A tip for controlling the main pulmonary artery during video-assisted thoracic major pulmonary resection: the outside-field vascular clamping technique.

Abstract

Cross-clamping the main pulmonary artery (PA) is a risky, stressful procedure for the general thoracic surgeon performing video-assisted thoracic major pulmonary resection (VATS). However, converting VATS to thoracotomy each time PA clamping is planned is a poor tactic. We present a simpler technique for VATS than the traditional method involving a thoracotomy. In VATS, DeBakey vascular clamps with double angle jaws are inserted through 1-cm access incisions. We clamped the main PA so as to maintain the limited visual field through the working port. Thus, we modified the position of these vascular clamps, which we call 'the outside-field vascular clamping technique'. Our technique should be used for VATS lobectomy to prevent conversion to open thoracotomy when one requires scheduled control of the PA during VATS.

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DOI: 10.1510/icvts.2010.246132
2010;
2010;11:693-695; originally published online Aug 19,
Interact CardioVasc Thorac Surg
Mitsuhiro Kamiyoshihara, Toshiteru Nagashima, Takashi Ibe and Isumi Takeyoshi

major pulmonary resection: the outside-field vascular clamping technique
A tip for controlling the main pulmonary artery during video-assisted thoracic
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Case report - Thoracic oncologic
A tip for controlling the main pulmonary artery during video-assisted
thoracic major pulmonary resection: the outside-field vascular
clamping technique
Mitsuhiro Kamiyoshihara*, Toshiteru Nagashima, Takashi Ibe, Isumi Takeyoshi
Department of General Thoracic Surgery, Maebashi Red Cross Hospital, 3-21-36 Asahi-Cho, Maebashi, Gunma 371-0014, Japan
Received 13 June 2010; received in revised form 2 August 2010; accepted 5 August 2010
Abstract
Cross-clamping the main pulmonary artery (PA) is a risky, stressful procedure for the general thoracic surgeon performing video-assisted
thoracic major pulmonary resection (VATS). However, converting VATS to thoracotomy each time PA clamping is planned is a poor tactic.
We present a simpler technique for VATS than the traditional method involving a thoracotomy. In VATS, DeBakey vascular clamps with
double angle jaws are inserted through 1-cm access incisions. We clamped the main PA so as to maintain the limited visual field through
the working port. Thus, we modified the position of these vascular clamps, which we call ‘the outside-field vascular clamping technique’.
Our technique should be used for VATS lobectomy to prevent conversion to open thoracotomy when one requires scheduled control of the
PA during VATS.
? 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Keywords: Pulmonary artery; Vascular clamp; Video-assisted thoracic surgery
1. Introduction
Cross-clamping the main pulmonary artery (PA) poses an
uncertain, demanding procedure for the general thoracic
surgeon performing video-assisted thoracic major pulmo-
nary resection (VATS). This procedure is usually done
through an open thoracotomy, but converting VATS to
thoracotomy each time PA clamping is planned is a poor
strategy. Some authors have described methodological
exploration w1, 2x. Here, we present an easier, simpler
technique compared to the traditional method. We believe
that this approach can be applied to a wide range of
surgical procedures, not only control of the main PAw1, 2x,
but also bronchoplasty w3, 4x and completion pneumonec-
tomy w5x.
2. Technique
In VATS, a working port measuring -8 cm in length is
made in the fourth or fifth intercostal space. We commonly
decide the length of the utility access incision based on
the size of the specimen to be removed and the operating
technique, while adhering to the principle of cutting inter-
costal muscle for a length equal to the skin incision. One
or two additional 1.2-cm thoracic ports are made in the
seventh or ninth intercostal space. The working port is
protected with a polyurethane wound retractor (Alexis?
wound retractor; Applied Medical Resources, Rancho Santa
*Corresponding author. Tel.: q81-27-224-4585; fax: q81-27-243-3380.
E-mail address: micha2005jp@yahoo.co.jp (M. Kamiyoshihara).
Margarita, CA, USA). Naturally, no patient required seg-
mental rib resection or rib spreading. We perform a pro-
cedure in which the ratio of direct visualization to
monitoring is about 7:3, which has been previously reported
w3x.
Two DeBakey vascular clamps with double angle jaws are
inserted through 1-cm access incisions. We clamp the main
PA to maintain the limited visual field through the working
port. In the conventional approach, the vascular clamps
are inserted through a thoracotomy, but they sometimes
obstruct the limited visual field through the working port.
Thus, we modified the position of these vascular clamps,
which we call ‘the outside-field vascular clamping tech-
nique’ (Figs. 1 and 2).
We performed this procedure in two patients; case 1 was
a 78-year-old woman with primary adenocarcinoma of the
anterior segment (segment 3) of the left upper lobe. The
tumor had invaded the anterior branch w6x of the left PA,
and we performed an arterioplasty with a left upper lobec-
tomy. After the outside-field vascular clamping, we sutured
the left PA at the base of the apicoposterior branch using
continuous non-absorbable 3-0 monofilament. The operat-
ing time was 176 min, and blood loss was 55 g. Her post-
operative course was uneventful and she was discharged
on postoperative day 5.
Case 2 involved an 81-year-old woman with primary ade-
nocarcinoma of the inferior segment (segment 5) of the
lingula of the left upper lobe. Hilar lymph nodes had
inflammatory adhesions to the apicoposterior and anterior
branches w6x of the left PA, and we also performed an
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Fig. 1. The exterior appearance of our technique using DeBakey vascular
clamps with double angle jaws through two 1-cm access incisions viewed
from directly above (a) and edge-on (b). The pathway of the vascular clamps
(blue dotted lines) involves ‘outside-field clamping,’ which avoids obstruct-
ing the limited visual field through the working port.
Fig. 2. (a) Design of the left pulmonary artery anastomosis in the two cases.
(b) Schematic depiction of the technique.
arterioplasty with a left upper lobectomy. After the out-
side-field vascular clamping, we reduced the PA pressure
and then resected the left PA at the base of both the
apicoposterior and anterior branches using a stapler device,
loaded with a 45-mm gray cartridge (Endo GIA? Universal
Roticulator? 45-2.0; Tyco Healthcare Group LP, Norwalk,
CT, USA). The operating time was 200 min, and blood loss
was 56 g. Her postoperative course was uneventful and she
was discharged on postoperative day 10.
3. Discussion
Care should be taken regarding the location of the 1-cm
access incisions. With regard to identifying sites for the
access incisions, there are differences that depend on the
shape of the vascular clamps, body size, and the relative
anatomical position of the PA. Liberally interpreted, the
access incision for the center vascular clamp should be
made in the third intercostal space on the mid-axillary line
and the other access incision, for the distal clamp, in the
sixth or seventh intercostal space on the posterior axillary
line. Our method has several advantages: the DeBakey
vascular clamps with double-angle jaws do not obstruct the
visual field, conventional vascular clamps can be used, and
the surgery is minimally-invasive. Disadvantages are the
increased number of 1-cm access incisions and the limited
handling of the vascular clamps, resulting from the pivot
point of the 1-cm access incisions.
The advent of minimally-invasive surgery can enable
methodological changes. However, maintaining the quality
of surgery is important, while minimizing the destruction
and deformity of the thoracic cage. In particular, we think
that rib cutting and spreading is a major disadvantage to
the patient, because of impaired cellular immunity w7x,
increased pain, shoulder dysfunction, and impaired early
pulmonary function w8x. We do not always adhere to a
complete VATS w9x because more procedures can be per-
formed with direct visualization through a minithoracotomy
w10x. We aim to perform as wide a range of techniques as
possible. No need exists to focus on whether a procedure
is complete or assisted with the VATS approach. This
depends on the surgeon’s preference and a complete or
VATS approach is immaterial to the patient.
In summary, the presented technique should be used for
VATS lobectomy to prevent conversion to open thoracotomy
when one requires scheduled control of the PA during VATS.
At present, we do not recommend this technique when one
requires urgent control of PA bleeding.
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Work in
Progress Report
ESCVS
Article
Negative
Results
State-of-the-art
Best Evidence
Topic
Brief
Communication
Case Report
Follow-up
Paper
Editorial
Protocol
Proposal for Bail-
out Procedure
Nomenclature
Historical
Pages
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DOI: 10.1510/icvts.2010.246132
2010;
2010;11:693-695; originally published online Aug 19,
Interact CardioVasc Thorac Surg
Mitsuhiro Kamiyoshihara, Toshiteru Nagashima, Takashi Ibe and Isumi Takeyoshi

major pulmonary resection: the outside-field vascular clamping technique
A tip for controlling the main pulmonary artery during video-assisted thoracic
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