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Image-guided thoracoscopic lung resection using a dual-marker localization technique in a hybrid operating room

Abstract

Background

We sought to describe the feasibility and safety of a dual-marker technique—based on a combination of near-infrared (NIR) marking and microcoil localization—before image-guided video-assisted thoracoscopic surgery (iVATS) of small and/or deep pulmonary lesions in a hybrid operating room (HOR).

Methods

We retrospectively reviewed the clinical records of consecutive patients who underwent iVATS resection in a HOR using the proposed dual-marker localization technique. Patients were initially imaged with cone-beam CT, and the needle trajectory was subsequently planned with the Syngo iGuide Needle Guidance software. Using a coaxial needle technique, a microcoil was initially deployed either in the immediate proximity or within the lesion of interest followed by injection of diluted indocyanine green (ICG; quantity: 0.3–0.5 mL; dye concentration: 0.125 mg/mL) at the pleural surface. A NIR thoracoscopic camera and a C-arm portable fluoroscopic system were used to guide the subsequent resection.

Results

A total of 11 patients were examined. The median lesion size was 6 mm, with a median distance from the pleural surface of 4 mm. Three nodules were solid, whereas the remaining eight were GGOs. All lesions were identifiable on intraoperative cone-beam CT images. The median time required for localization was 19 min. No conversion to thoracotomy or a multi-port approach was required, and there were no clinically significant adverse events after ICG injection or microcoil placement.

Conclusions

Our study indicates that iVATS with a dual-marking approach (NIR marking and microcoil localization) is safe and useful to localize difficult-to-identify pulmonary nodules.

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Correspondence to Yin-Kai Chao.

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Disclosures

Yin-Kai Chao, Osbert Qi Yao Leow, Chih-Tsung Wen, and Hsin-Yueh Fang have no conflicts of interest or financial ties to disclose.

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Workflow of the dual-marking technique for localization of pulmonary nodules performed during image-guided video-assisted thoracoscopic surgery. The iVATS procedure was entirely performed in a HOR equipped with cone-beam CT (ARTIS zeego; Siemens Healthcare GmbH, Erlangen, Germany) and a Magnus surgical table (Maquet Medical Systems, Wayne, NJ, USA). The patient underwent an initial scan for surgical planning during end inspiration breath-hold using a standard 6-sec DynaCT Body protocol. Under the syngo Needle Guidance provided by the syngo X-Workplace (Siemens Healthcare GmbH), we laid out the access path in the isotropic data set. The needle path was outlined by marking the needle entry and target points 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 entry site and angulation were visualized by projecting a laser-targeting cross onto the patient’s surface. Needle orientation and positioning were adjusted after pointing the planned, virtual needle path onto a live fluoroscopic image. A post-procedural cone-beam CT scan was obtained to confirm an appropriate needle location. Using a coaxial technique, one microcoil was placed at the deep lesion margin followed by the injection of diluted indocyanine green (ICG; quantity: 0.3−0.5 mL; dye concentration: 0.125 mg/mL) at pleural surface. Upon initiation of VATS, real-time intraoperative NIR fluorescence images were obtained using a minimally invasive ICG fluorescence system (PINPOINT®; Novadaq, Mississauga, ON, Canada) which includes a 10-mm, 30-degree NIR thoracoscopic camera for the identification of the NIR tattoo.

Workflow of the dual-marking technique for localization of pulmonary nodules performed during image-guided video-assisted thoracoscopic surgery. The iVATS procedure was entirely performed in a HOR equipped with cone-beam CT (ARTIS zeego; Siemens Healthcare GmbH, Erlangen, Germany) and a Magnus surgical table (Maquet Medical Systems, Wayne, NJ, USA). The patient underwent an initial scan for surgical planning during end inspiration breath-hold using a standard 6-sec DynaCT Body protocol. Under the syngo Needle Guidance provided by the syngo X-Workplace (Siemens Healthcare GmbH), we laid out the access path in the isotropic data set. The needle path was outlined by marking the needle entry and target points 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 entry site and angulation were visualized by projecting a laser-targeting cross onto the patient’s surface. Needle orientation and positioning were adjusted after pointing the planned, virtual needle path onto a live fluoroscopic image. A post-procedural cone-beam CT scan was obtained to confirm an appropriate needle location. Using a coaxial technique, one microcoil was placed at the deep lesion margin followed by the injection of diluted indocyanine green (ICG; quantity: 0.3−0.5 mL; dye concentration: 0.125 mg/mL) at pleural surface. Upon initiation of VATS, real-time intraoperative NIR fluorescence images were obtained using a minimally invasive ICG fluorescence system (PINPOINT®; Novadaq, Mississauga, ON, Canada) which includes a 10-mm, 30-degree NIR thoracoscopic camera for the identification of the NIR tattoo.

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Chao, Y., Leow, O.Q.Y., Wen, C. et al. Image-guided thoracoscopic lung resection using a dual-marker localization technique in a hybrid operating room. Surg Endosc 33, 3858–3863 (2019). https://doi.org/10.1007/s00464-019-06883-y

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Keywords

  • Near-infrared marking
  • Small pulmonary nodules
  • Indocyanine green
  • Image-guided video-assisted thoracoscopic surgery
  • Hybrid operating room
  • ARTIS zeego
  • Microcoil localization