Image-guided video-assisted thoracoscopic small lung tumor resection using near-infrared marking
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Localization of non-visible, non-palpable small pulmonary nodules during video-assisted thoracoscopic surgery (VATS) remains challenging. We sought to investigate the feasibility and safety of image-guided video-assisted thoracoscopic surgery (iVATS) with near-infrared (NIR) marking in a hybrid operating room (OR).
Both localization and surgery were performed by a single team of thoracic surgeons. Diluted indocyanine green (ICG; quantity: 0.3–0.5 mL; dye concentration: 0.125 mg/mL) was injected percutaneously to pinpoint the tumor’s location under cone beam computed tomography (CBCT) guidance using a laser-guided navigation system. Real-time fluorescence images were intraoperatively obtained using a NIR thoracoscopic camera to guide subsequent resection.
Between March and December 2017, 26 patients underwent NIR marking of small pulmonary nodules for iVATS. The median tumor size was 7 mm (interquartile range [IQR] 5.3–10.8 mm), whereas their median distance from the pleural surface was 5 mm (IQR 0.3–10.5 mm). Seven nodules (35%) were solid, whereas 17 (65%) were ground-glass opacities. All lesions were identifiable on intraoperative CBCT. The median time required for NIR localization was 13 min. An NIR(+) “tattoo” was identified in all cases, and no intraoperative conversion to thoracotomy occurred. The final pathological diagnoses were primary lung cancer (n = 11), metastatic cancer (n = 6), and benign lung tumor (n = 9). Adverse events were not observed, and the median length of post-operative stay was 4 days (IQR 3–4 days).
Our data show that iVATS with NIR marking is useful, has no adverse effects, and can successfully localize difficult-to-identify small pulmonary nodules.
KeywordsNear-infrared Small pulmonary nodules Indocyanine green Imaging-guided video-assisted thoracoscopic surgery Hybrid operating room ARTIS zeego
This study was financially supported by a Grant (CMRPG3F1812) from the Chang Gung Memorial Hospital, Taiwan.
Compliance with ethical standards
Drs. Chih-Tsung Wen, Yu-Yin Liu, Hsin-Yueh Fang, Ming-Ju Hsieh, and Yin-Kai Chao, MD have no conflict of interest or financial ties to disclose.
The study protocol was approved by the Institutional Review Board of the Chang Gung Memorial Hospital (CGMH-IRB 201600671A3).
All patients gave their written informed consent.
Supplemental Video 1. Workflow of near-infrared lesion marking during image-guided video-assisted thoracoscopic surgery. The entire iVATS procedure was performed in a hybrid OR equipped with CBCT (ARTIS zeego; Siemens Healthcare GmbH, Erlangen, Germany) and a Magnus surgical table (Maquet Medical Systems, Wayne, NJ, USA). Under end-inspiratory breath-holding, an initial scan was obtained for needle-path planning. The access path was laid out in the isotropic data set using the syngo Needle Guidance of a syngo X-Workplace (Siemens Healthcare GmbH). The needle path was initially defined by marking the entry and the target point of the needle and subsequently projected with a laser beam onto the patient’s skin. A laser-targeting cross was projected onto the patient’s surface to visualize the needle entry point and angulation. The needle was subsequently introduced using a fluoroscopic “bull eye” approach until the tip was inside the projected target. The accuracy of the needle path was verified upon completion of the procedure using CBCT imaging. After the acquisition of a post-procedural CBCT aimed at confirming the correct needle location, diluted ICG (0.3−0.5 mL) was injected percutaneously. After the start of VATS, real-time NIR fluorescence images were intraoperatively obtained using a minimally invasive ICG fluorescence system (Karl Storz, Tuttlingen, Germany) that includes a 10-mm, 30-degree NIR thoracoscopic camera to facilitate the subsequent wedge resection. (MP4 201478 KB)
Supplemental Video 2. Troubleshooting in case of indocyanine green spillage. When ICG spills, the extravasated dye may be easily wiped off. This represents a significant advantage over other fiducial markers used for tumor localization (which should be removed after surgery and may pose significant challenges when spillage occurs). (MP4 52521 KB)
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