Surgical Endoscopy

, Volume 34, Issue 1, pp 477–484 | Cite as

Real-time augmented fluoroscopy-guided lung marking for thoracoscopic resection of small pulmonary nodules

  • Shun-Mao Yang
  • Kai-Lun Yu
  • Kun-Hsien Lin
  • Yueh-Lun Liu
  • Shao-En Sun
  • Ling-Hsuan Meng
  • Huan-Jang KoEmail author
Dynamic Manuscript



Small pulmonary nodule localization via an endobronchial route is safe and has fewer complications than that with the transthoracic needle approach, but accurate marking without a navigation system remains challenging. We aimed to evaluate the safety and efficacy of endobronchial dye marking using conventional bronchoscopy guided by cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) for small pulmonary nodules.


We retrospectively reviewed the clinical records of 61 nodules in 51 patients who underwent preoperative CBCT-AF-guided bronchoscopic dye marking, followed by thoracoscopic resection, between July 2018 and March 2019.


The median nodule size was 8.6 mm [interquartile range (IQR) 7.0–11.8 mm], and the median distance from the pleural space was 15.4 mm (IQR 10.6–23.1 mm). All nodules were identifiable on CBCT images and annotated for AF. The median bronchoscopy duration was 8.0 min (IQR 6.0–11.0 min), and the median fluoroscopy duration was 2.2 min (IQR 1.2–4.0 min). The median radiation exposure (expressed as the dose area product) was 2337.2 µGym2 (IQR 1673.8–4468.8 µGym2). All nodules were successfully marked and resected, and the median duration from localization to surgery was 16.4 h (IQR 4.2–20.7 h). There were no localization-related complications or operative mortality, and the median length of the postoperative stay was 4 days (IQR 3–4 days).


Bronchoscopic dye marking under CBCT-AF guidance before thoracoscopic surgery was safely conducted with satisfactory outcomes in our initial experience.


Cone-beam computed tomography Augmented fluoroscopy Dye marking Small pulmonary nodules 



This work was supported by grant from the National Taiwan University Hospital, Hsin-Chu Branch, Taiwan [Grant Number 107-HCH003].

Compliance with ethical standards


Ling-Hsuan Meng works for Siemens Company as a medical scientist. Shun-Mao Yang, Kai-Lun Yu, Huan-Jang Ko, Kun-Hsien Lin, Yueh-Lun Liu, and Shao-En Sun have no conflicts of interest or financial ties to disclose.

Supplementary material

Video 1 The entire workflow of augmented fluoroscopy-guided lung marking and thoracoscopic resection. Supplementary material 1 (MP4 337868 kb)

Video 2 Comparison of true target-reaching and false target-reaching. The C-arm fluoroscopy is rotated to confirm that the catheter tip had reached the 3D-annotated target area. 3D, three-dimensional. Supplementary material 2 (MP4 46839 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Shun-Mao Yang
    • 1
    • 2
  • Kai-Lun Yu
    • 3
  • Kun-Hsien Lin
    • 4
  • Yueh-Lun Liu
    • 4
  • Shao-En Sun
    • 4
  • Ling-Hsuan Meng
    • 5
  • Huan-Jang Ko
    • 2
    Email author
  1. 1.Department of SurgeryNational Taiwan University Hospital and National Taiwan University College of MedicineTaipeiTaiwan
  2. 2.Department of SurgeryNational Taiwan University Hospital, Hsin-Chu BranchHsinchuTaiwan
  3. 3.Department of Internal MedicineNational Taiwan University Hospital, Hsin-Chu BranchHsinchuTaiwan
  4. 4.Department of Medical ImagingNational Taiwan University Hospital, Hsin-Chu BranchHsinchuTaiwan
  5. 5.Department of Advanced TherapySiemens HealthineersTaipeiTaiwan

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