Abstract
Background The management of intraoperative bleeding during thoracoscopic lobectomy is challenging,
especially for non-experienced surgeons. We evaluated intraoperative bleeding in relation
to learning curve of thoracoscopic lobectomy, the strategies to face it, the outcomes,
and the target case number for gaining the technical proficiency.
Methods This was a retrospective single center study including consecutive patients undergoing
thoracoscopic lobectomy for lung cancer. Based on cumulative sum analysis, patients
were divided into early and late experience groups, and the differences on surgical
outcomes, with particular focus on vascular injury, were statistically compared.
Results Eight-three patients were evaluated. Cumulative sum charts showed a decreasing of
operative time, blood loss, and hospital stay after the 49th, the 43th, and the 39th
case, respectively. Early (n = 49) compared with late experience group (n = 34) was associated with higher conversion rate (p = 0.08), longer operative time (p <0.0001), greater blood loss (p <0.0001), higher transfusion rate (p = 0.01), higher postoperative air leak rate (p = 0.02), longer chest tube stay (p <0.0001), and hospitalization (p <0.0001). Six patients (7%) had intraoperative bleeding during early phase of learning
curve, successfully treated by thoracoscopy in four cases. Patients with vascular
injury (n = 6) compared with control group (n = 77) presented a longer operative time (p = 0.003), greater blood loss (p = 0.0001), and higher transfusion rate (p = 0.001); no significant differences were found regarding postoperative morbidity
(p = 0.57), length of chest tube stay (p = 0.07), and hospitalization (p = 0.07).
Conclusion Technical proficiency was achieved after 50 procedures. All vascular injuries occurred
in the early phase of learning curve; they were safely managed, without affecting
surgical outcomes.
Keywords
surgery - complications - thoracoscopy - VATS - pulmonary artery - left upper lobectomy
