Resection Of Small Pulmonary Nodules Research Articles

The use of an RFID marking system after adhesion debridement for tumor localization, identification, and accurate resection of small pulmonary nodules.

The use of an RFID marking system after adhesion debridement for tumor localization, identification, and accurate resection of small pulmonary nodules.

A novel localization device for small pulmonary nodules in thoracoscopic wedge resection with adequate margin distance: a retrospective study.

Thoracoscopic wedge resection of small pulmonary nodules (SPNs) is a common surgical procedure. Adequate surgical margin distance is challenging and key to successful resection for malignant nodules. The aim of this study was to evaluate the feasibility of a novel localization needle in wedge resection for SPNs with adequate margin distance. A retrospective review of needle localization cases from November 2021 to August 2022 was performed, in which 58 patients who underwent modified computed tomography (CT)-guided needle localization following thoracoscopic wedge resection were enrolled. Nodules were localized by placing a novel device characterized by a 4-hook anchor and a tricolored suture with a scale. The clinical characteristics were collected to evaluate the feasibility of the procedure in obtaining a sufficient margin distance. A total of 68 SPNs were collected, and the median size of SPNs was 10.0 mm with a median depth of 18.9 mm. Needle localization was successful in 65 nodules (95.6%), and all nodules were completely removed. The median resection margin distance was 14 mm (range, 8-26 mm). There were 62 (91.2%) SPNs with a margin distance to tumor size ratio ≥1, 38 (92.7%) SPNs with a depth <20 mm, and 24 (88.9%) SPNs with a depth ≥20 mm, respectively. Regardless of the nodule depth, the median resection margin distances were both 14 mm. This study indicated that modified preoperative CT-guided 4-hook needle with scaled suture localization is a safe, efficient strategy for the wedge resection of SPNs via thoracoscopic surgery. Furthermore, it was considerably advantageous for obtaining adequate margins distance, especially for deep nodules.

Percutaneous Computed Tomography (CT)-Guided Localization with Indocyanine Green for the Thoracoscopic Resection of Small Pulmonary Nodules.

The identification of small lung nodules is challenging during mini-invasive thoracic surgery. Unable to palpate them directly, surgeons have developed several methods to preoperatively localize pulmonary nodules, including the computed tomography-guided positioning of coils or metallic landmarks (hook wire) or bronchoscopic marking. We present a series of patients scheduled for the video-assisted thoracoscopic sublobar resection of small pulmonary nodules, in which we performed preoperative percutaneous computed tomography (CT)-guided nodule localization through the injection of a mixture of indocyanine green and human albumin. A total of 40 patients underwent a preoperative CT-guided injection of indocyanine green followed by VATS resection within 24 h. Patients tolerated the procedure well, no pain medication was administrated, and no complications were observed during the marking procedure. All pulmonary nodules were easily detected and successfully resected. the near-infrared dye marking solution of indocyanine green (ICG) with diluted human albumin was safe, effective, and easy to perform. The ICG solution has the potential to facilitate the accurate localization and resection of pulmonary nodules during VATS surgery, avoiding the risk of marker displacement/migration.

α-Cyanoacrylate Rapid Medical Adhesive (Medical EC Glue) Localization of Pulmonary Nodules Guided by Computed Tomography before Thoracoscopic Surgery.

The study aims to conduct lung cancer screening by low-dose CT to identify the nature of the pulmonary nodule. The purpose of this study was to evaluate the role of preoperative medical EC glue localization of pulmonary nodules of uncertain nature by minimally invasive surgical resection. From December 2017 to December 2019, 18 patients (12 women, 6 men; median age: 54 years)with pulmonary nodules were located using medical EC glue under the guidance of preoperative CT and then resected under video thoracoscopy at Air Force Medical Center of PLA. The clinical characteristics were retrospectively collected to evaluate the effectiveness, safety and feasibility of the operation. The mean value of the maximum diameter of pulmonary nodules on CT images before the operation was 10.8 mm. The average depth was 10.3 mm (1.0-39.5 mm). Among 18 nodules, 8 were pure ground glass nodules, 3 were solid nodules, and 7 were partial solid nodules. The diagnosis rate of medical glue localization under the guidance of CT after the operation was 100%. Postoperative pathological diagnosis showed that there were 10 cases of primary lung adenocarcinoma, 1 case of invasive lung adenocarcinoma, 3 cases of adenocarcinoma in situ, 1 case of metastatic adenocarcinoma, and 3 cases of benign nodules. No obvious serious complications were found after localization. This study suggests that CT-guided percutaneous medical EC glue localization is a reliable, safe, feasible and practical method for undiagnosed pulmonary nodules and can significantly improve the rate of resection of small pulmonary nodules. Furthermore, it was considered to be more reasonable to remove pulmonary nodules and maximize the preservation of lung function.

Accurate and patient-friendly intraoperative lung nodule localization method for sublobar resection using a hybrid operating room.

A hybrid operating room (OR) is an OR that uses advanced imaging techniques, such as multidetector computed tomography (CT), cone-beam computed tomography (CBCT), fluorescence imaging and magnetic resonance imaging [1]. Hybrid ORs were originally developed for cardiovascular surgery, but they are now used for many other clinical areas including thoracic surgery, neurosurgery, vascular surgery, urology and orthopaedic surgery. In thoracic surgery, a hybrid OR has been used as an intraoperative localization method for pulmonary nodules that are difficult to identify visually or by finger palpation. Yang et al. [2] reported a feasibility study of single-stage augmented fluoroscopic bronchoscopy localization and thoracoscopic resection of small pulmonary nodules in a hybrid OR. Their localization method had 2 main characteristics: a single-stage procedure performed in a hybrid OR and marking under an augmented fluoroscopic bronchoscopy. Marking is important for localizing small pulmonary nodules that are otherwise difficult to identify intraoperatively, especially subsolid nodules or deep-seated nodules.

Single-stage augmented fluoroscopic bronchoscopy localization and thoracoscopic resection of small pulmonary nodules in a hybrid operating room.

Hybrid operating rooms (HOR) have been increasingly used for image-guided lung surgery, and most surgical teams have used percutaneous localization for small pulmonary nodules. We evaluated the feasibility and safety of augmented fluoroscopic bronchoscopy localization under endotracheal tube intubation general anaesthesia followed by thoracoscopic surgery as a single-stage procedure in ab HOR. We retrospectively reviewed clinical records of patients who underwent single-stage augmented fluoroscopic bronchoscopy localization under general anaesthesia followed by thoracoscopic surgery in an HOR between August 2020 and March 2022. Single-stage localization and resection were performed for 85 nodules in 74 patients. The median nodule size was 8 mm [interquartile range (IQR), 6-9 mm], and the median distance from the pleural space was 10.9 mm (IQR, 8-20 mm). All nodules were identifiable on cone-beam computed tomography images and marked transbronchially with indigo carmine dye (median markers per lesion: 3); microcoils were placed for deep margins in 16 patients. The median localization time was 30 min (IQR 23-42 min), and the median fluoroscopy duration was 3.3 min (IQR 2.2-5.3 min). The median radiation exposure (expressed as the dose area product) was 4303.6 μGym2 (IQR 2879.5-6268.7 μGym2). All nodules were successfully marked and resected, and the median global operating room time was 178.5 min (IQR 153.5-204 min). There were no localization-related complications, and the median length of postoperative stay was 1 day (IQR, 1-2 days). Single-stage augmented fluoroscopic bronchoscopy localization under general anaesthesia followed by thoracoscopic surgery was feasible and safe.

The improved success rate and reduced complications of a novel localization device vs. hookwire for thoracoscopic resection of small pulmonary nodules: a single-center, open-label, randomized clinical trial.

BackgroundIn our previous study, we developed a 4-hook claw-suture localization device for pulmonary nodule resection, which acheived satifisfactory results. Following this, we conducted this single-center, open-label, randomized clinical trial to compare the success rate and complication rate of this novel localization device and currently widely-used hookwire.MethodsPatients with small pulmonary nodules (0.4–1 cm) who received preoperative localization and thoracoscopic resection at Shanghai Chest Hospital were randomly assigned (1:2 ratio, via computer-generated randomized numbers) to undergo localization using either a novel claw-suture system (claw group) or classical (hookwire group) localization device. The primary endpoint of this study was localization success rate, and the secondary endpoints included complications, localization-related time, and pain.ResultsA total of 411 patients were randomly assigned to the claw group (n=136) or the hookwire group (n=275) before thoracoscopic resection of small pulmonary nodules and analyzed. Compared with the hookwire group, the claw group had a significantly higher success rate (133/136, 97.8% vs. 254/275, 92.4%, P=0.027), less asymptomatic hemorrhage (16.9% vs. 37.5%, P=0.003) and pleural reaction (0% vs. 5.1%, P=0.017), as well as better pain alleviation 10 min after localization (measured using the difference between two visual analog scale scores, 0.84±0.98 vs. 0.35±0.79, P<0.001). In contrast, the hookwire group was associated with a shorter localization procedure duration than the claw group (7.2±2.9 vs. 14.4±6.6 min, P<0.001). In the multiple localization subgroup, the claw group compared to the hookwire group also achieved higher success (32/33, 97.0% vs. 70/86, 81.4%) and less pleural reaction (0% vs. 16.3%).ConclusionsThe new claw-suture localization device is superior to traditional hookwire, with a higher success rate, fewer complications, and better patient tolerance for preoperative localization of small pulmonary nodules.Trial RegistrationChinese Clinical Trial Registry ChiCTR1900027346.

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

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. 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. 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. 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.

Virtual-assisted lung mapping in sublobar resection of small pulmonary nodules, long-term results.

The short-term efficacy of virtual-assisted lung mapping (VAL-MAP), a preoperative bronchoscopic multi-spot lung-marking technique, has been confirmed in 2 prospective multicentre studies. The objectives of this study were to analyse the local recurrence and survival of patients enrolled in these studies, long-term. Of the 663 patients enrolled in the 2 studies, 559 patients' follow-up data were collected. After excluding those who did not undergo VAL-MAP, whose resection was not for curative intent, who underwent concurrent resection without VAL-MAP, or who eventually underwent lobectomy instead of sublobar resection (i.e. wedge resection or segmentectomy), 422 patients were further analysed. Among 264 patients with primary lung cancer, the 5-year local recurrence-free rate was 98.4%, and the 5-year overall survival (OS) rate was 94.5%. Limited to stage IA2 or less (≤2 cm in diameter; n = 238, 90.1%), the 5-year local recurrence-free and OS rates were 98.7% and 94.8%, respectively. Among 102 patients with metastatic lung tumours, the 5-year local recurrence-free rate was 93.8% and the 5-year OS rate was 81.8%. Limited to the most common (colorectal) cancer (n = 53), the 5-year local recurrence-free and OS rates were 94.9% and 82.3%, respectively. VAL-MAP, which is beneficial in localizing small barely palpable pulmonary lesions and determining the appropriate resection lines, was associated with reasonable long-term outcomes. 152, 1542.

CT-guided localization techniques of small pulmonary nodules: a prospective non-randomized controlled study on pulmonary nodule localization needle and methylene blue staining with surgical glue.

BackgroundThoracoscopic resection of small pulmonary nodules (SPNs) is challenging. Accurate preoperative computed tomography-guided localization of SPNs is key to successful rection. The aim of the present study was to evaluate the clinical value of a novel localization needle and methylene blue staining combined with surgical glue (MBSG) and to explore the risk factors for post-localization complications.MethodsThis prospective, non-randomized controlled study was conducted on 110 patients who received either MBSG or novel needle localization prior to video-assisted thoracoscopic surgery (VATS) from January 2019 to December 2019 at Shenzhen People’s Hospital. The primary endpoints were the safety and the success rates of the 2 localization techniques. The secondary endpoints were operative time and feasibility.ResultsThe 110 patients were categorized into 2 groups: the MBSG group (n=84) and the pulmonary nodule localization needle group (n=26). The success rate of pre-VATS localization was 100% in both groups. No deaths or serious complications occurred during localization. The rates of pneumothorax, pulmonary hemorrhage, and localization-induced cough were 38.1%, 25%, and 7.14%, respectively, in the MBSG group, and 26.92%, 19.23%, and 0%, respectively, in the pulmonary nodule localization needle group. Differences between the 2 groups were not statistically significant (P>0.05). Total complication rate and the incidence of pain were significantly lower in the pulmonary nodule localization needle group (χ2=4.441 and 4.295, respectively; P<0.05). The difference in operative time between the 2 groups was not statistically significant (P>0.05). Dye diffusion occurred in 2 patients in the MBSG group; however, it had no impact on VATS or on the pathological analysis. Neither displacement nor dislocation was observed in the pulmonary nodule localization needle group. Logistic regression analysis showed that the localization technique was an independent risk factor for total complications (odds ratio: 2.634, 95% confidence interval: 1.022–6.789, P<0.05).ConclusionsBoth techniques can localize SPNs effectively prior to VATS. The pulmonary nodule localization needle technique has a lower incidence of complications.

Clinical value of holographic multimodal real-time three-dimensional navigation technology in the surgical location of pulmonary lesions

Objective: To investigate the clinical value of holographic multimodal real-time three-dimensional navigation (3D-HMRN) technology for navigation and localization of pulmonary micro lesions. Methods: A total of 152 patients who underwent thoracoscopic partial resection of small pulmonary nodules in the Department of Thoracic Surgery of the First Medical Center of Chinese PLA General Hospital from June 2017 to December 2019 were retrospectively collected and were divided into two groups by computer random number. The experimental group consists of 76 patients (31 males and 45 females) with a mean age of (47±17) years. CT scan in lateral position navigation mode and 3D reconstruction of the surgical area were performed on all patients. Before the operation, holographic multimodal real-time 3D navigation technology was used to guide the puncture of the lesion. After the operation was completed, the intraoperative CT was used to verify the location of the puncture and determine the accuracy and error rang of the puncture. The control group consists of 76 patients (34 males and 42 females) with a mean age of (50±19) years. Intraoperative CT positioning was directly subjected to the patients. And then, the localization data of the two groups were compared and statistically analyzed. Results: Seventy-six cases of positioning puncture using navigation technology, the first success rate was 97.4%, the error was (3.9±0.9) mm, and the average operation time was (4.4±1.2) min; while the success rate of one-time CT positioning during routine surgery was 98.7%, the error was (3.5±1.0) mm, and the average operating time was (10.7±2.6) min. Compared with intraoperative CT positioning, the success rate and positioning accuracy of 3D-HMRN were not statistically significant (both P>0.05), however the operation time was significantly shortened (P<0.01). Conclusion: The holographic multi-modal real-time 3D navigation technology saves time and has accurate positioning, which may be used as an effective method for localization of pulmonary micro nodules during surgical treatment.

Feasibility of injecting Fluorescent Agent under the Guidance of Electromagnetic Navigation Bronchoscopy in Pulmonary Nodule Resection

背景与目的临床上肺内体积小，位置深且无实性成分的结节在电视辅助胸腔镜手术下切除给外科医生带来很多挑战。本研究的目前在于探讨经磁导航支气管镜（electromagnetic navigation bronchoscope, ENB）引导下肺部结节注入吲哚菁绿（indocyanine green, ICG）定位及在荧光腔镜下肺部小结节切除的可行性。方法2018年12月-2019年8月，我院连续16例共计30个肺周围病变患者接受了荧光胸腔镜下肺部结节切除术。术前均行磁导航引导注入ICG定位。结果所有患者均先行磁导航引导下肺结节定位术，染色完成后立即行手术切除。结节的平均大小为（11.12±3.65）mm。平均导航时间为（12.06±2.74）min，染料标记与肺部手术切除的平均间隔为（25.00±5.29）min。所有病灶均被完全切除，定位成功率100.00%，无出血及其他并发症发生，术后病理结果证实定位的准确性。结论经磁导航引导下注入荧光染剂是一种新颖且有效的方法，可以定位肺部微小不可触及的病灶。这种方法可帮助外科医生更快更方便的识别病灶，实用性强，值得推广。

Electromagnetic Navigation-Guided Preoperative Localization of Small Malignant Pulmonary Tumors

Thoracoscopic resection of small pulmonary nodules can be challenging, which highlights the importance of preoperative localization. We report our experience with electromagnetic navigation-guided localization. The clinical, radiographic, surgical, and pathologic data of patients who underwent electromagnetic navigation-guided preoperative localization for pulmonary tumors smaller than 2 cm were reviewed. Successful localization was defined as successful identification of target lesions during the thoracoscopic procedure without palpation. Included were 30 patients with 35 nodules. There were 31 transthoracic and 5 transbronchial approaches performed. One patient received both approaches for the same tumor, and 3 received both approaches for localization of multiple targets. The median nodule size was 1.0 cm (interquartile range [IQR], 0.8-1.2 cm), and the median distance from the pleural surface was 1.1 cm (IQR, 0.6-2.0 cm). The most commonly used marker for localization was dye (n= 18), followed by microcoils (n=15). In nodules located with microcoils, the median distance between the microcoil and nodule was 1 mm (IQR, 0-3 mm). There were no complications related to the localization procedure. Successful localization was achieved in 27 of 30 patients (90.0%) and in 32 of 35 nodules (91.4%). The pathologic diagnosis was primary pulmonary malignancy in 29 nodules and secondary pulmonary malignancy in6. Our experience with electromagnetic navigation-guided transbronchial and transthoracic preoperative localization of small, malignant pulmonary tumors shows this technique is feasible and appears to be a viable option for preoperative localization of pulmonary nodules that may be difficult to locate thoracoscopically.

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

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

Thoracoscopic small pulmonary nodule detection using computed tomography-guided cutaneous marking and pleural marking.

In recent years, small lung nodules have been detected by computed tomography (CT). Wedge resection of small pulmonary nodules is widely performed with video-assisted thoracoscopic surgery (VATS). However, it is extremely difficult to identify the position of a small tumor by palpation using a small access port. Therefore, this study aimed to describe a newly devised method of marking the location of the tumor. In 51 cases, we marked the skin directly above the tumor under CT guidance before surgery and then placed a pleural marker with dye on the parietal pleura directly below the region marked on the skin using a catheter needle. To evaluate the accuracy of the marking, the distance between the center of the marking and the visceral pleura closest to the tumor was measured. The mean distance between the center of marking and the visceral pleura closest to the tumor was 12.4 mm. In 47 cases (92%), the tumor was within 30 mm from the marking site. The surgical approach was VATS in 44 cases. In one case, conversion to open surgery was required for palpation of the tumor. All tumors were resected completely. No morbidity was observed during or after surgery. Our CT-guided cutaneous marking and pleural marking method was able to identify the location of the tumor with high accuracy, making palpation easier during VATS. This new procedure should be implemented in the clinical setting given its ease of application, safety, and accuracy.

Intraoperative Percutaneous Microcoil Localization of Small Peripheral Pulmonary Nodules Using Cone-Beam CT in a Hybrid Operating Room.

OBJECTIVE. Thoracoscopic surgical resection of small peripheral pulmonary nodules can be challenging, and often preoperative localization techniques are needed to avoid conversion to open thoracotomy. In this article, we show the feasibility and benefits of performing intraoperative percutaneous microcoil localization with C-arm cone-beam CT in a hybrid operating room immediately before video-assisted thoracoscopic surgery for wedge resection of a small pulmonary nodule. CONCLUSION. This technique can provide safe and accurate localization while minimizing patient discomfort and thus enhancing the patient's experience.

Hybrid operating room for the intraoperative CT-guided localization of pulmonary nodules.

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.

The feasibility of electromagnetic navigation–guided percutaneous microcoil localization for thoracoscopic resection of small pulmonary nodules

The feasibility of electromagnetic navigation–guided percutaneous microcoil localization for thoracoscopic resection of small pulmonary nodules

Computed tomography-guided cyanoacrylate localization of small pulmonary nodules: feasibility and initial experience.

We report our initial technical experience with computed tomography (CT)-guided cyanoacrylate localization for resection of small pulmonary nodules (SPNs) and evaluate the feasibility of this technique. Between June 2016 and December 2017, the diagnostic results of 55 consecutive patients (69 SPNs) who underwent preoperative CT-guided cyanoacrylate localization and consequent video-assisted thoracoscopic surgery (VATS) resection were retrospectively evaluated. Localization-related outcomes and perioperative outcomes were assessed. Preoperative CT-guided cyanoacrylate localization was successfully performed in all the cases. Simultaneous localization was achieved in 8 (14.5%) patients with 2 nodules and 3 (5.5%) patients with 3 nodules. The mean size of the nodules was 8.5 ± 3.2 mm (range 5-20 mm), and their mean depth from the nearest pleural surface was 10.9 ± 7.7 mm (range 2-36 mm). The overall mean localization procedural time was 13.7 ± 7.2 min (range 6-37 min). Two localization-related complications (intrapulmonary focal haemorrhage and pneumothorax) were observed in 7 (12.7%) and 12 (21.8%) patients, respectively. All patients with complications were asymptomatic and received conservative treatment only. All SPNs were resected under VATS without any conversion to minithoracotomy or thoracotomy. CT-guided cyanoacrylate localization is a feasible procedure to localize SPNs. The advantages of this technique include flexibility between insertion and excision, the ability to be applied to the whole lung field, a high success rate, patient comfort after insertion and a fast learning curve. Further studies are warranted to confirm the efficacy of this technique.

Combined lipiodol marking and video-assisted thoracoscopic surgery in a hybrid operating room.

The development of diagnostic technology has led to detection of an increasing number of small pulmonary nodules (SPNs), which can be difficult to locate intraoperatively. Here, we report our experience performing single-stage lipiodol localization and surgical resection in a hybrid operating room (OR). Between June 2016 and August 2017, 30 patients with 32 SPNs underwent sliding gantry-based multidetector computed tomography (MDCT)-guided lipiodol marking followed by video-assisted thoracoscopic surgery (VATS) in a hybrid OR. After induction of general anesthesia, all nodules were marked with 0.2 mL lipiodol under MDCT fluoroscopic guidance, followed by immediate VATS. The mean SPN diameter and distance from the pleural surface were 10.7±4.5 mm (range, 5.0-21.0 mm) and 18.0±9.0 mm (range, 2.8-32.0 mm) respectively. The MDCT-guided localization procedure required 15.8±6.0 min (range, 8.0-32.0 min). All the nodules were marked with lipiodol and detected during fluoroscopy as a clear spot. The median deviation between the radio-opaque nodule and the target nodule was 7.8±3.6 mm (range, 3.0-20.0 mm). In two cases, MDCT scans performed after completion of marking revealed mild pneumothorax, which did not need further intervention. VATS resection was converted to thoracotomy in two patients because of strong pleural adhesions and intraoperative bleeding from the pulmonary vein. No other complications occurred during the combined approach, and there was no intra- or post-operative mortality or morbidity. These results suggest that a combined approach using MDCT-guided lipiodol marking followed by VATS is feasible and has acceptable accuracy in resection of SPNs.