Image‐guided video‐assisted thoracoscopic resection (iVATS): Translation to clinical practice—real‐world experience

Abstract

Objective: We developed a novel approach for localization and resection of lung nodules, using image-guided video-assisted thoracoscopic surgery (iVATS). We report our experience of translating iVATS into clinical care.Methods: Methodology and workflow for iVATS developed as part of the Phase I/II trial were used to train surgeons, radiologists, anesthesiologists, and radiology technologists. Radiation dose, time from induction to incision, placement of T-bar to incision and incision to closure, hospital stay, and complication rates were recorded.Results: Fifty patients underwent iVATS for resection of 54 nodules in a clinical hybrid operating room (OR) by six surgeons. Fifty-two (97%) nodules were successfully resected.Forty-two (84%) patients underwent wedge resection, four (7%) lobectomies, and two (4%) segmentectomy all with lymph node dissection. Median time from induction to incision was 89 minutes (range: 13-256 minutes); T-bar placement was 14 minutes (10-29 minutes); and incision to closure, 107 minutes (41-302 minutes). Average and total procedure radiation dose were: median = 6 mSieverts (range: 2.9-35 mSieverts). No deaths were reported and median length of stay was 3 days (range: 1-12 days).Conclusions: Translation of iVATS into clinical practice has been initiated using a safe step-wise process, combining intraoperative C-arm computed tomography scanning and thoracoscopic surgery in a hybrid OR. K E Y W O R D Sadvanced image-guided operating room, C-arm CT, fiducials, hybrid operating room, lung cancer, VATS

Sublobar resection in high-risk patients for lobectomy: current and future strategy

“…Radiomics is being studied to predict histologic subtypes, specific mutations, and benefit of adjuvant chemotherapy after resection [40][41][42] . Radiomics has already been used to predict OS in NSCLC; specifically, the recurrence of NSCLC after SBRT [43][44][45] . Radiomics may even be able to predict survival based on resection type and offer high-risk patients more tailored care.…”

“…Image-guided video-assisted thoracoscopic surgery (iVATS) is an emerging technology that is being developed to allow localization of non-palpable lesions [44] . Early reports indicate excellent rates of localization using modifications of previously developed techniques with wires, microcoils, and indocyanine green with near-infrared imaging [46][47][48] . These lesions are then removed with sublobar resections.…”

Image-guided video assisted thoracoscopic surgery (iVATS) and the future of surgical management

“…Pure ground glass opacities (GGO), partially solid, and solid nodules less than 1 cm can be managed with close observation, percutaneous biopsy, navigational biopsy, or excisional biopsy, depending on clinical factors and associated imaging findings (2)(3)(4). Percutaneous or navigational biopsy may fail to obtain a diagnosis due to inadequate sampling of the target lesion (2)(3)(4)(5)(6)(7)(8)(9). The accuracy of biopsy diminishes with smaller (<1 cm) targets and pure ground glass lesions (2).…”

“…The accuracy of biopsy diminishes with smaller (<1 cm) targets and pure ground glass lesions (2). Some nodules, especially central ones, may not be amenable to percutaneous or navigational biopsy due to their anatomic location (3,6,10). For instance, lesions behind a rib or under the scapula cannot be accessed percutaneously and peripheral lesions may not be accessible via navigational bronchoscopy.…”

“…While a peripheral, solid pulmonary nodule may be readily palpable, lesions that are partially solid, centrally located, or less than 1 cm in size can be difficult to locate intraoperatively (2)(3)(4)6,10,12,13). For these lesions, it is more feasible to identify them with localization techniques prior to resection (2,3,6,8,9,14,15). An alternative approach, for lesions centered within bronchovascular segments, is to perform anatomic segmentectomy (16).…”