Authors: Ishaan Chauhan, Rebecca Weedle, Akshay Jatin Patel, Andrea Bille
Categories: Thoracic: Lung Cancer: Original Manuscript, robotic thoracic surgery, thoracic surgery, serious complications, conversion, intraoperative emergency
Source: JTCVS Techniques
Authors: Ishaan Chauhan, Rebecca Weedle, Akshay Jatin Patel, Andrea Bille
Numerous studies have shown robotic-assisted thoracoscopic surgery (RATS) to be a safe alternative to video-assisted thoracoscopic surgery, and its use has been widely adopted and continues to increase. However, there are a number of potential serious complications that necessitate conversion to thoracotomy. We reviewed our experience with the management and outcomes of such complications in a high-volume robotic center.
We performed a retrospective review of all major robotic resections (single surgeon, single center) performed between May 2018 and June 2025. Serious complications were defined as any major vascular or bronchial injury, erroneous transection, and any other event resulting in an extra procedure beyond the planned operation.
Between May 2018 and June 2025, a total of 1480 major RATS cases were performed. We identified 25 serious complications (17 intraoperative and 8 postoperative). Intraoperative complications included 13 major vascular injuries (including 1 transection of the main pulmonary artery requiring an arterial sleeve), 1 cardiac injury, and 3 bronchial injuries (1 occurring during intubation). Interestingly, these resulted in only 10 (59%) conversions to open surgery, with the rest managed robotically. There were no intraoperative deaths and 2 in-hospital deaths among patients with serious complications.
RATS is safe and the risk of serious complications is low, and these complications do not always necessitate conversion. However, vigilance, understanding, and preparation for potential complications are key for surgeons as well as the entire robotic theater team. This ensures that complications can be dealt with efficiently and decisively, enhancing patient safety and optimizing surgical outcomes.
Sling around the right mPA (mistaken for truncus anterior) during right upper lobectomy. Central MessageRates of serious complications in robotic thoracic surgical procedures are low, and these complications often can be managed without conversion to thoracotomy. PerspectiveRobotic-assisted thoracoscopic surgery is transforming minimally invasive thoracic surgery by offering improved visualization, dexterity, and precision. As with any minimally invasive technique, acknowledging the potential associated serious complications is imperative. We present our experience in managing these complications and their outcomes at a high-volume robotic surgery center.
Since the inception of robotic-assisted thoracoscopic surgery (RATS) in 2001,^1^ there has been a significant gain in momentum, especially during the last decade. While video-assisted thoracoscopic surgery (VATS) is the established surgical standard of care for lobectomy in lung cancer,^2^ most of the literature has shown RATS to be noninferior to VATS,3, 4, 5, 6 with comparable early postoperative outcomes, cost utility, and oncologic equivalence to VATS.7, 8, 9, 10 RATS is now widely adopted internationally, and in 2023-2024 the number of RATS operations exceeded the number of open operations in the United Kingdom for the first time.^11^ While RATS offers superior visualization and more precise dissection, it comes with its own specific challenges, such as the loss of haptic feedback (although newer systems will have forced feedback) and difficulty in immediate conversion to open when encountering complications. Despite this, there are only a few studies relating to the incidence and management of serious complications with RATS.12, 13, 14, 15
Here we examine and describe our experience with the incidence of serious intraoperative complications of RATS, their immediate management, and strategies to mitigate their risk.
We retrospectively examined all major RATS cases (anatomic lung and anterior mediastinal mass resections) performed by a single surgeon at our institution between May 2018 and June 2025 and identified those in which a serious complication occurred. A serious complication was defined as any major vascular, bronchial, or organ injury; erroneous transection; or any other event resulting in an extra procedure other than the planned operation, including a return to the theater for complications. We then analyzed these data to determine how often each complication occurred, whether it necessitated conversion to an open procedure, how it was remedied, and patient outcome. Institutional Review Board approval and patient consent were not required, as no identifiable patient data were used.
The surgical procedures were performed using the Da Vinci Xi Robotic Surgical System (Intuitive Surgical). Lung resections were performed using 5 4 robotic ports (two 8-mm and two-12 mm) and one 15-mm assistant port. The standard instruments used included Cadiere forceps, cautery spatula, fenestrated bipolar forceps, and Intuitive SureForm stapler, with Maryland bipolar forceps used on occasion. Anterior mediastinal resections were done using 4 ports—three 8-mm robotic ports and one 12-mm assistant port—with the Cadiere forceps, vessel sealer, and cautery spatula. All cases included CO2 insufflation (to a pressure of 6 mm Hg), intercostal nerve blocks or paravertebral catheters (using 0.25% chirocaine), and a 24 Fr apical chest drain (on suction, 1 kPa for 24 hours).
Anesthesia was provided by a dedicated thoracic anesthetist following a standardized anesthetic double-lumen endotracheal tube, arterial line, nasogastric tube, and total intravenous anesthesia.
Over the study period, 1480 major RATS cases were performed, including 683 lobectomies, 388 segmentectomies, 125 wedge resections, and 284 mediastinal resections. Thirty-eight cases were post–neoadjuvant chemoimmunotherapy, and 42 of the lobectomies were sleeve resections. We identified 25 (1.7%) serious complications (17 intraoperative and 8 postoperative). The intraoperative complications included 13 (0.9%) major vascular injuries (including 1 [0.07%] erroneous transection), 1 (0.07%) cardiac in/jury, and 3 (0.2%) major bronchial injuries. Of these, 10 (59%) required conversion to open, and the other 7 (41%) were managed robotically. Eight (0.5%) patients required a return to the operating heater for complications, which included 3 (0.2%) bleeding, 4 (0.3%) bronchopleural fistulas (BPFs), and 1 (0.07%) chyle leak. There were no intraoperative deaths. Two (0.14%) patients died postoperatively during the same admission (both with BPF). By procedure, the proportions of serious complications were 2.2% (n = 15) of lobectomies, 1.5% (n = 6) of segmentectomies, 1.4% (n = 4) of mediastinal resections, and 0% (n = 0) of wedge resections. Three (7.9%) serious complications occurred in patients post–neoadjuvant chemoimmunotherapy. Table 1 summarizes the patients, procedures, and complications.Table 1Summary of complicationsPatientAge, y/sexOperationComplicationAdditional procedurePathologyLOS, d183 FLeft RATS upper lobectomy + LNDBleeding (PA)Conversion and primary repairStage IIB adenocarcinoma7283 FLeft RATS upper lobectomy + LNDBleeding (PA)Conversion and primary repairStage IB adenocarcinoma8368 FRight RATS upper posterior (S2) segmentectomyBleeding (PA)Conversion and primary repairStage IA2 adenocarcinoma24466 MLeft RATS upper trisegmentectomy + LNDBleeding (PA)Conversion and primary repairStage IA3 adenocarcinoma7573 FLeft RATS upper lobectomy + LNDBleeding (PA)Conversion and primary repairStage IIB SqCC6650 FLeft RATS upper lobectomy + LNDBleeding (PA)Conversion and primary repairStage IA3 adenocarcinoma4775 FLeft RATS upper lobectomy + LNDBleeding (PA)Conversion and primary repairAdenocarcinoma in situ11866 MLeft RATS thymectomyBleeding (IV)Conversion and innominate divisionpT1a, type AB thymoma5986 FRight RATS lower lobectomyBleeding (PA)Robotic primary repairStage IA1 SqCC101062 FRight RATS middle lobectomy + upper posterior (S2) segmentectomy + LNDBleeding (IPV)Repaired roboticallyBenign71138 FRight RATS lower lobectomy + LNDBleeding (PA)Repaired roboticallyypT1cN0 adenocarcinoma61253 FLeft RATS thymectomyBleeding (IV)Repaired roboticallyParathyroid adenoma81381 FRight RATS upper lobectomy + LNDErroneous transection (mPA)Conversion and re-anastomosisStage IB adenocarcinoma61453 MRight RATS resection of internal mammary artery lymph nodeCardiac injury (LA)Conversion and primary repairBenign91566 MRight RATS resection of subcarinal lymph nodeBronchial injury (LMB)Robotic primary repairMetastasis, thyroid carcinoma31665 FLeft RATS upper lobectomy + LNDBronchial injury (LMB)Robotic primary repair and muscle flapMetastasis, renal carcinoma61771 FRight RATS lower lobectomy + LNDBronchial injury (LMB), intubation-relatedRobotic primary repair and muscle flapStage IIIA typical carcinoid601868 MRight RATS upper lobectomy + LNDBleeding requiring reoperationVATS washoutStage IB adenocarcinoma141976 MLeft RATS apicolower (S6) segmentectomy + LNDBleeding requiring reoperationVATS washoutStage IB SqCC52064 MRight RATS upper wedge + apicolower (S6) segmentectomy + LNDBleeding requiring reoperationVATS washoutpT1b and pT2a N1 adenocarcinomas162167 MRight RATS lower bilobectomy + LNDBPFThoracotomy and intercostal muscle flappT1cN1 atypical carcinoid392269 FLeft RATS upper trisegmentectomy + LNDBPFThoracotomy, intercostal muscle flap and Permacol meshStage IA2 adenocarcinoma422380 MRight RATS upper lobectomy + LNDBPF (died)Thoracotomy and intercostal muscle flapStage IIA adenocarcinoma472473 MRight RATS upper lobectomy + LNDBPF (died)Thoracotomy and intercostal muscle flap then stenting then Clagett's windowypT2aN0 SqCC732575 FLeft RATS apical (S1) segmentectomy + LNDChyle leakRATS thoracic duct ligationStage IA2 adenocarcinoma6LOS, Length of stay; RATS, robotic-assisted thoracoscopic surgery; LND, lymph node dissection; PA, pulmonary artery; IV, innominate vein; SqCC, squamous cell carcinoma; IPV, inferior pulmonary vein; mPA, main pulmonary artery; LA, left atrium; LMB, left main bronchus; VATS, video-assisted thoracoscopic surgery; BPF, bronchopleural fistula.
The vast majority of the major vascular injuries were bleeding from the pulmonary artery (PA) (n = 9), but these injuries also included bleeding from the pulmonary vein (n = 1) during anatomic lung resection. Eight cases required conversion, and 4 cases were managed robotically. In anterior mediastinal cases, bleeding occurred from injury to the innominate vein in 2 cases, 1 of which required conversion and the other was managed robotically.
The following cases required conversion for
*Patient * Extrapleural left upper lobectomy. The fissure had been dissected to expose the PA, and the lingula and posterior branches had been isolated and divided. Dissection of the anterior and apicoposterior branches proceeded. While stapling the A3 branch, bleeding occurred from the origin of the truncus anterior. This was controlled with the posterior arm holding a cigar swab on the main pulmonary artery (mPA) at the origin of the truncus. Given the 1 to 1.5 L of blood loss, the decision was made for a controlled conversion to thoracotomy. Intrapericardial control of the left mPA was established with a vascular clamp. The apical and lingula veins were stapled separately. The bronchus was stapled and divided, after which the remaining upper lobe PA branches were divided. The arterial injury was repaired with 4/0 Prolene and covered with a hemostatic patch (Veriset) prior to completion of the left upper lobectomy.
*Patient * Left upper lobectomy. The fissure was dissected to identify the PA, and the posterior fissure was completed. The anterior hilum was dissected, and the superior pulmonary vein (SPV) was isolated and stapled. The PA was identified posterior to the vein stump, and the first branch was isolated and divided with the stapler. A posterior PA branch was isolated from fissure and divided using a stapler. Attempts to isolate a second posterior branch with an adherent calcified lymph node caused a PA injury. This was controlled with pressure, and a controlled conversion to posterolateral thoracotomy was performed. The PA injury extended to the mPA. A clamp was placed around the mPA. Total blood loss was 1800 mL. The lobectomy was completed with the clamp in situ, after which the PA injury was repaired with 4/0 Prolene sutures. Haemostatic agents were added to the area.
*Patient * Right upper lobe posterior segmentectomy. The posterior oblique fissure was completed. A2 was identified and divided using a stapler, and B2 was isolated and divided using a stapler. The lung parenchyma was fibrotic. During completion of parenchymal stapling to complete the segmentectomy, bleeding occurred from the staple line. A small PA branch was identified. It was difficult to establish control robotically, and so the decision was made to convert to posterolateral thoracotomy. Total blood loss was 1800 mL. The posterior segmentectomy was completed, and the staple line was reinforced with multiple 3/0 and 4/0 Prolene, and no further bleeding occurred.
*Patient * Left upper trisegmentectomy. The posterior mPA had highly inflamed perivascular tissue. Two posterior PA branches were isolated and divided. During isolation of the apical truncus, there was bleeding from the posterior wall of the artery. Control was obtained with pressure, and controlled conversion to thoracotomy proceeded. A further posterior PA branch was isolated and ligated. A Satinsky clamp was applied to the mPA at the origin of the truncus, which was then divided and oversewn. On release of the clamp, further bleeding occurred from the distal portion of the PA below the previous stitches. The tissue was extremely friable (likely due to dissection of the fibrotic tissue encasing the PA). Multiple 4/0 and 5/0 Prolene sutures and 2 Teflon pledgets were applied, and the area was covered with hemostatic agents. Total blood loss was 1600 mL. The upper division trisegmentectomy was completed with division of the bronchus and parenchyma.
*Patient * Left upper lobectomy. The PA was dissected in the fissure, and the posterior and lingula branches were isolated and stapled. Intrapericardial division of the SPV was performed. There was an enlarged lymph node around the superior hilum and main PA immediately below the apical truncus branch which was dissected with the Maryland bipolar forceps. An injury was caused to the mPA with a small amount of bleeding. Conversion to thoracotomy was performed. The inferior pulmonary vein (IPV) and mPA were clamped, and sharp dissection of the truncus anterior and bronchus was performed. The bronchial stump was oversewn with 4/0 PDS, and the arterial defect was repaired with 4/0 Prolene. The artery was unclamped with no further bleeding, and hemostasis was ensured with hemostatic agents. Total blood loss was 250 mL.
*Patient * Left upper lobectomy. The PA had been dissected in the fissure and the posterior oblique fissure completed using a stapler. The lingula artery, posterior ascending artery and SPV were isolated and divided with the stapler. There was fibrotic tissue around the apical truncus, which when released with the Maryland bipolar forceps, resulted in arterial bleeding. Immediate control was gained with a cigar swab followed by controlled conversion via a posterolateral thoracotomy. An arterial clamp was applied below the bleeding point. The artery was sharply dissected and divided, after which the upper lobe bronchus was stapled and the lobectomy completed. The arterial defect was then repaired with running 5/0 Prolene and covered with haemostatic agents. There was 400 mL blood loss.
*Patient * Left upper lobectomy. The SPV was divided and the PA explored in the fissure. The lingula arteries were isolated and divided with a stapler, but there was bleeding from the staple line, which was oversewn with Prolene 4/0. This was unsuccessful, and the bleeding continued. Controlled conversion via a posterolateral thoracotomy was performed. The arterial stumps were oversewn with no further bleeding, and the lobectomy was completed. Total blood loss was 150 mL.
*Patient * Left RATS thymectomy (anterior mediastinal mass). A vessel sealer was used to divide the mass where it was close to the innominate vein. On release of the vessel sealer, bleeding ensued from the innominate. The bleeding was controlled with cigar swabs, and partial sternotomy performed to obtain definitive vascular control. The injury was such that the innominate vein was not salvageable without significant narrowing, and thus it was divided with no further bleeding. The patient had some left arm swelling postoperatively but otherwise recovered well.
The following 4 cases with significant intraoperative bleeding were managed
*Patient * Right RATS lower lobectomy post–neoadjuvant chemoimmunotherapy. The lymph nodes were highly adherent to the bronchovascular structures, and dissection in the interfissural plane was challenging. During maneuvering and dissection with the fenestrated bipolar forceps, an injury to the basal PA trunk occurred that extended to the middle lobe artery. The arterial defect was repaired robotically using 3/0 Prolene but required oversewing of one of the middle lobe segmental arteries. Once vascular control was established, the right lower lobe arteries, IPV, and right lower lobe bronchus were stapled, and the right lower lobectomy was completed.
*Patient * Right middle lobectomy and upper posterior (S2) segmentectomy. The patient was noted to have thick, lipomatous tissues. The middle lobectomy was completed, but a diathermy injury occurred from the spatula to the IPV during dissection of a station 9 lymph node, resulting in 800 mL of blood loss. This was repaired robotically with 3/0 Prolene prior to completion of the segmentectomy.
*Patient * Salvage right lower lobectomy (stage IV lung cancer post–neoadjuvant chemoimmunotherapy) for residual disease in the right lower lobe. As expected, diffuse adhesions and highly fibrotic tissues were noted. The IPV was isolated and divided using a stapler. Dissection of the PA in the fissure revealed fibrotic tissue encasing the apical lower PA branch. Attempted blunt dissection with the spatula resulted in bleeding at the origin of the apical lower branch from the mPA, resulting in a 400-mL blood loss. The arterial injury was repaired robotically using 3/0 and 4/0 Prolene. The basal trunk was then divided, followed by the lower lobe bronchus (stapled and reinforced with a V-Loc suture), and the lobectomy was completed.
*Patient * Left RATS thymectomy. It was not possible to site an assistant port because of the patient's high body mass index. The thymus was dissected en bloc with the anterior mediastinal mass. Further inspection of the space along the innominate vein was carried out for residual thymic tissue. During dissection with the spatula, bleeding occurred from the innominate vein, with 300 mL of blood loss. This was controlled with compression and hemostatic agents (Veriset), and the procedure was completed.
There were no erroneous airway transections. In 1 case, the mPA was mistakenly
*Patient * Right upper lobectomy. What was thought be the anterior truncus branch was isolated and divided with the stapler, but this was found to be the right mPA. The decision was made to convert to posterolateral thoracotomy and perform a proximal vascular sleeve. There was aberrant arterial anatomy with very distal division of the mPA into the truncus arteriosus and right middle and lower lobe PA branches. An end-to-end reconstruction of the mPA to the interlobar PA with right middle and lower lobe PA branches was performed with 4-0 Prolene while maintaining vascular control with Satinsky clamps. The right upper lobectomy was completed.
One case involved a significant cardiac injury and required
*Patient * Right RATS resection of an enlarged internal mammary artery lymph node suspicious for metastasis (previous colorectal cancer). The patient had a high body mass index (>45) and an elevated diaphragm (previous open hepatic surgery). The lesion was in the mediastinal fat and extremely adherent to the diaphragm and pericardium. Careful and prolonged dissection of the tissue was done en bloc with the lesion. The lesion was dissected from the diaphragm and sternum but was extremely adherent to the pericardium. During mobilization from the pericardium to detach the lesion completely with the spatula, there was bleeding from the heart within the pericardium. The bleeding was controlled with cigar swabs, and emergency conversion to anterolateral thoracotomy was performed. Bleeding from the left atrium was identified and controlled with Prolene sutures. Further careful dissection of the pericardium from the diaphragm was performed. The pericardium was opened and partially excised to ensure no further bleeding. A haemostatic patch was applied to the left atrial suture line. Estimated blood loss was 1100 mL.
There were 3 cases of bronchial injury, related to nodal disease in 2 patients and to intubation in 1 patient. All were managed robotically.
*Patient * Left RATS resection of subcarinal lymph node (suspicious for metastatic medullary thyroid cancer). Diathermy injury occurred to the pars membranacea of the left main bronchus (LMB). The LMB defect was repaired robotically via primary closure using 3/0 PDS. There was no air leak on positive pressure after the repair. Full closure with no defect was confirmed with bronchoscopy at the end of the case.
*Patient * Left upper lobectomy. The subcarinal lymph node was densely adherent to the LMB. During dissection, a small hole occurred in the pars membranacea of the LMB. This was repaired robotically via primary closure using 4/0 Prolene, then covered with an intercostal muscle flap (secured using PDS). Pneumostasis was confirmed with an underwater test that showed no air leak, and the repair was confirmed visually with bronchoscopy at the end of the case.
*Patient * Right lower lobectomy. There was evidence of pneumomediastinum before dissection began. Systematic lymphadenectomy was performed. An air leak was noted from the LMB after dissection. A tear was identified in the pars membranacea, approximately 2 to 3 cm from the origin of LMB, likely an intubation injury. This was repaired robotically via primary closure using 3/0 and 4/0 PDS, then buttressed with a pedicled intercostal muscle flap and reinforced with Permacol. The right lower lobectomy was then performed.
Eight patients required a return to the operating theater for various complications, including bleeding in 3, bronchopleural fistula in 4, and refractory chyle leak in 1. These patients are described below.
These 3 patients were returned to the theater from recovery within a few hours of the initial
*Patient * Bleeding from chest wall adhesions.
*Patients 19 and * Bleeding related to port sites.
These 4 patients developed early BPF during their postoperative admission. They all underwent bronchoscopic assessment once a BPF was suspected due to persistent air leaks (with or without worsening surgical emphysema) rather than due to the size of the air leak. Both analog (underwater seal) and digital (Thopaz) drainage devices were used.
*Patient * Right RATS lower bilobectomy. The patient subsequently developed an early bronchopleural fistula, which was repaired with a thoracotomy and intercostal muscle flap on day 17.
*Patient * Left upper trisegmentectomy. The patient subsequently developed an early bronchopleural fistula in the LMB as a consequence of lymphadenectomy, which was repaired via a posterolateral thoracotomy using an intercostal muscle flap and Permacol mesh on day 21.
*Patient * Right RATS upper lobectomy. The bronchus was divided with the robotic stapler. The patient developed an early bronchopleural fistula and was returned to the theater on day 14. Bronchoscopy demonstrated a defect in the mucosa 2 mm lateral to the right upper lobe bronchial stump, but the mucosa and stump were otherwise healthy. This was repaired with thoracotomy and an intercostal muscle flap and Bioglue.
Patient 24: Right RATS upper lobectomy post–neoadjuvant chemoimmunotherapy, with a background of chronic lymphocytic leukemia (treated with immunotherapy). The bronchus was sharply cut and oversewn given the proximity of the tumor to the origin of the upper lobe bronchus. They developed a bronchopleural fistula from the right upper lobe bronchial stump extending to the distal trachea. A repair was attempted on day 21 via thoracotomy and an intercostal muscle flap; however, the bronchopleural fistula recurred. Bronchial stenting was performed from the trachea to the LMB (using a J stent), but a pleural space infection developed, which was managed with a redo thoracotomy, washout, and Claggett window. Unfortunately, the patient developed Steven-Johnson syndrome and toxic epidermal necrolysis and died during the same admission.
*Patient * This patient had a chyle leak after a left RATS upper apical segmentectomy, which did not improve with conservative management and required a return to the theater for RATS thoracic duct ligation on day 4.
As demonstrated by our present results, the rate of serious complications in RATS was very low (1.7%), as was the need for conversion to thoracotomy (0.7%). This compares favorably to other studies reported in the literature. One large series of 2881 patients undergoing VATS reported major complication rates 8.3%,^16^ and other smaller studies reported conversion rates between 2% and 6.5% in VATS and between 1.5% and 10% in RATS.^13^
Serious intraoperative complications during robotic thoracic surgery remain rare but are potentially life-threatening events, most commonly involving vascular injury to the PA or pulmonary vein. Early recognition, maintenance of haemodynamic stability, and decisive management are paramount. Key principles include prompt application of pressure to obtain temporary control, clear communication with the team, and preparation for controlled conversion to thoracotomy when required. Where feasible, selected vascular and bronchial injuries may be safely repaired robotically, particularly in experienced hands, but conversion should not be delayed in the setting of uncontrolled bleeding or poor exposure. Mitigation strategies include meticulous dissection in areas of dense fibrosis or postinduction therapy changes, avoidance of excessive traction on bronchovascular structures, early use of proximal and distal vascular control when anticipating difficult hilar dissection, and a low threshold for intrapericardial control of the PA. Bronchial injuries should be repaired with tension-free closure, often reinforced with vascularised tissue flaps, and the risk of bronchopleural fistula is heightened in patients with prior chemotherapy, immunotherapy, or frailty. Surgeons should maintain a high index of suspicion for airway or vascular injury when encountering dense nodal disease, fibrotic tissue, or unexpected bleeding and ensure readiness with appropriate hemostatic adjuncts, patch materials, and sutures. Structured team training, crisis simulation, and multidisciplinary planning are essential to improve preparedness, optimize outcomes, and reduce mortality from these uncommon but serious events.
In our institution, there is a standard operating procedure for uncontrolled bleeding in robotic surgery, and this is simulated with all theater staff on various days throughout the year. This standard operating procedure is detailed in Table 2.Table 2Robotic emergency standard operating uncontrolled bleedingRoleActionSurgeon• Call “emergency undock”• Ensure instrument jaws open and in straight line in operative field• Don sterile gown and gloves• Attend bedside for open surgeryBedside assistant• Remove robotic instruments and ports in one movement• Shout “clear”• Perform/assist with opening patientScrub nurse• Prepare emergency instruments and swabsCirculating nurse 1• Move robot away from patient• Open emergency setsCirculation nurse 2• Open sterile gowns and gloves for surgeon• Call for helpAnesthetist• Manage patient hemodynamicallyAnesthetic practitioner• Support anesthetist• Order blood products as instructed
When confronted with a major intraoperative injury during robotic thoracic surgery, the first priority is immediate control of bleeding or air leak with compression, suction, or selective ventilation as appropriate. Once temporary stability is achieved, the surgeon should assess exposure and feasibility of definitive robotic repair versus the need for urgent conversion. In cases where the injury involves the mPA, atrium, or proximal vascular structures, or where bleeding exceeds 500 to 1000 mL with poor visualization, controlled conversion to thoracotomy should be undertaken without delay. Conversely, more distal segmental or lobar vascular injuries, as well as limited bronchial defects, often may be repaired robotically with fine interrupted sutures and buttressing materials, provided that exposure is satisfactory and the team is experienced. For bronchial injuries, primary closure with absorbable or nonabsorbable sutures, reinforced with vascularized tissue when feasible, remains the standard of care.
For all injury types, anticipation is cases with dense nodal disease, prior therapy (surgery, radio/chemo/immunotherapy), or adhesions should be approached with readiness for proximal (or complete) pulmonary vascular control, availability of hemostatic agents, and a low threshold for conversion.
This study demonstrates that the rate of serious intraoperative complications in major RATS procedures is low, and that conversion to an open procedure is not always necessary to address the issue. Of course, here we have described the experience on a single surgeon at a single (albeit high-volume) institution, and more work is needed to accumulate more data to determine a widely accepted complication and conversion rate.
Regardless, being aware of potential serious complications, anticipating when they are likely to occur, and being proactive in preparedness is essential to ensure patient safety and better surgical outcomes. This extends not just to the surgeon, but to the entire robotic theater team, who should be well versed in both emergency and controlled undocking and conversion procedures.
Dr Bille is a proctor for Intuitive Surgical. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.