Danger Ahead, Proceed with Caution!

The fear of pulmonary artery (PA) injury influences every surgeon that performs anatomic pulmonary resection. It impacts trainee autonomy and the adoption of learning curves for both video-assisted thoracoscopic surgery and robotic surgery. In this issue of The Annals of Thoracic Surgery, the study by Takeda and colleagues 1 Takeda T. Matsuoka S. Miura K. Hamanaka K. Shimizu K. Eguchi T. Prediction of pulmonary artery-adherent lymph nodes for minimally invasive lung resection. Ann Thorac Surg. 2022; 114: 969-978 Abstract Full Text Full Text PDF Google Scholar provides a thoughtful analysis of how to predict potentially complicated pulmonary resections associated with PA-adherent lymph nodes (LNs). Bronchoscopic identification of dark mucosal pigmentation as well as nodal enlargement by computed tomography helped to predict patients that were found to have PA-adherent nodes intraoperatively. As one might expect, the presence of PA-adherent nodes also predicted conversion and PA injury rates. Among the cohort of 772 patients undergoing minimally invasive anatomic resections, predominantly via a video-assisted thoracoscopic surgery approach, 4% underwent conversion to thoracotomy, with 34% (n = 11 of 32) undergoing emergent conversion related to PA injuries associated with PA-adherent nodes. In contrast, 19% (n = 6 of 32) underwent conversion to thoracotomy without PA injury, suggesting perhaps variable intraoperative reasoning on how to proceed during dissection. While this preoperative predictive model is informative and perhaps strategically helpful to surgeons, it is this intraoperative decision making that most greatly influences the performance of an emergent conversion vs a more controlled elective conversion to thoracotomy. Prediction of Pulmonary Artery-Adherent Lymph Nodes for Minimally Invasive Lung ResectionThe Annals of Thoracic SurgeryVol. 114Issue 3PreviewDuring minimally invasive surgery (MIS), pulmonary artery (PA)-adherent lymph nodes (LNs) may increase the risk of conversion to thoracotomy and/or PA injury. The aims of this study were to investigate (1) preoperative workups as predictors of PA-adherent LNs and (2) predictors of conversion/PA injury during MIS. Full-Text PDF