Devising the guidelines: the techniques of pulmonary nodule localization in uniportal video-assisted thoracic surgery-hybrid operating room in the future

Abstract

Pulmonary nodules beneath the pleura can be hard to visualize or palpate, especially during the uniportal thoracoscopic surgery. Conventionally, thoracic surgeons would use adjuvant modalities to localize the lesion preoperatively, of which computed tomography-guided hookwire implantation has been adopted most widely due to its feasibility and high success rate. However, procedure-associated complications such as pneumothorax and wire dislodgement can cause patient discomfort or localization failure. Occasionally more healthy tissue is resected than needed to guarantee the lesion is removed and with an adequate margin. A thoracotomy is necessary for specific scenario. With the development of imaging technology, it is now possible to replace the traditional workflow carried out in the radiology suite by centralizing the hookwire placement and uniportal minimally-invasive pulmonary resection inside the hybrid theater which equipped with advanced imaging devices. Theoretically, the advanced intra-operative imaging-guided techniques help to precisely locate and resection pulmonary lesion in a potentially tissue-sparing and quick paradigm.

Keywords: Image-guided; hybrid theater; localization.

Figure 1

Percutaneous hookwire insertion in hybrid OR. (A) Right upper lobe subcentimeter pure ground glass opacity for uniportal VATS resection marked by green arrow; (B) dynaCT image in hybrid operating room immediately following hookwire insertion. OR, operation room; VATS, video-assisted thoracic surgery.

Figure 2

Electromagnetic navigation bronchoscopy dye marking of right upper lobe subcentimeter pure ground glass opacity (GGO) for uniportal VATS resection, (A) navigation of locatable guide to within 3 millimeters from the centre of the target lesion, (B) dynaCT showing the dye injection needle directly on the GGO, (C) dynaCT following injection of mixed iohexol and methylene blue dye contrast at the lung lesion, (D) measurement of distance from target lesion/injection needle to pleura for advancement of needle to pleura for second injection, (E) dynaCT following injection of contrast at the pleura. VATS, video-assisted thoracic surgery.