A new method for accurately localizing and resecting pulmonary nodules

Abstract

With the use of low-dose CT for early screening of lung cancer, more and more early lung cancers are found. At the same time, patients with small lung nodules have also increased, it is a great challenge for surgeons to resect pulmonary nodules with small volume, deep position and no solid components under video-assisted thoracoscopic surgery. Many studies have reported preoperative and intraoperative methods for localizing lung nodules before minimally invasive resection. Methods for preoperative localization include CT-guided hook-wire positioning, coil positioning, or dye injection and radionuclide location Methods for intraoperative localization include intraoperative ultrasound localization and tactile pressure-sensing localization. After the localization of pulmonary nodules under the guidance of CT patients need to restrict their activities; otherwise, it is easy for the nodules to move, causing the operation to fail, and may also cause complications such as pneumothorax, puncture site pain, and pulmonary parenchymal bleeding. In the past, we injected melamine dye under the guidance of electromagnetic navigation bronchoscope to locate lung nodules. The purpose of this case is introducing a new method for accurately localizing and resecting pulmonary nodules by injecting indocyanine green (ICG) under the guidance of electromagnetic navigation bronchoscope and the resection of small pulmonary nodules under the fluoroscope.

Keywords: Pulmonary nodules; electromagnetic navigation bronchoscope; fluoroscope; indocyanine green (ICG).

Figure 1

Chest and abdomen enhanced CT showing 9 mm × 7 mm nodules found in the posterior segment of the upper lobe of the left lung, with a clear boundary and uneven density (as shown by the arrow).

Figure 2

Ultrasonic cardiogram. (I) The inner diameter of the ascending aorta is normal, the wall is smooth, and the amplitude of the main wave is normal. (II) The repulse wave is present, the inner diameter of the pulmonary artery is normal, and the diameter of each atrioventricular cavity is normal. (III) The thickness of the ventricular wall and the movement are normal. The continuity of atrioventricular septum is intact, and the morphology, structure and movement of the valves are normal. (IV) There are no abnormalities in the pericardium or pericardial cavity.

Figure 3

(A) Flow volume curve. (B,C) Flow time volume. (D) Lung function index value. Pulmonary function results. (I) Lung ventilation function is normal. (II) Dispersion and residual function is normal.

Figure 4

Preoperative 3D reconstruction results.

Figure 5

(I) During the operation, the sensor probe was loctated 1.0 cm from target lesion. Indocyanine green (ICG) was injected into the pulmonary nodules under the guidance of electromagnetic navigation. (II) The ICG solution was injected with 0.1 mL under the guidance of magnetic navigation (medtronic).

Figure 6

After entering the chest cavity, the fluorescence staining area of the posterior segment of the left upper pulmonary apex was observed. The pulmonary parenchyma with the target lesion was stained with ICG before VATS resection. After the artery, vein, and trachea of the posterior segment of the left upper pulmonary apex were severed, indocyanine green was injected into the vein.

Figure 7

This is a planar view of the lung segment under a fluorescent endoscope. (A) Lung segment boundary plane in normal mode; (B) lung boundary plane in fluorescence mode; (C) three views of the lung segment.