Indications in Thoracoscopic Suturing

Summary
Thoracoscopic suturing can be performed in different clinical scenarios, from pulmonary iatrogenic injuries to bronchoplastic resections, avoiding the necessity of conversion to open surgery. In this video, some of the prevailing indications for suturing are shown using a full thoracoscopic technique (1).

Description
This video shows some of the most common indications for thoracoscopic suturing. A multiport full thoracoscopic technique is used, with a high-definition deflectable-tip thoracoscope, a motorized scope-holder, and dedicated instruments.

Lung Injuries
Lung injuries caused by the tip of the trocar are quite common incidents that can occur in particular when the lung is still inflated or when pleural adhesions are present. Repairs can be performed at the end of surgery using absorbable suture (Vycril 3/0) and absorbable clips (Lapra-Ty® by Johnson & Johnson) that can be applied to anchor and secure each end of the running suture.

Prophylactic Lung Fixation
The prophylactic fixation is usually performed to avoid parenchymal torsion around the bronchovascular pedicle after a major resection. For this purpose, suturing can be an easy and cost-saving option.

Suturing After Parenchymal Stapling Failure
Stapling failure nowadays rarely occurs thanks to tri-stapling technology. Should it occur, however, a continuous suture can be performed to reinforce the staple line and to ensure hemostasis and aerostasis.

Suturing After Intraparenchymal Lung Dissection

1. Pulmonary Hamartoma
   Thoracoscopic sutures can be used at the end of intraparenchymal lung resections. In fact, even if different energy devices allow coagulation and division of the lung tissue, air leaks are frequent and additional sutures are required. In the video, intracorporeal knots are used for tying.
2. Solitary Fibrous Tumor of the Pleura
   When parenchymal repair is needed, barbed sutures provide a knotless alternative. The barbs penetrate the tissue and lock them into place, eliminating the need for knots to tie the suture.

Suturing in Bronchoplastic Resections: Left Upper Sleeve Lobectomy and Right Upper Sleeve Lobectomy
Several methods have been described to perform the bronchial anastomosis in thoracoscopic sleeve resections. In these two cases, superior left and superior right sleeve lobectomies are performed. Interrupted sutures are used for both the membranous and cartilaginous portions of the bronchus. Extracorporeal knotting is used for tying.

Reference

1. Gossot D. Atlas of Endoscopic Major Pulmonary Resections. 2^nd ed. Basel, Switzerland: Springer International Publishing. https://doi.org/10.1007/978-3-319-55901-8.