Time to remind old good principles
Introduction of video-assisted thoracic surgery (VATS) of anatomic pulmonary resection brought major changes to various technical aspects of dissection and management of elements of the hilum of the lung. Older techniques of how to manage pulmonary arterial and venous branches with ligatures or sutures were replaced by endostaplers, which theoretically made this technique easier and faster. However, complications occur also during the use of endostaplers as was described by Shimizu et al. (1). The authors analyzed mechanisms of injury of the pulmonary vessels with erroneous lifting and/or twisting of vessels with endostaplers. For older surgeons who gained their experience in the era before introduction of VATS, the conclusions of Shimizu et al. were nothing new—we have all been taught how to be extremely delicate during dissection of the branches of the pulmonary artery, how to avoid stretching vessels during ligation, avoid excessive force during securing sutures and how to eliminate lifting and twisting of the vessels, mentioned by Shimizu et al. With growing experience, minimally invasive thoracic surgeons intuitively learn to be more and more careful with management of pulmonary vessels, especially with pulmonary artery branches, which are exceptionally vulnerable. Such prudent strategy is invariably rewarded with lower and lower intraoperative complications rate.
The same principles how to manage pulmonary vessels correctly apply also to management of bronchi. Goffi et al. recommended to avoid stretching of the main bronchus during stapling because they recognized this maneuver as one of the factors leading to development of postoperative bronchial fistula (2). Although it was not analyzed by Shimizu et al., but supposedly twisting, lifting and the other erroneous movements may also lead to development of the bronchial fistula in the era of endostaplers, the same as it was with the use of staplers for open procedures (3).
Concluding, Shimizu et al. should be commended for reminding old good surgical principles which are the same valid for VATS as they were for open thoracic operations.
Acknowledgements
None.
Footnote
Conflicts of Interest: The author has no conflicts of interest to declare.
References
- Shimizu N, Tanaka Y, Okamoto T, et al. How to prevent adverse events of vascular stapling in thoracic surgery: recommendations based on a clinical and experimental study. J Thorac Dis 2018;10:6466-71. [Crossref] [PubMed]
- Goffi FS, Goncalves EL. Closure of bronchial stump after pneumonectomy. Surgery 1957;42:511-20. [PubMed]
- Vester SR, Faber LP, Kittle CF, et al. Bronchopleural fistula after stapled closure of bronchus. Ann Thorac Surg 1991;52:1253-7; discussion 1257-8. [Crossref] [PubMed]
