Which is the best vessel-sealing method for pediatric thoracoscopic lobectomy?

The general aim of this report was to determine how a vascular accident (VA) or vascular incident (VI) could be prevented and controlled during thoracoscopic lung lobectomies (TLLs).

Clinical records and videos of patients (n:21) who underwent a programmed TLL during a 3-year period at the Private Children's Hospital "Fundación Hospitalaria" and CEMIC University Hospital (Buenos Aires, Argentina) were reviewed retrospectively. A VA was defined as the accidental bleeding during dissection, depending on the surgeon and/or inflammatory conditions, adhesions, and so on. A VI was defined as the unexpected bleeding after successful vascular sealing, depending on the vascular-sealing device. The conversion criteria to thoracotomy were uncontrollable VA or VI, limited visibility, difficult dissection, and other.

There were no VA, but there was a 24% rate of VI (n:5). All the VI were arterial, not venous. All the VI were observed in children older than 7 years of age because of deficient sealing. All of them were successfully controlled with LigaSure() (Valleylab, Boulder, CO) and/or one proximal Hem-o-Lok((R)) clip (Weck Closure Systems, Research Triangle Park, NC) without conversion. Conversion was due to limited visibility (n:2) or difficult dissection (n:2) of the diseased lobe.

Based on our early experience and a review of the literature, we believe TLL is a feasible and technically reproducible approach that avoids the inherent morbidity of a major thoracotomy incision. Bleeding should not be the main argument to decide in favor of a thoracotomy. LigaSure's reliability would depend on vascular diameter and on patient age. VIs can be prevented in older children by using the sealing device and a proximal Hem-o-Lok clip.