P1.08-049 CT Guided Labeling with Indocyanine Green of Small Lung Nodules for Sublobar Resection Utilizing Robotic Assisted Thorascopic Surgery (RATS)

Abstract

Localization of deep and small pulmonary lung nodules undergoing a wedge or sublobar resection may be challenging during thoracoscopy, and may necessitate greater resection or conversion to thoracotomy. Particularly in robotic surgery, with the absence of tactile feedback. Percutaneous CT guided Indocyanine Green injection provides a means to pinpoint these nodules. A retrospective study of 40 consecutive patients who underwent preoperative CT-guided localization of solitary pulmonary nodules with ICG. Nodules ≤ 15mm were 21/40 (52.5%), ≤ 20mm 30/40 (75%), and ≤ 30mm 38/40 (95%). A 22-gauge spinal needle (BD, NJ) or Chiba needle (Cook, IA) was positioned into or adjacent to the nodule. 0.4cc Indocyanine Green was injected and the inner stylet withdrawn. The Xi daVinci robot (Intuitive Surgery, CA) was docked and the firefly filter of the 8mm camera was activated, and the nodule illuminates in a fluorescence green color. A wedge or sublobar resection was performed, with progression to lobectomy when indicated. CT guidance successfully localized the nodules in 100% of 40 patients employing this technique. Success was measured in nodule illumination as seen by the surgeon upon activation of the camera filter and confirmed on frozen and permanent section by pathology. Initial wedge resection for diagnosis prior to lobectomy and sublobar resection for decreased PFTs or decrease cardiac function were performed by Robotic Assisted Thoracoscopy (RATS). There were no conversions to thoracotomy. Diagnosis were adenocarcinoma in 18 patients (45%), squamous cell carcinoma in 7 patients (17.5%), carcinoid in 1 patient (2.5%), metastatic in 8 patients (20%), and benign in 6 patients (15%). There were no 30 or 90 day mortalities. A chest tube reinsertion in one patient for pneumothorax. Economically the cost for the vial of ICG is $79.56 compared to a fiducil marker at a cost of $128.00. Thoracic Surgery has access to CT scanners, without an extra cost, electromagnetic navigation systems come with significant added costs. Percutaneous CT guided labeling with ICG is quick and economical for the localization of small and deep nodules undergoing RATS wedge or sublobar resection. This technique may be supportive in preserving lung parenchyma and reduce the need for conversion to thoracotomy, maintaining minimal invasive thoracic surgery, especially where palpation or tactile feedback is absent.