Reports of recent large series support the safety of video-assisted thoracoscopic major pulmonary resections (MPR). However, although their rate of postoperative complications is low, the real incidence of intraoperative complications is unknown.

Clinical data from patients who underwent MPR through a full thoracoscopic approach between 2007 and 2012 were reviewed. Data were collected prospectively and analyzed retrospectively.

A thoracoscopic MPR was attempted in 338 patients; 68.6% of the patients underwent a lobectomy and 31.4%, an anatomic segmentectomy. The mean operation time was 182 minutes (range, 80 to 300), and the mean intraoperative blood loss was 80 mL (range, 10 to 400 mL). Inhospital mortality rate was 0.3%. The overall complication rate was 32.8%. Intraoperative adverse events and conversion to open thoracotomy occurred in 2.7% and 5.6% of patients, respectively. Risk factors for conversion were preoperative forced expiratory volume of air in 1 second (p < 0.001) and a fused fissure (p = 0.001). A fused fissure (p = 0.007) and surgical experience (p = 0.022) were independent factors associated with a longer duration of operation. Major adverse events and reoperation occurred, respectively, in 8.9% and 3% of cases. Surgical complications were mostly vascular injury (n = 9), laryngeal nerve palsy (n = 5), chylothorax (n = 3), and bronchus injury (n = 1). On multivariate analysis, the only independent risk factors for major postoperative complications were smoking status and surgical experience.

Although its overall rate of complications is low, a complete thoracoscopic approach might cause unusual adverse events. Surgeons must be aware of these complications to prevent them and anticipate their handling.