COR-KNOT Repair of Iatrogenic Tracheal Injury During VATS Right Upper Lobectomy in a 65-Year-Old Female Patient

Video-assisted thoracoscopic surgery (VATS) has truly changed pulmonary resections, providing a less invasive approach with lower morbidity and mortality. ¹ Although it has multiple advantages, VATS is not devoid of risks, and however rare, iatrogenic injuries to the trachea can happen during these procedures. These injuries might occur from direct trauma of surgical instruments, particularly during dissection close to the mediastinum, or from traction applied to the lung and nearby structures. Prompt recognition and immediate management of tracheal injuries are crucial to prevent life-threatening complications such as pneumomediastinum, tension pneumothorax, and mediastinitis.

This case report details the occurrence of an iatrogenic tracheal injury during a VATS right upper lobectomy in a 65-year-old female patient, with subsequent repair using a COR-KNOT device (LSI SOLUTIONS, Victor, NY, USA), and the patient’s postoperative course. The case highlights the importance of meticulous surgical technique, a thorough understanding of mediastinal anatomy, and the availability of appropriate tools and techniques as well as surgeon expertise for managing unexpected complications during VATS procedures (Supplemental Video).

A 65-year-old woman with a history of chronic obstructive pulmonary disease, smoking, and arthritis and family history of lung cancer was diagnosed with right upper lobe nodule on chest computed tomography scan via a lung health check program; positron emission tomography scan was subsequently performed. The images results were reviewed by the Thoracic-Respiratory multidisciplinary team, and lung resection was planned.

Preoperative pulmonary function tests revealed adequate respiratory reserve, and the patient was deemed an appropriate candidate for VATS right upper lobectomy. The patient was informed of the benefits and risks of the operation, including the possibility of conversion to open thoracotomy, bleeding, infection, and injury to the nearby structures, and informed consent was obtained.

On the day of surgery, following general anesthesia, flexible bronchoscopy was performed and revealed a clear bronchial tree; afterward, the patient was positioned in the left lateral decubitus position, and a standard 3-port VATS approach was used. The initial port was placed in the seventh intercostal space at the midaxillary line for camera insertion, followed by 2 additional ports, 1 anterior and 1 posterior, as functional ports. After general inspection, the upper lobe was carefully dissected from the mediastinum and fissure, followed by dissection of the pulmonary artery branches, pulmonary vein, and finally the bronchus. The specimen was retrieved using an endovascular tissue retrieval bag with string, This was followed by systematic lymph node sampling. During dissection of the 4R lymph node, injury was noticed in the lateral wall of the lower part of the trachea, about 1 inch above the carina. The balloon of the double-lumen endotracheal tube was observed, and the injury was obvious.

Immediate steps were taken to assess and evaluate the extent of the injury. The anesthesiologist was alerted to the situation and advised to reduce the airway pressure to minimize the air leak through the tracheal defect. The flexible bronchoscope supported the repair procedure because visualization from inside the trachea, along with the VATS camera from outside the lumen, helped to determine the extent of injury. Adequate ventilation was achieved, the cuff of the double-lumen endotracheal tube was deflated, and the tube was pushed further down to the left side. The surgical field was meticulously inspected to rule out other associated injuries to the esophagus or major vascular structures. The decision was made to primarily repair the injured area using pledgeted interrupted 5.0 Prolene sutures, and the COR-KNOT device was used to facilitate suture placement and knot tying. Each suture was carefully placed to ensure proper tissue alignment and avoid excessive tension, which could lead to ischemia or tearing. The COR-KNOT device was then used to secure the knots, effectively closing the tracheal defect.

The COR-KNOT device is a mechanical instrument designed for tying knots with precision and security primarily in minimally invasive surgery. ² It is mainly useful in situations in which access is limited and tricky for knot tying. Tracheal repair using VATS and COR-KNOT has not been reported previously in the literature; thus, this case can be considered the first case report of iatrogenic tracheal repair with VATS using COR-KNOT. The integrity of the repair was tested by gently inflating the lungs and watching for any air leak. No significant air leak was detected, indicating a successful repair. A chest tube was placed in the pleural space, and the ports were closed in a standard fashion. The patient was extubated in theater and transferred to the intensive care unit. She was closely monitored postoperatively in the intensive care unit. A chest X-ray was performed in the intensive care unit a couple hours after the operation, and chest X-rays were obtained each day for the next 4 days. The patient remained hemodynamically stable throughout recovery. The chest X-ray confirmed appropriate lung expansion, and there was no evidence of pneumomediastinum or pneumothorax.

The chest tube was removed on the second postoperative day, and the patient was discharged home on the seventh postoperative day. A follow-up plan was arranged and reiterated to the patient, starting with outpatient clinic follow-up in 4 weeks and regular appointments afterward for a minimum of 6 months, with the potential of elective flexible bronchoscopy to assess the trachea and the repair. The patient reported no respiratory symptoms, and a repeat chest X-ray prior to discharge showed satisfactory outcomes. The long-term outcome of tracheal repair following iatrogenic injuries is generally favorable, with most patients experiencing complete healing and resolution of symptoms.

Several factors contribute to the risk of iatrogenic tracheal injuries during VATS procedures, including limited visualization, especially in the posterior mediastinum; the use of sharp instruments in close proximity to the trachea; and the potential for inadvertent traction or compression of the trachea during lung manipulation.

However, close monitoring after repair is essential to detect and manage any potential complications, such as tracheal stenosis or tracheoesophageal fistula. In cases of recurrent tracheal stenosis, dilation or the placement of a tracheostomy or T-tube might be necessary. Reoperative tracheal surgery can yield satisfactory results in most cases, especially when risk factors are addressed preoperatively. Although tracheal resection and reconstruction is the preferred approach for managing tracheal stenosis, other techniques, such as laser excision, balloon dilation, and stenting, can be used in select cases. ³

The use of the COR-KNOT device facilitated precise suture placement and secure knot tying in a confined space, contributing to the successful repair. The availability of specialized instruments and devices can significantly enhance the surgeon’s ability to manage unexpected complications during VATS procedures.

This case highlights several important considerations for surgeons performing VATS procedures. A thorough understanding of mediastinal anatomy and potential complications is crucial for safe and effective surgery. Meticulous surgical technique, including gentle tissue handling and careful dissection, can help minimize the risk of iatrogenic injuries. Prompt recognition and management of tracheal injuries is essential to prevent serious morbidity and mortality. The availability of advanced surgical tools, such as the COR-KNOT device, can facilitate complex repairs in minimally invasive settings. The surgeon should not attempt to exceed the limits of what appears to be reasonably possible. It must be remembered that a permanent tracheal T-tube might be the best solution for a patient with extensive tracheal damage that would defy reconstruction. ⁴ Bronchoscopy plays a pivotal role in the diagnosis of tracheal injuries, aiding in the identification of subtle signs of trauma. When faced with an operative dilemma, surgeons must be prepared to convert to an open thoracotomy to ensure adequate exposure and facilitate safe repair. ⁵ The management of tracheal injuries necessitates a multidisciplinary approach, involving surgeons, anesthesiologists, critical care specialists, and sometimes a pulmonologist.

Iatrogenic tracheal injuries during VATS procedures are rare but potentially life-threatening complications. Prompt recognition, meticulous surgical technique, and the use of advanced tools such as the COR-KNOT device can facilitate successful repair and improve patient outcomes.