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When Things Go Wrong in Thoracic Surgery: A Middle Lobectomy With Bleeding That Required Cardiopulmonary Bypass to Address

Wednesday, July 17, 2019

By

Joel Dunning

Dunning J, Ferguson J, Kanani M, Mydin I. When Things Go Wrong in Thoracic Surgery: A Middle Lobectomy With Bleeding That Required Cardiopulmonary Bypass to Address. July 2019. doi:10.25373/ctsnet.8846354.

This is a video showing a procedure performed by open thoracotomy with a head camera that records audio. The patient had a large middle lobe tumor and had an ICD, an impaired left ventricular function, and previous coronary artery bypass grafting. Unfortunately, the operating surgeon got into a bleeding scenario that required the whole team to work together to get out of this problem.

This is a 34 minute video where the viewer can hear exactly how it went. The team has taken away many learning tips from this case, as this was the first time that the operating surgeon had to use cardiopulmonary bypass to rescue a bleeding situation in thoracic surgery. With good control of the bleeding and good planning, the team and patient were fortunate to have a good outcome.

The patient did very well and was safely discharged without any prolonged ventilation or air-leak issues.

Additional Resource

Surman TL, Worthington MG, Nadal JM. Cardiopulmonary bypass in non-cardiac surgery. Heart Lung Circ. 2019 Jun;28(6):959-969.

Comments

Submitted by Daniel Gwan-Nulla on
Well done! I admire your candor in sharing this video on how you and your team managed a very difficult intraoperative complication. Another option to consider is inserting a foley catheter (say 20 Fr foley) into the atrium, inflate the balloon and gently pull up. This should occlude the opening and provide temporary control of the bleeding as well as free up your hand. Depending on the size of the opening, you might be able to place a single figure-of-eight stitch that would provide reasonable hemostasis while you pull out the foley . You can then repair the tear with plegeted sutures or otherwise. This technique has proven useful in managing penetrating cardiac trauma in the multi-trauma setting, where the use of anticoagulation for CPB could result in severe bleeding in other areas. Thanks again for sharing this excellent video.
Submitted by Sandeep Sainathan on
Great video to learn crisis management. Aprreciate the calm, composed , and methodical approach to the situation. On a side note, If one is concerned about air-lock, one option would be to use cardiotomy suckers for venous drainage to get a controlled field to help facilitate the repair.
Submitted by Priyadharshanan Ariyaratnam on
That is a difficult situation but the Joel and the whole team handled it very effectively and efficiently. A nice illustration of why a broad training in Cardiac and Thoracic surgery is important despite which sub-specialty one decides on; as it allows the sub-specialist to consider all management strategies (eg CPB in thoracic emergencies) and then to seek the appropriate help.
Submitted by Shamsher Lohchab on
We had managed 18 months ago massive bleeding during left upper lobectomy by instituting CPB. It was bleeding from left pulmonary artery. Patient was taken on CPB descending thoracic aortic cannulation and suction bypass. Patient recovered fully. It was presented in North Zone Chd meeting in March 2018. Such types of cases give strong message that one has to be fully accomplished cardiothoracic surgeon. In case of even cardiac surgery one should be able to handle thoracic /lung complications.
Submitted by Haldun Tekinalp on
Great work. Congrats.... Have You ever considered a simple pursestring suture around your finger to control the bleeding ?? 4-O prolene on a 25 mm needle may bee double armed??
Submitted by Satinder Jain on
I viewed with interest the agony and ultimate successful outcome of a nightmarish bleeding unexpectedly. I have come and successfully managed cardiac chamber injuries in 3 patients with inserting a Foley's catheter in the rent and then suturing the hole in the cardiac chamber bit by bit while maintaining a small traction on the catheter. This simple maneuver comes handy and avoid large blood loss and may help to save a life where CPB or experienced cardiac surgeon is not easily available.

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