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Image-guided VATS (iVATS) workflow (13). (I) Preoperative planning on traditional computed tomography; (II) iVATS procedure was performed in a hybrid OR, with a C-arm CBCT and a Magnus surgical table; (III) After anesthesia, the patient was placed in the planned position; (IV) Pre-procedural CBCT scan for needle path planning; (V) Needle entry guided by laser-target cross; (VI) Post-procedural CBCT scan for needle path confirmed; (VII) Tumor resection with hook wire guided. Available online: http://www.asvide.com/articles/1752
Source publication
Background:
This case series demonstrated the feasibility of the image-guided video-assisted thoracoscopic surgery (iVATS) for localization and removal of ground glass opacities (GGOs). The procedure was performed in a hybrid operating room (OR) using C-arm cone-beam computed tomography (CBCT) equipped with a laser-guided navigation system.
Metho...
Citations
... From this perspective, CBCT can monitor the diagnosis and treatment process in real time and determine the interaction between the biopsy tool and the target lesion, so as to increase the accuracy of the diagnosis. In addition, studies [27,28] showed that GGOs are perfectly visible and able to localize on intraoperative CBCT images. Chen et al. [29] further reported that CBCT imaging can provide real-time confirmation of "tool-in-lesion" during transbronchial ablation so that the device position can be adjusted accordingly based on 3D images of tool position with respect to GGO nodules. ...
Objective
Transbronchial biopsy is a safe manner with fewer complications than percutaneous transthoracic needle biopsy; however, the current diagnostic yield is still necessitating further improvement. We aimed to evaluate the diagnostic yield of using virtual bronchoscopic navigation (VBN) and cone-beam CT (CBCT) for transbronchial biopsy and to investigate the factors that affected the diagnostic sensitivity.
Methods
We retrospectively investigated 255 patients who underwent VBN-CBCT-guided transbronchial biopsy at our two centers from May 2021 to April 2022. A total of 228 patients with final diagnoses were studied. Patient characteristics including lesion size, lesion location, presence of bronchus sign, lesion type and imaging tool used were collected and analyzed. Diagnostic yield was reported overall and in groups using different imaging tools.
Results
The median size of lesion was 21 mm (range of 15.5–29 mm) with 46.1% less than 2 cm in diameter. Bronchus sign was present in 87.7% of the patients. The overall diagnostic yield was 82.1%, and sensitivity for malignancy was 66.3%. Patients with lesion > 2 cm or with bronchus sign were shown to have a significantly higher diagnostic yield. Four patients had bleeding and no pneumothorax occurred.
Conclusion
Guided bronchoscopy with VBN and CBCT was an effective diagnostic method and was associated with a high diagnostic yield in a safe manner. In addition, the multivariant analysis suggested that lesion size and presence of bronchus sign could be a predictive factor for successful bronchoscopic diagnosis.
... However, histopathological evaluations of GGOs resected via iVATS have identified that 57-95% of these nodules are malignant. Most were primary lung cancer, but metastatic GGOs were discovered as well (9,(19)(20)(21)(22)(23)(24). The primary malignant nodules were mostly well-differentiated adenocarcinoma (with predominant subtype of non-lepidic) (25,26). ...
... Some centers have reported prone or supine positioning based on the location of the nodule. This may be helpful for obese patients (9,18,(20)(21)(22)32). ...
... Alternatively, PBV is cheaper. Many studies have reported the use of PBV for superficial nodules (pleural distance <20 mm) or for GGOs with a 100% success rate (20,22,25), while others have favored ICG due to the aforementioned advantages (21,23). ...
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.
... Aucune complication n'a été liée directement à la procédure de localisation ; en comparaison le gold standard (hameçon, coil, lipiodol) est entaché d'un taux de complication de plus de 30%, principalement lié à des hémothorax et pneumothorax 63,79 . Notre procédure est plus rapide que les techniques utilisant le CBCT pour mettre en place des dispositifs de localisation percutanés : notre durée de localisation moyenne est de 13 minutes, comparée à des procédures durant de 18 à 39 min rapportées dans la littérature74,75,79,81,88,[123][124][125][126] . Malgré une erreur de localisation pour un patient, notre taux de succès est comparable aux autres techniques (98% versus 91%-100% 9,106-113 ).Du point de vue du chirurgien, l'unité de lieu et de temps est également un avantage : il n'est pas nécessaire d'avoir recours à un scanner ni à un radiologue interventionnel. ...
Le cancer broncho-pulmonaire est un problème de santé publique, représentant la première cause de mortalité par cancer. La chirurgie a une place fondamentale dans sa prise en charge, représentant son seul traitement curatif. Avec le développement des programmes de dépistage, non seulement va augmenter le nombre de diagnostics de cancer pulmonaire, mais surtout le nombre de formes précoces et opérables. Le gold standard de leur prise en charge chirurgicale est maintenant l’approche mini-invasive : la VATS – Video Assisted Thoracic Surgery. Or dans certaines situations (nodule profond, faiblement dense, de petite taille), leur localisation et a fortiori leur résection peut s’avérer complexe. On a alors recours à des dispositifs de localisation. Ceux-ci sont actuellement invasifs en grande majorité, pourvoyeur de difficultés organisationnelles et techniques mais aussi de complications. Dans ce travail, nous détaillons l’élaboration d’une procédure de localisation intra-opératoire alternative strictement basée sur l’image. Le pneumothorax induit par la chirurgie est un frein majeur à l’utilisation de méthodes de recalage traditionnelles, basées sur les scanners pré-opératoires. De ce fait, notre approche repose sur l’utilisation d’une imagerie intra-opératoire acquise en salle hybride, le CBCT. Nous détaillons dans un premier temps les contraintes techniques à l’acquisition intra-opératoire des CBCT ainsi qu’une analyse de ceux-ci. Dans une deuxième partie nous proposons une approche de recalage reposant sur une approche hybride, basée sur l’image et sur un modèle biomécanique, de déformation du poumon. Nous présentons enfin une méthode de localisation en réalité augmentée basée sur les CBCT intra-opératoires. Il s’agit d’une technique innovante, non invasive, strictement basée sur l’image démontrant un intérêt clinique certain et offrant de nombreuses perspectives d’optimisation.
... [8] Subsequently, various iVATS-related studies have been published. [9][10][11][12][13][14][15] Generally speaking, small pulmonary nodules are first located using CT in the radiology department, followed by surgical resection in the operating room (OR). [16] However, this two-stage approach is associated with a superficial risk of complications, including pneumothorax (4.6%) and pulmonary hemorrhage (10.3%). ...
Background: The separated preoperative computed tomography-guided localization of multiple ipsilateral pulmonary nodules was difficult and with various complications, including pneumothorax and hemothorax. The introduction of image-guided video-assisted thoracoscopic surgery (iVATS) which combined intraoperative localization and the following VATS has solved these difficulties. The study examines the feasibility of using the ARTIS pheno system to localize multiple ipsilateral pulmonary nodules and the related complications.
Materials and Methods: Retrospective analysis of iVATS using the ARTIS pheno dye-based localization for multiple ipsilateral lung nodules at a single institution from June 2018 to July 2021.
Results: Totally 84 patients with 190 resected nodules were enrolled. 31 (37%) were men and 40 (48%) patients with a history of malignancy. The average localization procedure time was 16 min (interquartile range [IQR]: 13–19 min), and 4 (4.8%) patients developed slight pneumothorax after localization. The overall localization success rate was 99.5%, and one failed due to dye overflow on the lung surface. Among localized nodules, 89 (47%) were ground-glass opacities (GGOs), 97 (51%) were subsolid GGOs, and 4 (2%) were substantive nodules. 139 (73%) nodules were malignant, and 51 (27%) were benign. The average length of hospital stay was 5 days (IQR: 4–8 days).
Conclusion: The utilization of the ARTIS pheno system is safe and feasible for performing dye localization of multiple ipsilateral pulmonary nodules. Thoracic surgeons can complete multiple needle punctures in a single end-inspiratory apnea period, reducing localization procedure times, and complication risks.
... iVATS is a useful adaptation of conventional VATS wedge resection allowing localization of smaller, nonsolid nodules. 9,21,22 It is particularly useful for lesions <10 mm in diameter and GGOs or semisolid lesions where manual palpation by conventional VATS would be challenging or impossible. Our technique of coil localization clearly demonstrates the location of the lesion on entry into the chest. ...
Objectives
To demonstrate the feasibility and preliminary outcomes of a novel hybrid technique combining percutaneous microwave ablation and wire-assisted wedge resection for managing patients with multiple pulmonary metastasis using intra-operative imaging.
Methods
We describe our technique and present a retrospective case series of 4 patients undergoing iCART at our institution between August 2018 – January 2020. Procedures were performed in the hybrid operating suite using the Siemens ARTIS Pheno® cone beam computerized tomography scanner. Patient information included past history of malignancy and lesion size, depth, location and histological result. Surgical complications and length of stay were also recorded.
Results
Five procedures were performed on 4 patients during the study period. One patient underwent bilateral procedures 4 weeks apart. All patients underwent at least one ablation and one wedge resection during the combined procedure. Patient ages ranged from 40 – 66 years and the majority (75%) were male. All had a past history of cancer. Lesions were treated in every lobe. Size and depth ranged from 6 – 24 mm and 21 – 33 mm respectively for ablated nodules and 5 – 27 mm and 0 – 22 mm respectively for the wedge resected nodules. Three procedures were completed uniportal and operative time ranged from 51 – 210 minutes. All cases sustained <10ml blood loss. There were two intra-operative pneumothorax, one prevented successful completion of the ablation. One patient required a prolonged period of post-operative physiotherapy and was discharged on day 6. The other patients were discharged on post-operative day 2 or 3. All 5 histological specimens confirmed metastatic disease.
Conclusions
Our hybrid approach provides a minimally-invasive and comprehensive personalized therapy for patients with multiple pulmonary metastasis under a single general anesthetic. It provides histological diagnosis whilst minimizing lung tissue loss and eliminating the need for transfer from radiology to theatre. Emergence of ablation as a treatment for stage 1 non-small cell lung cancer and the expansion of lung cancer screening may widen the application of iCART in the future.
... Nowadays, iVATS is gaining popularity, and some studies demonstrate the feasibility of iVATS wedge resection. [8][9][10][11][12][13][14] The intraoperative percutaneous placement of markers in HOR promises to overcome the more common issues associated with the traditional 2-stage workflow (performed in the radiology suite and standard operating room), including patient discomfort, the need to coordinate between services, and the long time interval between CT-guided localization and surgery. An extended delay in surgery after localization may result in an increased risk of complications, such as pneumothorax or marker dislodgement. ...
... In literature, the localization rate of iVATS ranges between 92% and 100%. [7][8][9][10][11][12][13][14]26 We observed a localization rate of 92.3% and an overall iVATS success rate of 79.5%. iVATSoutcomesinthepreviousstudiesarevariablydefined. ...
Objective:
We report our experience with simultaneous localization and thoracoscopic removal for nonpalpable undiagnosed pulmonary nodules.
Methods:
All patients with nonpalpable lesions requiring video-assisted thoracoscopic surgery (VATS) wedge resection underwent localization of the targets and surgical removal in a hybrid operating room. Lesions were considered nonpalpable if they were small (<1 cm), deep (>1 cm from the surface), subsolid, or located within a dystrophic area. In all cases, intraoperative cone-beam computed tomography was performed for nodule localization and targeting, metal hookwires, or coils were alternatively used for intraoperative marking.
Results:
From April 2016 to November 2019, 39 image-guided VATS (iVATS) were performed. The mean lesion size was 12 ± 6 mm. The mean distance from the deep edge of the lesion to the pleural surface was 24 ± 9 mm. The localization was performed with 20 hookwires and 19 coils. iVATS localization was successful in 36 patients (92.3%). Thirty-seven wedge resections were completed by VATS, 2 (5%) required conversion to thoracotomy. In 9 patients with intraoperative diagnosis of lung cancer, a lobectomy was performed (7 VATS and 2 thoracotomies). Mean length of iVATS localization was 30 ± 13 minutes. Median postoperative length of stay was 4 days (IQR 3 to 5).
Conclusions:
iVATS seems to be a helpful tool for simultaneous localization and removal of nonpalpable nodules. A versatile approach using different devices seems advisable for the removal of targets in every clinical scenario reducing VATS conversion rate. Future research is required to compare iVATS with traditional preoperative localization techniques.
... We tried these three methods, and we preferred methyl blue dying because it saves time and costs less for patients. Initially, we tried injections of 0.5 mL methyl blue according to suggestions from previous studies (8,16). However, we found the dye spread out to the whole lobe, which caused difficulty in making the appropriate 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.
... T h e w o r k f l o w f o r C T-g u i d e d p u l m o n a r y l e s i o n localization has been described in several published studies (4,(7)(8)(9)(10)(11). First, patients should be intubated (either with a single-or a double-lumen tube) and placed under general anesthesia. ...
Video-assisted thoracic surgery (VATS) requires preoperative computed tomography (CT)-guided localization of small pulmonary nodules or ground glass opacities (GGOs). However, this traditional two-stage approach is not devoid of potential complications, including wire dislodgement, pneumothorax, and/or hemothorax. With the advent of hybrid operating rooms (HORs), simultaneous single-stage localization and removal of such lesions has become possible. Here, we review the technical developments and the state-of-the-art in the field of intraoperative CT-guided localization and resection of small pulmonary nodules performed within a HOR.
... Localization is traditionally performed in a CT suite before the patient is transferred to the operating room (OR) [7][8][9]. With the increasing availability of hybrid ORs, tumour localization and removal in a single stage under the guidance of intraoperative CT (IOCT) is gaining popularity [10][11][12]. The use of IOCT for localization of small pulmonary nodules may offer an improved surgical workflow associated with a more patient-centred approach. ...
Objectives:
With the increasing availability of hybrid operating rooms, single-stage tumour localization and removal under intraoperative computed tomography (CT) guidance is gaining popularity. The objective of this study was to describe the learning curve for this procedure.
Methods:
Over a 15-month period, a single team of thoracic surgeons without experience in intraoperative CT-guided lung tumour localization performed a total of 91 procedures in 89 patients. All these procedures were conducted in a hybrid operating room equipped with cone-beam CT and a laser navigation system. The learning curve was analysed using the cumulative sum method (target success rate 90%), whereas the moving average was used as an indicator of localization time.
Results:
The mean lung tumour size on preoperative CT images was 7.81 mm, whereas their mean distance from the pleural surface was 10.16 mm. The localization time (mean 21.19 min) was inversely associated with the surgeon's experience (Pearson's r = -0.6601; P < 0.001). The moving average analysis revealed that localization time stabilized after 32 procedures. There were 6 failures; of these, 2 occurred during lesion localization (as a result of needle puncture-related pneumothorax) and 4 during surgery (caused either by wire dislodgement or dye spillage). The cumulative sum analysis revealed that proficiency was achieved after 38 procedures. The mean localization time and success rates before and after procedure 38 were 32.13 min vs 13.34 min (P < 0.001) and 86.8% vs 98.1% (P = 0.078), respectively.
Conclusions:
The procedural time and success rates of intraoperative CT-guided lung tumour localization were optimized after 38 consecutive procedures.
Background:
The minimally invasive management of sub-centimetric and often sub-solid lung lesions is quite challenging for thoracic surgeons. As a matter of fact, thoracoscopic wedge resection can often require conversion to thoracotomy when pulmonary lesions cannot be visually identified. Hybrid operating rooms (ORs) can serve as a helpful tool in a multidisciplinary setting, providing real-time lesion imaging and targeting, allowing preoperative or intraoperative percutaneous placement of different lesions targeting techniques to help locate non-palpable lung nodules during video-assisted thoracic surgery. The aim of the study is to assess whether the lung nodule marking using methylene blue, indocyanine green, and gold seeds - the "triple-marking technique" - in the hybrid OR is effective in helping locate non-visible or palpable nodules.
Methods:
We conducted a retrospective study on 19 patients with non-palpable lung lesions requiring VATS wedge resection and underwent lesional targeting in the hybrid operating room with different marking systems, including gold seeds placement, methylene blue, or indocyanine green. Lesions were considered non-palpable due to sizing, radiological subsolid aspect, or location and then identified using intraoperative CT scans, also allowing to elaborate needle trajectory. The intraoperative diagnosis was obtained in all of the patients guiding the type of surgery performed.
Results:
The radio-opaque gold seed marker was used in all of the patients except for two cases that developed intraprocedural pneumothoraces with no major consequences. In these patients, the nodule marking using dyes was still performed and successful in allowing to locate the lesion. Methylene blue and indocyanine green were always used in combination during the dye-targeting phase. Methylene blue appeared to be non-visible in two patients. The indocyanine green was correctly visualized in every patient. We observed the gold seed dislocation in two patients. We were able to identify the lung lesion in all the patients correctly. No conversion was needed. No allergic reactions were observed due to dye administration, and no prophylaxis was performed prior to lesional marking. The lung lesions were visually identified in 100% of the patients thanks to at least one marking technique.
Conclusions:
Our experience confirms that the hybrid operating room can represent a suitable tool in helping locate hard-to-find lung lesions in planned VATS resections. Using different techniques, a multiple marking approach seems advisable to maximize the lung lesions detecting rate by direct vision, therefore reducing the VATS conversion rate.
