Video-assisted Wedge Resection Research Articles

Augmented reality navigation-guided pulmonary nodule localization in a canine model.

BackgroundThe current intraoperative pulmonary nodule localization techniques require specific medical equipment or skillful operators, which limits their widespread application. Here, we present an innovative nodule localization technique in a canine lung model using augmented reality (AR) navigation.MethodsPeripheral pulmonary lesions were artificially created in canine model. A preoperative chest computed tomography scan was performed for each animal. The acquired computed tomography images were analyzed, and an established intraoperative localization plan was uploaded into HoloLens (a head-mounted AR device). Under general anesthesia, lung localization markers were implanted in each canine, guided by the established procedure plan displayed by HoloLens. All artificial lesions and markers were removed by video-assisted wedge resection or lobectomy in a single operation.ResultsSince June 2019, 12 peripheral pulmonary lesions were artificially created in 4 canine models. All lung localization markers were precisely implanted with a median registration and implantation time of 6 minutes (range, 2–15 minutes). The average distance between pulmonary lesions and markers was 1.9±1.7 mm, based on computed tomography examination after localization. No severe pneumothorax was observed after marker implantation. After an average implantation period of 16.5 days, no marker displacement was observed.ConclusionsThe AR navigation-guided pulmonary nodule localization technique was safe and effective in a canine model. The validity and feasibility of using this technology in patients will be examined further (NCT04211051).

Comparison of Four-hook Needle and Memory Alloy Coil in Localization of Pulmonary Nodules

背景与目的随着肺结节微创手术的广泛开展，术前定位变得愈发关键。传统定位方式存在一定的缺陷，定位方式的改进很有必要。本研究旨在对比分析两种新型定位方式即四钩定位针和记忆合金弹簧圈在肺结节定位中应用的安全性和有效性。方法回顾性分析152例患者的资料，76例为四钩定位针组，76例为记忆合金弹簧圈组，术前均行肺结节定位，后行电视胸腔镜辅助肺结节楔形切除术，统计平均定位时间、定位并发症、结节切除时间等。结果两组患者均成功切除目标肺结节，四钩定位针组76例患者术中均找到定位装置，肺结节全部成功切除，1例因严重胸腔粘连而中转开胸行肺结节楔形切除术。记忆合金弹簧圈组76例患者肺结节均成功切除，1例因术中切除标本后未找到病灶而行妥协性扩大切除术。两组气胸、肺内出血发生率、定位成功率、结节楔形切除时间无统计学差异。四钩定位针组平均定位时间为（13.66±3.11）min，低于记忆合金弹簧圈组的（15.51±3.65）min，二者有统计学差异（P=0.001）。记忆合金弹簧圈组当结节至胸膜距离≥1.5 cm和 < 1.5 cm时，平均定位时间分别为（17.20±4.46）min、（14.91±3.15）min，二者有统计学差异（P=0.044）。结论四钩定位针和记忆合金弹簧圈两种新型肺结节定位方式均有较好的安全性及有效性，四钩定位针定位操作用时更短。在使用记忆合金弹簧圈定位时，对于到胸膜距离 < 1.5 cm的肺结节效果可能更佳。

Pleural Dye Marking Using Radial Endobronchial Ultrasound and Virtual Bronchoscopy before Sublobar Pulmonary Resection for Small Peripheral Nodules

Background: Minimally invasive surgery of pulmonary nodules allows suboptimal palpation of the lung compared to open thoracotomy. Objective: The objective of this study was to assess endoscopic pleural dye marking using radial endobronchial ultrasound (r-EBUS) and virtual bronchoscopy to localize small peripheral lung nodules immediately before minimally invasive resection. Methods: The endoscopic procedure was performed without fluoroscopy, under general anesthesia in the operating room immediately before minimally invasive surgery. Then, 1 mL of methylene blue (0.5%) was instilled into the guide sheath, wedged in the subpleural space. Wedge resection or segmentectomy were guided by visualization of the dye on the pleural surface. Contribution of dye marking to the surgical procedure was rated by the surgeon. Results: Twenty-five nodules, including 6 ground glass opacities, were resected in 22 patients by video-assisted thoracoscopic wedge resection (n = 11) or robotic-assisted thoracoscopic surgery (10 segmentectomies and 1 wedge resection). The median greatest diameter of nodules was 8 mm. No conversion to open thoracotomy was needed. The endoscopic procedure added an average 10 min to surgical resection. The dye was visible on the pleural surface in 24 cases. Histological diagnosis and free margin resection were obtained in all cases. Median skin-to-skin operating time was 90 min for robotic segmentectomy and 40 min for video-assisted wedge resection. The same operative precision was considered impossible by the surgeon without dye marking in 21 cases. Conclusions: Dye marking using r-EBUS and virtual bronchoscopy can be easily and safely performed to localize small pulmonary nodules immediately before minimally invasive resection.

Approach to a solid solitary pulmonary nodule in two different settings-"Common is common, rare is rare".

A new solid solitary pulmonary nodule (SPN) is a common feature in the daily practice of physicians, pulmonologists and thoracic surgeons. The etiology and consequently the diagnostic approach is very different in various parts of the world. Identification of malignant nodules is the universal goal to proceed to a potential curable therapy. In countries with a low incidence of inflammatory disease and a high incidence of lung cancer the diagnostic work up includes a positron emission tomography (PET) scan or PET-computer tomography (CT) as a main pillar. In countries with a high incidence of inflammatory and infectious disease and a low incidence in lung cancer this diagnostic work up needs to be adapted. In these settings a PET scan has a limited role and tissue diagnosis, whether with a trans-thoracic, trans-bronchial biopsy or a video-assisted wedge resection is the most targeted approach to determine or exclude malignancy. The evaluation of a solid SPN in the two different situations is outlined in our algorithm. Recommendations stress the value of clinical judgement in different settings, determination of probabilities of malignancy, cost-effective use of diagnostic tools and evaluation of various management alternatives according to the risk profile and the patients preferences.

Needlescopic video-assisted wedge resection combined with the subcostal trans-diaphragmatic approach for undetermined peripheral pulmonary nodules

Reduced mortality from lung cancer by computed tomography (CT) screening facilitates the use of video-assisted thoracic surgery (VATS) lung wedge resection to obtain a definite diagnosis and to treat tiny nodules. The authors evaluated their initial experience using novel needlescopic VATS wedge resection combined with the subcostal trans-diaphragmatic (SCTD) approach for managing undetermined peripheral pulmonary nodules. Between 2009 and 2012, 35 patients who had 36 operations underwent needlescopic VATS wedge pulmonary resection with the SCTD approach. Preoperative percutaneous CT-guided marking of the nodule was performed. Two 3-mm miniports were placed in the thorax for the thoracoscopic camera and minigrasper. Just anterior to the 10th rib, a 2-cm subcostal incision was made, and a 12- or 15-mm port was placed trans-diaphragmatically into the chest cavity. Wedge resection of the lung was performed with endostaplers introduced through a subcostal port. The median tumor size was 1.1cm. Localization of the tumor was widely distributed. The mean operation time was 51min, and the mean blood loss was 4.2mL. No patients required conversion to thoracotomy, and one patient required conversion to conventional VATS. Additional thoracic ports were placed in five patients, and the needlescopic incision was extended to 15mm in one patient. The median duration of chest drainage was 1day. Additional analgesia was not required for 22 patients and was used for less than 1day for three patients, less than 2days for seven patients, and less than 3days for seven patients. The pathologic diagnosis of the nodules was malignant for 28 patients and benign for 8 patients. On postoperative day 7 or at admission, 34 patients were free of postoperative neuralgia. Needlescopic VATS wedge pulmonary resection combined with the SCTD approach is both safe and feasible and offers the specific advantages of minimal invasiveness and good cosmetic outcomes.

Minimizing single-port access in video-assisted wedge resection, with a hookwire

Single-port video-assisted thoracic surgery lung resection is increasing in popularity. In selected cases, the incision length of single-port video-assisted thoracic lung wedge resection can be minimized by preoperative strategic positioning of a percutaneous hookwire to allow intraoperative traction of the lung nodule to facilitate endostapler wedge resection, thereby substituting the sponge-holding forceps for lung retraction during the procedure.

Primary Bronchus-Associated Lymphoid Tissue (BALT) Lymphoma

Primary Bronchus-Associated Lymphoid Tissue (BALT) Lymphoma Bronchus-associated lymphoid tissue (BALT) lymphoma is a rare extra-nodal marginal zone lymphoma representing 0.5% of lung tumours. In order to share experience in the management of BALT lymphoma, we report a well-investigated case with unusual features as complex familial oncologic history and synchronous benign thyroid disease. The patient was a 44-year-old woman with prolonged unspecific respiratory complaints. By computed tomography (CT), bilateral atelectasis-like pulmonary lesions were found in the 3rd, 5th, 6th and 8th segments of the right lung and in the 3rd segment of the left lung. We performed diagnostic video-assisted wedge resection of the 5th segment of right lung. Pathologic and immunohistochemical examination yielded the diagnosis of BALT lymphoma. After staging by bone marrow biopsy and abdominal CT, chemotherapy was recommended by the oncologic council.

General thoracic surgery is safe in patients taking clopidogrel (Plavix)

The objective of this study was to assess the safety of general thoracic surgery in patients taking antiplatelet (clopidogrel) therapy. A prospective study was conducted of consecutive patients who underwent general thoracic surgery and who were taking clopidogrel perioperatively. They were matched using a propensity score from our prospective database of 11,768 patients. Intraoperative and postoperative outcomes were compared. Between January 2009 and April 2010 there were 33 patients on clopidogrel at the time of surgery and 132 controls. The most common procedures were thoracotomy with lobectomy in 11 patients (robotic in 1), video-assisted wedge resection in 6, mediastinoscopy in 4, and Ivor Lewis esophagogastrectomy in 2. Epidurals were not used. There was no intraoperative morbidity or bleeding in primary thoracotomy; however, 2 of the 4 patients who underwent redo thoracotomy had bleeding that required transfusions. None of the 8 patients receiving clopidogrel who had a coronary artery stent and underwent lobectomy had a perioperative myocardial infarction whereas 5 of the 14 control patients undergoing lobectomy who had a coronary artery stent did (P=.05). Otherwise, morbidity, mortality, and length of stay were no different. Patients who are receiving clopidogrel and who have a coronary artery stent placed can safely undergo general thoracic surgery. The widely held belief that surgery cannot be performed without bleeding is untrue. This new finding not only eliminates much of the preoperative dilemma posed by these patients but also may reduce their risk of a postoperative myocardial infarction. However, patients who require a redo thoracotomy may be at increased risk of bleeding.

Limited Surgery and Radiofrequency Ablation for Recurrent Lung Cancer

A 72-year-old man who had been diagnosed with second recurrent lung cancer was referred for consideration of a surgical resection. He had undergone a right upper lobectomy with bronchoplasty for the primary lung cancer and stereotactic radiation therapy for the first recurrent tumor. Owing to the comorbid diseases, video-assisted wedge resection and radiofrequency ablation were performed for the second recurrent tumor. The postoperative course was uneventful and the patient was discharged home without complaints. Eighteen months after surgery, he is alive without recurrence. These procedures are minimally invasive and may decrease the local recurrence of lung cancer in properly selected patients.

Video-assisted wedge resection and local radiotherapy for peripheral lung cancer in high-risk patients: The Cancer and Leukemia Group B (CALGB) 9335, a phase II, multi-institutional cooperative group study

This study examined the feasibility of thoracoscopic wedge resection and radiotherapy for clinical T1 lesions in patients with compromised cardiopulmonary status. In this phase II, prospective, multicenter, cooperative group trial, high-risk patients had one or more of the following risk factors: forced expiratory volume in 1 second less than 40%, carbon monoxide diffusing capacity in lung less than 50%, and maximum oxygen consumption less than 45 mm Hg. Patients underwent video-assisted wedge resection followed by local (56 Gy) radiotherapy. The primary end point was the proportion of patients whose disease could be completely resected and who received radiotherapy without treatment complications. Between September 1995 and September 1999, a total of 65 patients were accrued, of which 58 were eligible (52% male, median age 69 years). Pathologic staging resulted in upgrading to T2 or greater in 16 of 58 cases (28%) and in reassessment as benign in 10 of 58 cases (17%). Conversion to thoracotomy was required in 10 cases (17%), including 1 of 10 benign T1-size lesion (10%), 4 of 35 non-small cell lung cancer T1 lesions (13%), and 5 of 14 non-small cell lung cancer T2 lesions (31%). Resection margins were positive in 5 patients: 6% of T1 and 23% of T2. Surgery was aborted in 2 cases (3.5%), and operative mortality was 4%. Overall operative failure rates of video-assisted wedge resection were 20% for benign T1-size lesions, 22% for T1 non-small cell lung cancer, 21% for all T1 lesions, 50% for T2 non-small cell lung cancer, and 29% for all lesions in this study (clinical T1). Prolonged air leaks occurred in 10%, pneumonia in 6%, and respiratory failure in 4%. Thirty-one patients were eligible for radiotherapy; 3 of them refused, and 1 died before treatment. Among the 28 patients who received radiotherapy, severe dyspnea was noted in 3 patients (11%) and moderate pneumonitis in 4 (14%). Clinical staging in high-risk patients is often inaccurate (45% difference from pathologic staging). Intention to treat clinically staged T1 disease by video-assisted wedge resection is associated with a high failure rate. Pathologically staged T1 lesions can be successfully resected in 75% of cases; however, narrow resection margins remain a concern.

CT-guided marking of lung lesions before minimally invasive operation

Video-assisted thoracoscopic surgery (VATS) is an established method for resection of suspicious pulmonary lesions. However, there are problems to detect small subpleural lesions. A procedure for localization of such lesions will be demonstrated. Since may 2000 our experience includes 5 patients (4m, 1f) suffering from solitary pulmonary lesions. In preparation of VATS a CT-guided marking was carried out using both a lasermarker system as well as a special marker system for lung lesions. All 5 procedures were successful. With the laser system the pulmonary nodule was exactly marked and the special wire was placed without any complications. Consequently, the pulmonary nodule was fixed. During video-assisted wedge resection the nodule can be tracted outside. Operating time was reduced in comparison to time consuming search of unmarked lesions. The combined application of CT-guided marking, transthoracic fixation of pulmonary nodule and VATS is recommended preoperatively. It should apply in lesions, which are located subpleural and thoracoscopically not visible.

Surgical aspects of resection for suspected invasive pulmonary fungal infection in neutropenic patients

Background. Morbidity and mortality of early resection of invasive pulmonary fungal disease in neutropenic patients are still considered prohibitive for surgical treatment. Methods. We retrospectively analyzed results of 28 (16 men, 12 women; mean age, 38.9 years) consecutive neutropenic hematologic patients who had lung resections for suspicion of invasive pulmonary fungal disease. Results. We did 28 lung resections (19 lobectomies, one bilobectomy, eight single or multiple wedge resections including three video-assisted wedge resections). The disease was proved histologically in 22 (78.6%) cases. Intraoperative difficulties, such as diffuse oozing or mycotic infiltration, and solid postinflammatory adhesions were encountered in 5 (17.8%) and 6 (21.4%) patients respectively. In one case (3.6%) it lead to a major intraoperative hemorrhage. There were no intraoperative deaths, overall 30-day mortality rate was two of 28 (7.1%), overall 90-day mortality rate was seven of 28 (25%), with one death (3.6%) possibly related to surgery. Minor surgery-related complications were seen in ten (35.7%) cases, major surgery-related complications occurred in three (10.7%) cases. Twelve of 22 patients (54.5%) with proven invasive fungal infection are currently alive (mean follow-up, 32.3 months). Conclusions. Surgery-related complications and mortality are acceptable for this high risk group of patients. Resection should be carried out early for diagnostic as well as therapeutic reasons.

Wedge resection versus lobectomy for stage I (T1 N0 M0) non-small-cell lung cancer

Background: The role of nonanatomic wedge resection in the management of stage I (T1 N0 M0) non-small-cell lung cancer continues to be debated against the present gold standard of care—anatomic lobectomy. Methods: We analyzed the results of 219 consecutive patients with pathologic stage I (T1 N0 M0) non-small-cell lung cancer who underwent open wedge resection ( n = 42), video-assisted wedge resection ( n = 60), and lobectomy ( n = 117) to assess morbidity, recurrence, and survival differences between these approaches. Results: There were no differences among the three groups with regard to histologic tumor type. Analysis demonstrated the wedge resection groups to be significantly older and to have reduced pulmonary function despite a higher incidence of treatment for chronic obstructive pulmonary disease when compared with patients having lobectomy. The mean hospital stay was significantly less in the wedge resection groups. There were no operative deaths among patients having wedge resection; however, a 3% operative mortality occurred among patients having lobectomy ( p = 0.20). Kaplan-Meier survival curves were nearly identical at 1 year (open wedge resection, 94%; video-assisted wedge resection, 95%; lobectomy, 91%). At 5 years survival was 58% for patients having open wedge resection, 65% for those having video-assisted wedge resection, and 70% for those having lobectomy. Log rank testing demonstrated significant differences between the survival curves during the 5-year period of study ( p = 0.02). This difference was a result of a significantly greater non-cancer-related death rate by 5 years among patients having wedge resection (38% vs 18% for those having lobectomy; p = 0.014). Conclusion: Wedge resection, done by open thoracotomy or video-assisted techniques, appears to be a viable “compromise” surgical treatment of stage I (T1 N0 M0) non-small-cell lung cancer for patients with cardiopulmonary physiologic impairment. Because of the increased risk for local recurrence, anatomic lobectomy remains the surgical treatment of choice for patients with stage I non-small-cell lung cancer who have adequate physiologic reserve. (J Thorac Cardiovasc Surg 1997;113:691-700)

Videothoracoscopy and video-assisted small thoracotomy for the treatment of pulmonary malignancies: Casadio C, Giobbe R, Cianci R, Molinatti M, Oliaro A, Maggi G. Department of Thoracic Surgery, University of Turin, Via Genova 3, 10126 Turin. J Cardiovasc Surg 1994;35:445–448

Video-assisted thoracic surgical procedures continue to be performed with increased frequency; the role of this new technique in the treatment of pulmonary malignancies or metastatic mediastinal adenopathies is not yet defined. Out of a series of 100 consecutive video-assisted thoracic operations, 22 patients resulted affected by a malignancy in the lung or in the subcarinal lymphnodes: six patients had a primary lung cancer and were operated with a video-assisted small thoracotomy of 5 cm (three lobectomy and three segmentectomy) because of a very poor respiratory reserve. Nine patients received a video-assisted wedge resection of a nodule resulted at the frozen section a metastasis of a carcinoma: a small thoracotomy of 8 cm was made and a hand entered the thoracic cage to obtain a careful palpation of the entire lung; five patients had enlarged lymphnodes only in posterior and inferior mediastinum, inaccessible by cervical mediastinoscopy or anterior mediastinotomy: thoracoscopic exploration obtained a useful mediastinal nodal sampling for these adenopathies. In selected cases video-assisted thoracic surgery can be used for resection or assessment of thoracic malignancies.