Hybrid technique of virtual-assisted lung mapping and systemic indocyanine green injection for extended segmentectomy

Abstract

Background: Various approaches have been used to assist and facilitate segmentectomy with favorable oncological outcomes. We describe a hybrid approach comprising virtual-assisted lung mapping (VAL-MAP), which is a preoperative bronchoscopic dye-marking technique, combined with systemic indocyanine green (ICG) injection.

Clinical presentation: An asymptomatic 64-year-old man was referred to our department because of a lung nodule detected during his annual medical checkup. The chest computed-tomography image revealed a 16-mm, partly solid, ground-glass nodule in the left segment 4. Because the nodule was hardly palpable and deeply located between the left upper division segment and the left lingular segment, we performed VAL-MAP to facilitate extended left lingulectomy. Five dye markings were undertaken preoperatively. Surgery to remove the nodule was then conducted via complete three-port video-assisted thoracic surgery. The VAL-MAP markings were easily identified intraoperatively and helped locate the nodule. The intersegmental plane was identified by the ICG injection. The resection line was determined based on the intersegmental plane identified by the ICG injection and the site of the nodule suggested by the VAL-MAP markings. Following the resection line, we thoracoscopically achieved extended lingulectomy with sufficient surgical margins. The patient was discharged with no complications. The pathological diagnosis was adenocarcinoma in situ.

Conclusion: The hybrid technique of VAL-MAP and systemic ICG injection can be useful for accomplishing successful extended segmentectomy.

Keywords: Bronchoscopy; Indocyanine green; Intersegmental plane; Lung cancer; Segmentectomy; Thoracic surgery; Video-assisted thoracic surgery; Virtual-assisted lung mapping.

Fig. 1

a Chest computed tomography reveals a partly solid, ground-glass nodule that is highly suspicious for malignancy. b Preoperative three-dimensional computed tomography reconstruction imaging reveals that the nodule (purple) is in the left lingular segment, but is close to the intersegmental plane between the left upper division segment and the left lingular segment

Fig. 2

Post-mapping three-dimensional image (center) and photographs (arrows) of the mapping. Dye markings are apparent in the peripheral branches of B3aii, B3bi, B3bii, B3c, and B4bii (green). Among them, two markings (B3c and B4bii) were complicated with bulla formation. The tumor is shown in dark brown, the left upper lobe in pale orange, and the left lower lobe in orange

Fig. 3

a Near-infrared imaging shows the delineation of the intersegmental plane (arrowheads) between the left lingular segment and the left upper division segment, created by the systemic indocyanine green injection. The white circle surrounded by dotted lines suggests a VAL-MAP mark (B3c) and the red lines show the resection lines. b Three-dimensional image shows the intersegmental plane and the resection line. The blue color represents the VAL-MAP marking and the dark brown area is the tumor

Fig. 4

Intraoperative view of the surgical field after extended lingulectomy. PA pulmonary artery