Abstract
BACKGROUND: With advancements in minimally invasive thoracic surgery techniques, such as video-assisted thoracoscopic surgery and robotic surgery, the design of vascular staplers has evolved to meet the requirements of these procedures. Consequently, newer generations of automatic staplers with improved handling and reduced size have been introduced, such as two-row staplers, which are more maneuverable and less bulky than their three-row counterparts. CASE PRESENTATION: A 68-year-old man with lung cancer underwent a right middle and lower lobectomy due to tumor invasion into the central middle bronchial trunk, rendering the preservation of the middle lobe impossible. His medical history included chronic atrial fibrillation. The surgery involved a posterolateral incision and a fifth intercostal thoracotomy, where various pulmonary arteries and veins were dissected using vascular staples. Despite completing the surgery without initial complications, the patient experienced significant postoperative bleeding, leading to approximately 800 mL of bloody fluid being drained after coughing episodes. Reoperation was necessary to address and control the bleeding, which was challenging due to the location and nature of the hemorrhage. The source was identified at the transected edge of the inferior pulmonary vein, requiring direct suture after pericardium incision for better access. The total operative time amounted to 751 min, with a blood loss of 2092 mL. The patient recovered smoothly from the second operation and was discharged on the fifth postoperative day. Histopathological examination revealed myocardial cell presence adjacent to the pulmonary vein wall, suggesting that vein thickening could have played a role in the observed postoperative bleeding. CONCLUSIONS: In conclusion, when selecting staples for vascular use, particularly for the detachment of pulmonary veins, it is advisable to carefully choose between two-row and three-row staples.