Preoperative small pulmonary nodule localisation using hookwires or coils: strategy selection in adverse events

OBJECTIVE

This is a retrospective study of adverse events associated with preoperative computed tomography (CT)-guided hookwire or coil localisation. We analysed the experience and process flaws in resecting ground-glass nodules (GGNs) through video-assisted thoracoscopic surgery (VATS) and determined the remedial strategy.

METHODS

Adverse events were evaluated in 40 patients with 45 GGNs who underwent CT-guided hookwire or coil localisation before VATS. For lesions not successfully marked or detected, palpation, resection of the highly suspected area, segmentectomy or lobectomy was performed.

RESULTS

Among all adverse events, 15 were dislodgement of the marking materials, 5 were breakaway of the marking materials, 7 were > 2 cm distance between the lesions and the tips, 3 was marking material across the two adjacent lobes, 15 were pneumothorax and 2 were certain parts of marking materials stuck into the chest wall. All GGNs were resected successfully. 20 lesions were detected by palpation. 9 GGNs were discovered after the resection of highly suspected areas. Segmentectomies and lobectomies were performed directly on 7 and 9 GGNs, respectively.

CONCLUSIONS

When adverse events occur, a second intraoperative localisation, by resecting the highly suspected area either through non-anatomical resection (wedge resection) or anatomical resection (segmentectomy or lobectomy) using the VATS should be considered the alternatives for GGNs localization.

[Preliminary Study of CT Three-dimensional Reconstruction Combined with Ground Glass Nodules of Natural Lung Collapse in Thoracoscopic Pulmonary Segmental Resection]

BACKGROUND

Computed tomography (CT) three-dimensional reconstruction technology is increasingly used in preoperative planning of patients with ground glass nodule (GGN), but how to accurately locate the nodule and ensure the safe resection edge is still a difficult problem for clinicians. The purpose of this study was to investigate the accuracy, convenience and safety of CT three-dimensional reconstruction combined with intraoperative natural collapse localization in total thoracoscopic segmental pneumonectomy.

METHODS

A total of 45 patients with radiographic findings of pulmonary GGN admitted from July 2019 to December 2019 were selected as the study group. All patients received thin-slice CT scan and underwent preoperative three-dimensional reconstruction. After anesthesia, the small thoracic operation opening and the airway of the patients were quickly opened, and the lung was rapidly and naturally collapsed by pressure difference. GGN were positioned according to the natural marker line, and marked with 3-0 prolene line. After specimen removal, the distance between the GGN and the suture mark, the distance between the GGN and the incision margin were measured, and the incision margin was routinely examined. The general clinical data, pathological data and postoperative complications were counted and compared with 45 consecutive patients who were located with hookwire positioning needle in the same period.

RESULTS

The average localization time of non-invasive GGN with natural lung collapse during operation was 6.9 min, and the localization accuracy was 90.6%. There were 2 cases of extensive pleural adhesion and 1 case of emphysema. Postoperative pathology was confirmed as lung adenocarcinoma, and the examination of incision margin was negative. No GGNs were scanned again after surgery, and the precise resection rate of lung segment was 100.0%.

CONCLUSIONS

CT three-dimensional reconstruction combined with GGN localization of natural lung collapse during operation can shorten the time of searching for GGN during operation and guarantee the safety of the incision margin. It is a more economical and convenient localization method and makes pulmonary segment resection more accurate.

[Preliminary Application of Body Surface Theodolitic Puncture Localization Method in Thoracoscopic Surgery of Pulmonary Ground-glass Nodules]

背景与目的

肺磨玻璃结节在胸腔镜手术中如何定位是微创胸外科的重要临床课题, 目前尚无统一的定位方法。本研究拟探讨体表经纬法穿刺定位法在电视胸腔镜肺磨玻璃结节手术中肺结节定位的准确性及安全性。

方法

回顾性分析2018年8月-2019年12月期间我院收治的41例肺磨玻璃结节患者的临床资料, 其中男性28例, 女13例。患者于麻醉后采用体表经纬法穿刺法定位, 然后行胸腔镜下部分肺叶切除术。对手术切除标本测量结节至标记缝线距离和结节至切缘的距离, 统计定位准确率、并发症率和手术切除成功率。

结果

采用体表经纬法穿刺定位法对41例患者共51枚结节进行定位, 准确率达96.1%, 平均定位时间8.3 min。有5例(12.2%)出现穿刺出血, 均胸腔镜下成功止血, 无其他并发症出现。所有患者行胸腔镜部分肺叶切除术, 其中33例行解剖性肺段切除, 8例行肺叶楔形切除术, 手术过程均顺利。测量结节与切缘的距离, 所有标本均 > 2 cm, 达到安全距离, 手术切除成功率100.0%。

结论

在电视胸腔镜肺磨玻璃结节手术中, 体表经纬穿刺定位法是准确、安全、简便的定位方法。

Instrumental palpation in endoscopic renal surgery: case reports and analysis

Palpation is one of the classic examination methods in open surgeries. In minimally invasive surgery, intra-operational manual palpation is impossible to use for assessing tactile characteristics of tissues. In Russia, the only available instrument for intra-operational assessment and objective registration of tissue visco-elastic properties is the Medical Tactile Endosurgical Complex (MTEC). The aim of this work was to study the performance of MTEC in renal surgery. The study was performed during nine elective laparoscopic surgeries for clear cell renal carcinoma and simple renal cysts. We have found several differences in the use of MTEC in renal surgery, as compared to its use in gastrointestinal or lung surgeries. The key factor determining these differences was the inverse relations between tissue visco-elastic properties: the studied tumors were softer than the surrounding tissue. Detection of intraparenchymal tumors by tactile methods was impossible. For surface tumors, in one case out of nine it was possible to strictly locate the border of the tumor by tactile examination. We were able to quantitatively assess and determine the difference in hardness of tumors and intact tissue using MTEC. This allows studying the prognostic value of objectively registered tactile characteristics of renal tumors.

Instrumental Mechanoreceptoric Palpation in Gastrointestinal Surgery

Background and Aims

Small gastric or colorectal tumours can be visually undetectable during laparoscopic surgeries, and available methods still do not provide a 100% localisation rate. Thus, new methods for further improvements in tumour localisation are highly desirable. In this study, we evaluated the usage of the Medical Tactile Endosurgical Complex (MTEC) in gastrointestinal surgery for localisation of tumours. The MTEC provides the possibility of instrumental mechanoreceptoric palpation, which serves as an analogue of conventional manual palpation.

Methods

Ninety-six elective surgeries were performed, including 48 open surgeries, 43 laparoscopies, and 5 robot-assisted surgeries. The 20 mm version of the MTEC tactile mechanoreceptor was used in open surgeries, and the 10 mm version in laparoscopic and robot-assisted surgeries.

Results

The mean time of instrumental mechanoreceptoric palpation was 3 minutes 12 seconds for open surgeries, which constituted the early stage of the learning curve, and 3 minutes 34 seconds for laparoscopic surgeries. No side effects or postoperative complications related to instrumental mechanoreceptoric palpation were observed, and this procedure provided data sufficient for tumour localisation in more than 95% of cases.

Conclusion

Instrumental mechanoreceptoric palpation performed using MTEC is a simple, safe, and reliable method for tumour localisation in gastrointestinal laparoscopic surgery.

An autoclavable wireless palpation instrument for minimally invasive surgery

Minimally invasive surgery prevents surgeons from manually palpating organs to locate subsurface tumors and other structures. One solution is to use ultrasound; however, it is not always reliable. Various minimally invasive surgery instruments that provide tactile feedback have been proposed to augment ultrasound sensing for tumor localization; however, current designs have limitations such as cumbersome wiring, difficulty in manipulation, lack of sterilizability and high cost. This paper presents a novel, autoclavable, wireless, hand-held palpation instrument that uses a custom, low-cost, disposable tactile sensor to provide tactile and kinesthetic force feedback. The use of a replaceable, disposable tactile sensor avoids deterioration in sensor performance due to repeated autoclaving. The instrument features a passive joint in the end effector that allows the sensor to self-align to the palpation surface in a wide range of orientations. All of the electronics are packaged in a removable module that allows the rest of the instrument to be easily cleaned and autoclaved. Two versions of the tactile sensor, using piezoresistive sensing and capacitive sensing respectively, have been designed for use with this instrument. The instrument is shown to be able to detect 6 mm diameter spherical tumors at a depth of 9-10 mm in ex vivo tissue samples.

Supplement CT-Guided Microcoil Placement for Localising Ground-glass Opacity (GGO) Lesions at "Blind Areas" of the Conventional Hook-Wire Technique

BACKGROUND

In the conventional hook-wire technique of pulmonary nodular localisations there are several "blind areas", including the mediastinum-vicinity region, interlobar fissure-neighbouring areas and scapulae-shadowed areas. The present study aims to summarise the experiences of CT-guided microcoil placement as an alternative method for localising pulmonary ground-glass opacity (GGO) lesions before thoracoscopic wedge resections.

METHODS

Sixteen GGO lesions at "blind areas" in 16 patients were localised with platinum-fibered microcoils under CT assistance before undergoing video-assisted thoracoscopic surgical resections. Information regarding coil placement, operations and complications was recorded.

RESULTS

Of all lesions, 1 was in the mediastinum-vicinity region, 8 were covered by the scapulae, and 7 were close to interlobar fissures (3 horizontal fissures, 4 oblique fissures). All 16 (100%) lesions had been successfully marked with microcoils. No major complications of the puncture procedure occurred; there were only minor pneumothorax (n=2) and haemoptysis (n=1) complications, which required no intervention before operations. All GGO lesions and microcoils were successfully removed by initial wedge resections. Of the 16 lesions in "blind areas", 8 were adenocarcinoma in situ (AIS), 4 were minimally invasive adenocarcinoma (MIA), 3 were atypical adenomatous hyperplasia (AAH), and 1 was interstitial fibrous tissue proliferation. No major complications occurred postoperatively.

CONCLUSIONS

For the "blind areas" of the hook-wire technique, CT-guided microcoil placement is an effective method of marking GGO lesions that makes thoracoscopic wedge resection easier.

Instrumental tactile diagnostics in robot-assisted surgery

BACKGROUND

Robotic surgery has gained wide acceptance due to minimizing trauma in patients. However, the lack of tactile feedback is an essential limiting factor for the further expansion. In robotic surgery, feedback related to touch is currently kinesthetic, and it is mainly aimed at the minimization of force applied to tissues and organs. Design and implementation of diagnostic tactile feedback is still an open problem. We hypothesized that a sufficient tactile feedback in robot-assisted surgery can be provided by utilization of Medical Tactile Endosurgical Complex (MTEC), which is a novel specialized tool that is already commercially available in the Russian Federation. MTEC allows registration of tactile images by a mechanoreceptor, real-time visualization of these images, and reproduction of images via a tactile display.

MATERIALS AND METHODS

Nine elective surgeries were performed with da Vinci™ robotic system. An assistant performed tactile examination through an additional port under the guidance of a surgeon during revision of tissues. The operating surgeon sensed registered tactile data using a tactile display, and the assistant inspected the visualization of tactile data. First, surgeries where lesion boundaries were visually detectable were performed. The goal was to promote cooperation between the surgeon and the assistant and to train them in perception of the tactile feedback. Then, instrumental tactile diagnostics was utilized in case of visually undetectable boundaries.

RESULTS

In robot-assisted surgeries where lesion boundaries were not visually detectable, instrumental tactile diagnostics performed using MTEC provided valid identification and localization of lesions. The results of instrumental tactile diagnostics were concordant with the results of intraoperative ultrasound examination. However, in certain cases, for example, thoracoscopy, ultrasound examination is inapplicable, while MTEC-based tactile diagnostics can be efficiently utilized.

CONCLUSION

The study proved that MTEC can be efficiently used in robot-assisted surgery allowing correct localization of visually undetectable lesions and visually undetectable boundaries of pathological changes of tissues.

CT-guided microcoil VATS resection of lung nodules: a single-centre experience and review of the literature

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is standard of care for small lung resections at many centres. Computed tomography (CT)-guided insertion of microcoils can aid surgeons in performing VATS resections for non-palpable lung nodules deep to the lung surface.

METHODS

Retrospective analysis of CT-guided microcoil insertions prior to VATS lung resection at a single institution from October 2008 to January 2014.

RESULTS

A total of 63 patients were included (37% male, mean age 61.6±11.4 years). Forty-two patients (67%) had a history of smoking, with 10 current smokers. Sixty one (97%) patients underwent wedge resection and 3 (5%) patients had segmentectomy. Three (5%) patients required intra-operative staple line re-resection for positive or close margins. Eleven (17%) patients had a completion lobectomy, 5 of which were during the same anaesthetic. The average time between the CT-guided insertion and start of operation was 136.6±89.0 min, and average operative time was 84.0±53.3 min. The intra-operative complication rate was 5% (n=3), including 1 episode of hemoptysis, and 2 conversions to thoracotomy. The post-operative complication rate was 8% (5 patients), and included 2 air leaks, 1 hemothorax (drop in hemoglobin), 1 post chest tube removal pneumothorax, and one venous infarction of the lingula after lingula-sparing lobectomy requiring completion lobectomy. . Average post-operative length of stay was 2.2 days. A diagnosis was made for all patients.

CONCLUSIONS

CT-guided microcoil insertion followed by VATS lobectomy is safe, with short operative times, short length of stay and 100% diagnosis of small pulmonary nodules. This technique will become more important in the future with increasing numbers of small nodules detected on CT as part of lung cancer screening programs.