1. Brief medical history.
Male, 70 years old, was admitted to the hospital with a left lower lung mass found on physical examination. Chest CT suggested: left lower lung mass with uniform density, maximum diameter about 3.6 cm, interlobular pleura was affected, and enlarged lymph nodes in groups 4L, 5L, 6 and 7. Preoperative diagnosis: left lower lung heterogeneous shadow, consider malignant possibility, proposed surgery: VATS left lower lung lobectomy plus mediastinal lymph node removal.
2. Surgical profile.
Lumpectomy: mild adhesions at the top of the pleural cavity, no pleural metastases, no pleural fluid, and well-developed lung fissures. The lower lobe of the left lung was resected in the order of left lower pulmonary ligament – lower pulmonary vein – oblique fissure – lower pulmonary artery stem – lower lobe bronchus. During the removal of the fifth group of lymph nodes, the operator hooked the mediastinal pleura at the main pulmonary artery window with an electric hook in preparation for incision, at which time the patient became agitated due to insufficient depth of anesthesia, resulting in bleeding from injury to the root of the left pulmonary artery.
Due to the small size of the rupture, the bleeding was stopped by sponge clamp compression to stop the bleeding, but blood was still oozing. The bleeding around the rupture was removed by suction, and clots were seen to accumulate at the rupture. The clots were removed and the rupture bled again. A 5-0 Prilling suture was prepared, and the operator loosened the oval clamp and sutured while bleeding. After entering the needle from the vascular breach, the length of the suture was not enough, so it could not exit from the opposite side of the breach, and the first single-hole lumpectomy vascular repair failed.
Subsequently, the second and third time were unsuccessful and the vascular rupture was enlarged than before. Finally, the broken vessel was successfully repaired by intermediate open thorax, and the operation was concluded by routine removal of mediastinal lymph nodes, with an intraoperative bleeding of about 1500 ml and blood transfusion of about 800 ml.
3. Experience.
After the operation, a discussion was held within the group, and some questions were raised about the bleeding from this anatomical site, taking into account the previous experience. Influenced by the riding of the aortic arch, if the left pulmonary artery trunk injury bleeds, the technical difficulty of lumpectoscopic hemostasis is significantly greater than that of the right side. First, in terms of the site of bleeding, there are two cases: one in which the exact site of bleeding can be exposed by retraction of the left upper lung lobe; the other in which the site of bleeding cannot be adequately exposed by retraction of the left upper lung lobe.
If it is the second case, the operation should be performed immediately by turning the chest open, incising the pericardium, blocking the common pulmonary artery trunk in the pericardium, and blocking the distal end of the left pulmonary artery trunk breach, and then repairing the vascular breach. If the first scenario occurs, the choice of whether to open the chest is based on the operator’s proficiency in lumpectomy.
It is relatively easy to open the chest to stop the bleeding, so I will not go into the details here. The following is a discussion of lumpectomy to stop the bleeding: expose the bleeding site, clamp the breach with a toothless oval clamp, and if the left pulmonary artery root can be freed; then use a “Romeo” to block it, the following suturing process may be more relaxed.
If it is difficult to free the root of the left pulmonary artery, direct suture repair of the broken vessel is an option, but there are several details to be noted.
① Choose a small-headed, toothless oval forceps whenever possible, because the large oval forceps are not conducive to the later suture operation after clamping the vessel;
②After clamping the vessel, adjust the clamping position of the oval clamp, too much or too little clamping of the breach is not appropriate, too little clamping cannot effectively control bleeding, too much may cause pulmonary artery stenosis after suturing. If it is impossible to adjust, the oval clamp is used as a sidewall clamp, and vascular repair is performed from within the oval hole of the oval clamp.
③The 3-0 Prilling thread can be chosen to suture the repaired vessel. The 3-0 Prilling thread needle is slightly larger, which facilitates the exit of the needle from the opposite side of the rupture.
④Select 2 or 3 holes for microscopic operation as appropriate. Because safety is the first priority, a multi-hole operation may reduce the difficulty of exposure and increase the operating space, and the assistant can pick up the needle for the operator from the secondary operating hole, so that the instruments do not “fight” and facilitate the smooth completion of the suture repair. In fact, the first stitch of the suture is crucial. After the completion of the first stitch, one is that the bleeding will be effectively controlled, and the second is that with the support of the first stitch, the operation of the second and third stitches will be easier.
It is not necessary to emphasize that the first stitch should be sutured in the center of the rupture; it is certainly good to suture to the center of the rupture to effectively control the bleeding. If conditions do not permit, a suture can be placed at one end of the incision along the long axis of the incision, which has the advantage of being relatively easy to perform, and then the subsequent sutures can be placed in sequence.
(6) In addition to the surgical operation described above, the anesthesiologist should also be instructed to work closely to increase the depth of anesthesia and implement controlled hypotension.
The following is another review of the operator’s procedure, and a question may be raised as to why the operator released the oval clamp to stop the bleeding.
The main reasons are.
(1) Single-hole operation, too many instruments can easily “fight”;
②The head end of the oval forceps is too large, which affects the access to the needle;
③The 5-0 Prilling vascular suture was chosen, and the stitches were too small;
④Single hole operation, the assistant can not connect the needle for the operator. Of course, each patient’s clinical situation is different and cannot be bound by a fixed surgical model, but requires the operator to make simple, reasonable and effective treatment decisions according to the specific situation at the time.