Ligation of the segmental pulmonary artery during video-assisted thoracoscopic lobectomy and segmentectomy: Are DS...

The use of clips for ligation of segmental arteries in thoracoscopic surgery has not yet been validated in clinical studies and is currently authorized based primarily on technical specifications. Clips are advantageous in endoscopic surgery because they are easy to apply, time-efficient, and cost-effective. We evaluated our experience with vascular dissection in video-assisted thoracoscopic anatomic lung resection. We analyzed all VATS anatomic lung resections performed between 2012 and 2018 using our prospective patient registry. Pulmonary arteries were ligated using linear endoscopic staplers (Endo GIA TM 30-45 mm, vascular medium [Medtronic] or Echelon Flex TM 45 mm, GST 45D [Ethicon]), hand sutures (Premilene 5 - 0 or 4 - 0, 0.1-0.2 mm [B. Braun], running suture or single stitch), or clips (Aesculap^® DS Titanium Ligation Clips, medium-large and large). The primary endpoint was postoperative bleeding leading to re-exploration or blood transfusion. We identified patients after VATS lobectomy and segmentectomy (449 lobectomies, 296 segmentectomies). Staplers, hand sutures, and clips were used for pulmonary artery ligation in 369, 83, and 293 procedures, respectively. Eighteen bleeding events occurred (2.4%) : clips 8 (2.7%), stapler 6 (1.6%), suture 4 (5.0%). Seven patients received blood transfusions, and 11 underwent re-exploration. No clip failure leading to bleeding was observed. There was no significant difference among the three groups regarding bleeding or overall postoperative complications. Multivariable logistic regression showed no difference between the groups (clips vs. stapler OR 0.99, 95% CI 0.30-3.27, p = 0.99). Operative time was significantly shorter with staplers in lobectomy and with clips in segmentectomy compared with hand sutures. The estimated device cost showed a potential 80% reduction in direct device cost for clip use in comparison with stapler use. DS Titanium Ligation Clips appear to be a safe, fast, and cost-effective option for ligation of segmental pulmonary arteries during thoracoscopic anatomical lung resection.