Intraoperative bleeding during thoracic surgery. Avoidance strategies and surgical treatment concepts

Background. As a direct result of the thoracic anatomy, heavy bleeding is possible during nearly all central resections in thoracic surgery. Objective. Description of the incidence of intraoperative bleeding including avoidance strategies and treatment concepts. Presentation of special anatomical features of pulmonary arteries. Material and methods. A literature search was performed in Pubmed, medline and by manual searching. Publications from the last 60 years were analyzed and the results are summarized in a structured review. Results. Little data is available on the incidence of intraoperative bleeding during thoracic surgery. Most data were collected retrospectively. For mediastinoscopy the incidence of severe bleeding is 0.2%, for minimally invasive anatomical resections the incidence of intraoperative bleeding is 4.7% and for open surgery 5%. Bleeding from the central pulmonary artery can take a dramatic course and requires rapid and targeted therapy. Discussion. Knowledge of the anatomical topographic details, the structure, the course and the specific features of the vessels of the lungs is essential to prevent and treat bleeding. Avoidance strategies include techniques of proximal and distal vessel control, intrapericardial preparation and sharp preparation in general. Techniques of forward-looking preparation and well-prepared exit strategies in case of bleeding have to be part of the training in thoracic surgery.