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

Abstract

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.

Pleural dye marking of lung nodules by electromagnetic navigation bronchoscopy

“…However, the lesion was only visible by fluoroscopy in 12/21 cases. Radial EBUS has been shown effective for pleural dye marking in a recent study, although lesion visualization may be challenging when the image is not concentric. The combined method of ENB, fluoroscopy and radial EBUS may be advantageous when indicated and available.…”

Development of a precision multimodal surgical navigation system for lung robotic segmentectomy

“…3D reconstruction (Visible Patient TM ) for preoperative planning Pilot Study (6) 2013-2015 3D reconstruction for pre-operative planning and intraoperative real-time imaging 2016-2017 3D reconstruction and Pleural dye marking for certain tumor location (7) 2016-2017…”

“…We added this latest procedure to our 3D reconstruction technique because previously we had missed one lesion in our series due to the proximity of the intersegmental plan. The efficacy of this procedure has been assessed in a clinical study (7).…”

“…It is considered oncologically safe and presents the advantage of having a very limited impact on pulmonary function. The technical aspects of the procedure require a thorough understanding of the complex and highly variable pulmonary anatomy which could be improve by 3D model (7).…”

“…Such an approach has been described by others using Oisrix 3D reconstruction and the robotic platform (7,14,15). However, the quality of the Oisrix 3D model was less accurate than the 3D model provided by Visible …”