Video-assisted thoracic surgery for tiny pulmonary nodules with real-time image guidance in the hybrid theatre: the initial experience

Image-guided video-assisted thoracoscopic surgery (iVATS): a single center experience and review

Lung cancer screening techniques using low-dose computed tomography (LDCT) scans have improved over the last decade. This means that there is an increased rate of detection of small, often non-palpable, nodules and ground-glass opacities. Obtaining a definitive diagnosis of these nodules using techniques such as percutaneous image-guided biopsy or intraoperative localization is challenging, and these nodules have traditionally undergone routine surveillance. Image-guided video-assisted thoracoscopic surgery (iVATS), which is performed in a hybrid operating room, has made it more feasible to biopsy and resect these nodules. The first thoracic surgery hybrid operative room was introduced at our institution at Brigham and Women's Hospital. Herein, we describe our experience implementing this technique including the methods we used to train key personnel such as radiologists, surgeons, and anesthesiologists to ensure that this technique successfully translated to a clinical setting. We review the benefits of iVATS, which includes decreased rate of fiducial dislodgement, real-time imaging which facilitates successful fiducial placement, and smaller sized resection of lung parenchyma. We will also describe the comparisons between traditional diagnostic methods and iVATS, patient selection criteria and important technical details. Some centers describe alternative techniques for several of the technical aspects, including patient positioning, which we also mention. Lastly, we describe adverse events after iVATS, which are comparable to those seen after a standard VATS.

Computer tomography guided thoracoscopic resection of small pulmonary nodules in the hybrid theatre

Purpose

Thoracic surgeons are currently asked to resect smaller and deeper lesions which are difficult to detect thoracoscopically. The growing number of those lesions arises both from lung cancer screening programs and from follow-up of extrathoracic malignancies. This study analyzed the routine use of a CT-aided thoracoscopic approach to small pulmonary nodules in the hybrid theatre and the resulting changes in the treatment pathway.

Methods

50 patients were retrospectively included. The clinical indication for histological diagnosis was suspected metastasis in 46 patients. Technically, the radiological distance between the periphery of the lesion and the visceral pleura had to exceed the maximum diameter of the lesion for the patient to be included. A spiral wire was placed using intraoperative CT-based laser navigation to guide the thoracoscopic resection.

Results

The mean diameter of the lesions was 8.4 mm (SD 4.27 mm). 29.4 minutes (SD 28.5) were required on average for the wire placement and 42.3 minutes (SD 20.1) for the resection of the lesion. Histopathology confirmed the expected diagnosis in 30 of 52 lesions. In the remaining 22 lesions, 9 cases of primary lung cancer were detected while 12 patients showed a benign disease.

Conclusion

Computer tomography assisted thoracoscopic surgery (CATS) enabled successful resection in all cases with minimal morbidity. The histological diagnosis led to a treatment change in 42% of the patients. The hybrid-CATS technique provides good access to deeply located small pulmonary nodules and could be particularly valuable in the emerging setting of lung cancer screening.

Use of the hybrid room for thoracic surgery procedures: single-stage localization and removal of non-palpable nodules

With the widespread availability of lung cancer screening programs, the number of small lung nodules requiring histological characterization has dramatically increased. Because computed tomography-guided fine-needle aspiration may frequently yield false-negative results, excisional biopsy using thoracoscopy is frequently required. Although thoracoscopic procedure has been known to be ideal for nodule resection, the identification of very small, subsolid and deep pulmonary nodules may still be challenging. Precise lesion localization is a key prerequisite to avoid conversion to an unplanned thoracotomy. In the traditional workflow, the localization procedure is performed in the radiology suite, after which the patient is moved to an operating room. With the availability of hybrid operating rooms, a new approach encompassing simultaneous localization and removal of non-palpable lung nodules has become feasible. In this article, we review the procedural workflow of this new technique and discuss its indications and results.

Hybrid Theater Facilitates Lung-Preserving Multimodal Treatment for Multiple Pulmonary Metastases

A patient with a history of hepatocellular carcinoma was found to have multiple pulmonary metastases. Staged treatments were combined into a single operation session in the hybrid theater, encompassing bronchoscopic microwave ablation of central right upper lobe lesions and uniportal surgical wedge resections of peripheral right middle lobe lesions. All lung metastases were successfully treated with adequate margin clearance. Microwave ablation under the guidance of electromagnetic navigation bronchoscopy in the hybrid theater is a novel contribution to the multimodal operative management of multiple pulmonary neoplasms. It is a unique choice for patients with multilobar, subcentimeter metastases, and with concerns about lung function preservation.

Uniportal VATS approach to sub-lobar anatomic resections: literature review and personal experience

Surgical scientific literature contains relatively little information regarding the surgical outcomes of anatomic sublobar resections performed with the uniportal video-assisted thoracoscopic surgery (U-VATS) technique. This paper attempts to evaluate the role of U-VATS segmentectomies in the landscape of a minimally invasive approach to the treatment of early stage non small cell lung cancer (NSCLC).

Image-guided video-assisted thoracoscopic surgery with Artis Pheno for pulmonary nodule resection

Background

One challenging aspect of video-assisted thoracoscopic surgery (VATS) is finding the small pulmonary lung nodules for resection. Pre-operative localization of nodules is important for resection. Recently, image-guided VATS (iVATS) in a hybrid room has received attention. Our study aims to compare pros and cons between traditional CT room localization and iVATS localization with Artis Pheno.

Methods

This study was a retrospective analysis in our institute (Changhua Christian Hospital, Changhua). Patients with pulmonary nodules who received localization between January 2018 and December 2018 were included in the study. There were 126 patients included in the study. Among these, 63 patients received localization in a CT room and the other 63 patients received iVATS. We measured the time from localization to skin incision, success rate, complication rate, operation time, blood loss and length of hospital stay.

Results

Time from localization to skin incision was significantly shorter in the iVATS group than in the CT room group (23.57 vs. 372.11 min, P<0.001). The CT room group had a significantly higher complication rate than the iVATS group (n=49, 77.8% vs. n=2, 3.2%, P<0.001). There were no significant differences in operation methods, operation time, blood loss and length of hospital stay.

Conclusions

iVATS provides shorter time from localization to skin incision and fewer complications than CT room localization.

Comparison of CT-guided localization using hook wire or coil before thoracoscopic surgery for ground glass nodules

OBJECTIVE

To compare two kinds of metal markers for preoperative localization of ground glass nodules (GGNs).

METHODS

We retrospectively investigated data from 198 cases of GGN localization and compared the success rate and complications of both approaches.

RESULTS

In the hook wire and coil groups, the success rates of CT-guided localization for GGNs were 99.2 and 98.7%, respectively (p = 1.000). The success rates of video-assisted thoracoscopic surgery in both groups were 100% without transthoracic surgery. The post-localization complication rates in the hook wire group and coil group were 36.9 and 32.9% (p = 0.568), and the postoperative complication rates in the hook wire and coil groups were 13.9 and 11.8%, respectively (p = 0.672).

CONCLUSIONS

Preoperative localization of GGNs with both hook wire and coil methods proved to be useful and effective. Both methods have acceptable preoperative and postoperative complication rates, but the localization and operation times were shorter for the hook wire group than the coil group.

ADVANCES IN KNOWLEDGE

Most of previous articles studied a single preoperative localization method. Few studies have compared the preoperative and postoperative methods for metal markers. This paper compared two preoperative localization methods for GGNs to provide clinical guidance.

Devising the guidelines: the techniques of pulmonary nodule localization in uniportal video-assisted thoracic surgery-hybrid operating room in the future

Pulmonary nodules beneath the pleura can be hard to visualize or palpate, especially during the uniportal thoracoscopic surgery. Conventionally, thoracic surgeons would use adjuvant modalities to localize the lesion preoperatively, of which computed tomography-guided hookwire implantation has been adopted most widely due to its feasibility and high success rate. However, procedure-associated complications such as pneumothorax and wire dislodgement can cause patient discomfort or localization failure. Occasionally more healthy tissue is resected than needed to guarantee the lesion is removed and with an adequate margin. A thoracotomy is necessary for specific scenario. With the development of imaging technology, it is now possible to replace the traditional workflow carried out in the radiology suite by centralizing the hookwire placement and uniportal minimally-invasive pulmonary resection inside the hybrid theater which equipped with advanced imaging devices. Theoretically, the advanced intra-operative imaging-guided techniques help to precisely locate and resection pulmonary lesion in a potentially tissue-sparing and quick paradigm.

Uniportal VATS Coil-Assisted Resections for GGOs

Backgrounds

Although uniportal video-assisted thoracic surgery (VATS) theoretically allows the direct palpation of any zone of the lung through a small incision, sometimes it can be difficult to localize pure ground-glass opacities anyway. The aim of this study is to evaluate the usefulness and safety of preoperative computed tomography (CT)-guided microcoil localization of GGO nodules in patients undergoing uniportal VATS lung resection.

Methods

The clinical data and CT images of 30 consecutive patients (30 pulmonary nodules) who underwent preoperative CT-guided coil localization and subsequent uniportal VATS resection, from January 2017 to October 2018, were reviewed.

Results

All the CT-localization procedures have been performed with success (30/30) and the mean procedure time was 35±15 minutes. The mean size of the nodules was 15,53±6,72 mm, and the mean distance of the nodules from the pleural surface was 19,08±12,08 mm. Eleven nodules (36,7%) were pure ground-glass opacities and 19 (63,3%) were mixed ground-glass with a solid component of 50% or more. In 5 cases, the localization procedure was complicated by asymptomatic pneumothoraxes and in 1 case the pneumothorax required chest tube insertion. In any case a conversion to thoracotomy was avoided because all nodules were identified and resected through uniportal VATS.

Conclusions

Preoperative CT-guided coil localization seems to be a feasible, safe, and accurate procedure. It makes uniportal VATS an easy approach even for resecting small, deep, and impalpable nodules.