Haemothorax following bullectomy caused by a sharp edge of the Endoloop

Abstract

A 22-year old man presented with a massive haemothorax 25 days after bullectomy for a spontaneous pneumothorax. Thoracoscopic surgery revealed ongoing bleeding from the chest wall caused by a sharp edge of the Endoloop Ligature (Ethicon Endo-Surgery) used to resect the remaining small part of the lung at the earlier staple bullectomy. The point where bleeding was occurring was clipped and covered using a collagen patch coated with human fibrinogen and thrombin. The protruding sharp edge of the Endoloop was excised together with the surrounding lung tissue, using a stapler. Although prevention of this type of complication is difficult, awareness of the potential problem may help in managing such extremely rare events.

INTRODUCTION

Many thoracoscopic devices have been developed for video-assisted thoracic surgery (VATS), but the serious complications sometimes occurring when using this technique require more attention [1–3]. Here, we report a delayed haemothorax caused by the sharp edge of the Endoloop Ligature (Ethicon Endo-Surgery), which consists of monofilament polydioxane inserted into a plastic tube.

CASE PRESENTATION

A 22-year old man presented at the emergency department at midnight with severe left chest pain, which had suddenly occurred 20 min earlier. He was supported by his family, but lost consciousness when he was transferred from the wheelchair to the bed in the emergency room. He developed tachycardia, pallor and hypotension, with a blood pressure of 80/50 mmHg. A rapid infusion of lactated Ringer's solution resulted in blood pressure recovery to 114/95 mmHg with a heart rate of 104 bpm. He had had a left spontaneous pneumothorax and had undergone bullectomy by VATS 25 days before in our hospital. The postoperative course had been uneventful, and he had been discharged 2 days after the bullectomy.

After the initial stabilization, blood examination and emergency chest computed tomography (CT) were performed, revealing a left haemothorax (Fig. 1). A thoracostomy tube was inserted 40 min after his arrival, which drained 1500 ml of fresh blood. At this time, the haemoglobin level was 12.4 mg/dl, blood pressure 109/69 mmHg and heart rate 63 per min. Over the next hour, blood pressure remained >100 mmHg, haemoglobin level was 11.4 mg/dl with 150 ml of blood draining during that time. Emergency thoracoscopic surgery was performed 3 h after admittance.

Figure 1:

Chest computer tomography (CT) on admission. (A) Scout view of CT showing massive left haemothorax. (B) CT showing staple line on apex of the left upper lobe, with small protrusion (arrow).

Thoracoscopic examination using three ports revealed a massive blood clot in the left thoracic cavity. On removal of this intrathoracic blood clot, ongoing bleeding from a small ulceration on the chest wall could be seen (Fig. 2A), which might have been temporarily stopped or reduced by being covered with the blood clot, and because of the hypotension. This lesion was clipped and covered using a collagen patch coated with human fibrinogen and thrombin. We suspected that the ulceration was caused by cuts from the sharp edge of the Endoloop that had been used to resect the remaining small part of the lung at the earlier staple bullectomy (Fig. 2B). The protruding sharp edge of the Endoloop was thought to have perforated the intercostal artery, and was excised together with the surrounding lung tissue using a stapler, without an Endoloop (Fig. 2C). The postoperative course was uneventful, and the patient was discharged 5 days later.

Figure 2:

(A and B) After removing the blood clot, active bleeding from the chest wall ulceration, probably from the intercostal artery, was seen. A sharp edge of the Endoloop, which was protruding at the dorsal end of the staple line (arrow), was assumed to be the cause of chest wall ulceration. (C) Resected specimen with protruding Endoloop. (D) Thoracoscopic view during the earlier bullectomy showing the protruding edge of the Endoloop over the covering with a polyglycolic acid sheet.

DISCUSSION

Massive bleeding caused by the Endoloop seems to be an extremely rare complication. While we and others routinely use the Endoloop for VATS bullectomy and VATS lobectomy, to the best of our knowledge, such a complication has not been previously described in the literature. The Endoloop has been widely used as one of the basic techniques for laparoscopic surgery also [4], without cases of such serious bleeding being recorded in the literature. In contrast, 3 cases of postoperative haemothorax caused by other VATS devices have been reported [1–3]. A scratch from the unstable staple caused bleeding from the intercostal artery in a 74-year old man 11 days after VATS lobectomy in 1 case [1] and from the internal thoracic artery in a 58-year old man 12 days after VATS lobectomy in another [2]. Both of these patients had suddenly experienced haemorrhagic shock and had required emergency surgery. One additional case of postoperative haemothorax was caused by the staple reinforcement material [3] in a 29-year old man 10 days after VATS bullectomy. The patient had presented with sudden onset chest pain and a relatively small haemothorax. Emergency VATS revealed bleeding from the injured intercostal muscle, which had been stabbed by the staple reinforcement material. This stapler with tissue reinforcement material was voluntarily recalled by the manufacturer, after reports had been received of 13 serious injuries and three fatalities over ∼3 years [5]. Compared with the situation with staple reinforcement material, postoperative haemothorax caused by the stapler and Endoloop seems to be extremely rare, and ceasing the use of the widely employed stapler and Endoloop is not to be recommended.

Although it may be difficult to prevent such a complication, awareness of the risk and the intention to minimize it are desirable. Thus, we always try to cut the Endoloop with the scissors at right angles to it in order to avoid making a sharp edge, and although the other edge is already pretreated, we try to leave it as long as possible. Covering with a polyglycolic acid sheet had been ineffective and had left a protruding edge of the Endoloop after the earlier bullectomy (Fig. 2D). Additional pleurodesis or pleurectomy might be beneficial to prevent unexpected intrathoracic accidents, including scratches by the staple or cuts from the sharp edge of the Endoloop; however, we still prefer not to perform additional pleurodesis or pleurectomy while carrying out bullectomy, because of possible future surgical difficulties, particularly for young patients. Awareness of this potential problem may help in preventing such extremely rare complications.

Conflict of interest: none declared.