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Complications - Uniportal VATS pneumonectomy right

thoracic
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Intraoperative Complications

    • Massive bleeding due to injury of major vessels, particularly caused by tumor infiltration or inflammatory adherent lymph nodes
      • By compression using a gauze swab, the situation can usually be controlled to the extent that, under continuous compression, the transition to thoracotomy can be managed in a controlled manner without excessive blood loss, allowing communication with the anesthesia team, preparation of further instruments, and if necessary, the organization of adequate assistance. Blind clamping and suturing attempts generally increase the damage.
    • Parenchymal lesions of the lung during mobilization or in the area of staple lines, especially with obliterated interlobar fissure
      • The attempt at suturing is often frustrating in vulnerable lung tissue or emphysematous lung. Here, the use of staple line reinforcement or a sealing matrix is helpful.
      • In individual cases, the surgeon must decide, based on information from anesthesia, about the fistula volume, whether conservative therapy with chest drainage is also justifiable.
    • Injury to the contralateral pleura
      • Especially during the preparation of infracarinal lymph nodes at station 7, an unnoticed opening of the contralateral mediastinal pleura can lead to tension pneumothorax. It is important to recognize the situation and either open the pleura widely or insert a chest drain on the opposite side.
    • Injury to the tracheal wall, main bronchi, or other segmental bronchi
    • Injury to the vagus nerve, phrenic nerve, and recurrent laryngeal nerve
    • Injury to the esophagus

  2. Postoperative Complications

    • Cardiac arrhythmia (35-45%)
      • Due to increased pressure in the right atrium with subsequent overstretching, atrial fibrillation can often be triggered.
      • In most patients, a sustained conversion to sinus rhythm is achieved after the postoperative adjustment phase and medication treatment.
    • Acute right heart failure
    • Respiratory insufficiency
      • Respiratory insufficiency frequently occurs after pneumonectomy and requires complex intensive medical care.
    • Postoperative pneumonia (5-10%)
      • After pneumonectomy, postoperative pneumonia occurs in up to 10% of cases, associated with a mortality rate of 20% to 40%.
    • ARDS (Acute respiratory distress syndrome 2-4%)
      • ARDS is a therapy-resistant interstitial pulmonary edema associated with a high mortality rate of up to 50%.
    • Postpneumonectomy syndrome (PPS 2% in adults up to 15% in children)
      • Mediastinal shift can lead to kinking of the bronchial system with stridor and dyspnea.
      • PPS occurs primarily in children and can be treated with the use of a tissue expander (e.g., silicone prosthesis).
    • Postoperative bronchial stump insufficiency (1-4%)
      • Early symptoms can include high fistula volumes, respiratory or cardiac decompensation, with purulent sputum and fever developing later. Early diagnosis through bronchoscopy is crucial for prognosis and course.
      • For high-risk patients (neoadjuvant pre-treatment, diabetes mellitus, ipsilateral prior surgery), primary coverage of the bronchial stump with a pericardial fat pad is recommended.
      • The therapy depends on the extent of the insufficiency and the timing of diagnosis and can be either endoscopic or through re-operation.
    • Postoperative pleural empyema (2-10%)
      • The most common cause is a persistent air fistula with contamination of the pleural cavity in the presence of an existing immune deficiency.
      • The therapy initially consists of adequate drainage and antibiotic therapy. Surgical revision is often required for persistent bronchopleural fistula.
      • Key measures include rapid initiation of therapy with broad-spectrum antibiotics, bronchial toilet, and bronchoscopic material collection (microbiology), as well as intensive physiotherapy.
    • Hemothorax (requiring transfusion or re-operation 1-4%)
      • Immediate surgical revision is necessary for 1L of bloody secretion in the first hour post-operation or persistent drainage volumes of 200-400ml/h in the first 5 hours post-operation.
    • Chylothorax (0.5-1%)
      • Initially, conservative therapy with MCT diet or parenteral nutrition. If secretion persists for over 14 days, radiological intervention or surgery is indicated.
    • Vocal cord paralysis (0-1%)
      • Speech therapy and ENT specialist co-management.
    • Nerve lesions due to positioning injuries