# Thoracoscopic Massive Bleeding After Firing Mediastinal Trunk of the Pulmonary Artery With Calcified Lymph Node

## TL;DR

A thoracoscopic surgery for lung cancer led to unexpected massive bleeding due to a calcified lymph node attached to the pulmonary artery, requiring emergency open surgery.

## Contribution

Highlights the risks and management strategies for thoracoscopic dissection involving calcified lymph nodes near the pulmonary artery.

## Key findings

- Thoracoscopic dissection of calcified hilar lymph nodes can lead to unexpected massive bleeding.
- Emergency thoracotomy was effective in controlling the bleeding caused by vascular injury.
- Open surgery is recommended when calcified lymph nodes are difficult to dissect thoracoscopically.

## Abstract

The thoracoscopic management of hilar calcified lymph nodes is a technical challenge as the dense adhesions with the bronchus and vessels prevented a safe dissection. Herein, we reported the unexpected bleeding after firing the mediastinal trunk of the pulmonary artery with calcified lymph nodes during the completion of thoracoscopic right upper lobectomy for the management of lung cancer. The bleeding was successfully fixed by an emergent thoracotomy. We used a standard white vascular cartridge that probably was unable to staple a thick tissue, such as the vessel with calcified lymph node. Thus, the best strategy remained to cut the pulmonary artery where the lymph nodes were not attached, and the plasty of the pulmonary artery should be considered if the lymph nodes could not be dissected from the vessels. If the surgeons were not confident to manage this situation under thoracoscopy, conversion to thoracotomy should never be forgotten. Open surgery could facilitate the dissection of calcified lymph nodes and safely fix unexpected bleeding due to vascular lesions.

CT and intraoperative view showed the presence of a hilar lymph node. Unexpected massive bleeding occurred after firing the mediastinal trunk with the calcified lymph node. The complication was successfully faced by emergent thoracotomy.