential error.
• Bleeding from the pulmonary artery is one of the biggest fears in VATS surgery; however, this is rarely a problem. Applying pressure and topical pro-coagulant product will often suffice. Reaction to the injury will often cause more harm when the surgeon tries to clamp a vessel, use a small device to pick up the vessel, or apply pressure with a small device.
• If an event occurs, the surgeon should initially apply pressure, release tension on the lobe, and acquire adequate back-up, if needed. Once the injury can be assessed, the decision to repair or convert to open thoracotomy should be made. Conversion can be done through a natural extension of the incision or a standard posterolateral thoracotomy. In difficult cases, it is often best to initially obtain control of the main pulmonary artery with a tape or vessel loop such that a tourniquet can be applied for repair and control when needed.