Safety tips for pulmonary artery management using clipping combined with an energy device: a surgical technique in...

Robotic-assisted thoracic surgery (RATS) provides excellent visualization and instrument dexterity; however, pulmonary artery (PA) management remains one of the most critical and potentially hazardous steps, particularly when dealing with small-caliber branches. Although energy devices are widely used for vessel sealing, concerns remain regarding sealing reliability, thermal injury, and limited safety margins in fragile pulmonary arteries. Mechanical clipping, on the other hand, offers secure occlusion but may be technically challenging in confined robotic fields when used alone. We describe a clipping plus vessel sealing (CV) technique for the management of small PA branches during RATS. This approach integrates the mechanical security of a proximal polymer clip with distal transection using a bipolar vessel sealing device. After circumferential skeletonization of the target branch, a Hem-o-lok clip is applied proximally at an appropriate distance from the vessel origin, followed by distal sealing and division with an energy device. Particular attention is paid to clip positioning, spacing between the clip and the sealing site, and gentle withdrawal of the clip applier to avoid inadvertent vessel injury. In our institutional experience, this technique was applied to 41 small PA branches (with an estimated diameter of ≤5 mm) in 28 patients undergoing robotic lung resection, with a median of 1 branch per patient (range, 1-3), without intraoperative bleeding or technique-related complications. The CV technique provides an additional safety margin by serving as a mechanical backup to the energy seal, thereby minimizing the risk of uncontrolled hemorrhage even in the event of incomplete sealing. Furthermore, distal application of the energy device may help reduce thermal spread to the vessel root. The CV technique represents a practical and structured approach for PA management in RATS using standard robotic instruments without additional cost or complexity. This approach may be particularly useful for surgeons introducing robotic lung resection, trainees in robotic surgery, or experienced surgeons seeking to further enhance safety when managing small pulmonary arterial branches.