- Massive bleeding due to injury of major vessels, particularly caused by tumor infiltration or inflammatory adherent lymph nodes
- By compression with 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 and without excessive blood loss, allowing for the information of anesthesia, preparation of further instruments, and if necessary, the organization of adequate assistance. Blind clamping and ligature attempts generally increase the damage.
- Parenchymal lesions of the lung during mobilization or in the area of staple lines, especially with obliterated interlobar fissure
- An 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 a conservative therapy with chest drainage is also justifiable.
- Injury to the contralateral pleura
- Especially during the preparation of infracarinal lymph nodes of station 7, 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
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Intraoperative Complications
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Postoperative complications
- Cardiac arrhythmia (10-15%)
- Lobe torsion (0.1-0.3%)
- In case of suspicion, immediate confirmation of diagnosis using CT imaging and surgical revision. If the rotated lobe still appears viable, a subpleural fixation suture to the adjacent lobe is possible. If viability is unclear or gangrene is present, the respective lobe must be removed.
- Postoperative bronchial stump insufficiency (0.5-4%)
- Early symptoms can include high fistula volumes, respiratory or cardiac decompensation, with purulent sputum and fever developing later. Early confirmation of diagnosis using bronchoscopy is crucial for prognosis and course.
- In high-risk patients (neoadjuvant pre-treatment, diabetes mellitus, ipsilateral prior surgery), primary coverage of the bronchial stump with a pericardial fat pad is recommended.
- Treatment depends on the extent of insufficiency and timing of diagnosis and can be either endoscopic or through re-operation.
- Treatment of a bronchial fistula or stump insufficiency is complex and should be performed at a specialized center.
- Persistent air fistula (from the 8th postoperative day, approximately 8-15%)
- Revision surgery due to a parenchymal fistula is very rarely required. Conservative therapy (with patience, suction release attempt, or chemical pleurodesis) is often sufficient.
- Postoperative pleural empyema (0.1-2%)
- The most common cause is a persistent air fistula with contamination of the pleural cavity in the presence of a pre-existing immune deficiency.
- Initial treatment consists of adequate drainage and antibiotic therapy. Surgical revision is often necessary if a bronchopleural fistula persists.
- The most important measures are, in addition to 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 required for 1L of bloody secretion in the first hour post-operation or persistent drainage 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