Technique, Outcomes With Navigational Bronchoscopy Using Indocyanine Green for Robotic Segmentectomy

Abstract

Background. The objectives of this study were to present outcomes of robotic segmentectomy and the investigators' preferred technique for nodule localization using indocyanine green both bronchoscopically and intravenously.Methods. This study was a retrospective review of a consecutive series of patients scheduled for robotic segmentectomy from a single surgeon's prospectively collected database.Results. Between January 2010 and October 2018, there were 245 consecutive patients who underwent planned robotic segmentectomy by one surgeon. Of these 245 patients, 93 (38%) received indocyanine green by electromagnetic navigational bronchoscopy, and all 245 received intravenous indocyanine green. Median time for navigational bronchoscopy was 9 minutes. Navigational bronchoscopy with indocyanine green correctly identified the lesion in 80 cases (86%). The preferred technique was as follows: 0.5 mL of 25 mg of indocyanine green diluted in 10 mL of sterile water given bronchoscopically, followed by a 0.5-mL saline flush, staying at least 4 mm from the pleural surface. The remaining 9.5 mL of indocyanine green was administered intravenously after pulmonary artery ligation. An R0 resection was achieved in all 245 patients, a median of 17 lymph nodes were resected, and the average length of stay was 3.1 days (range, 1 to 21 days). Major morbidity occurred in 3 patients, and there were no 30-or 90-day mortalities.Conclusions. Robotic segmentectomy is safe, with excellent early clinical outcomes. In this series, electromagnetic navigational bronchoscopy and indocyanine green localization were efficient and effective at identifying the target lesion. Intravenous indocyanine green delineated the intersegmental plane.

Current Novel Advances in Bronchoscopy

“…ENB can help locate peripheral nodules for indocyanine green injection for precise resection. In our experience of 93 patients undergoing segmentectomy, ENB was able to locate 86% of lesions with no ENB related complications (14). Data of ENB is summarized in Table 1.…”

“…Despite the technical difficulties, ENB is the most commonly used method to reach the peripheral bronchial tree for tissue sampling and remains the primary alternative to transthoracic biopsy with a more favorable risk profile, albeit with lower diagnostic yield. Tagging nodules endobronchially is also beneficial during sub-lobar resections and can locate nodules when unable to palpate or obscured by lung parenchyma (14).…”

Commentary: The Incidence of Node-Positive Non-small-Cell Lung Cancer Undergoing Sublobar Resection and the Role of Radiation in Its Management

“…The robotic approach, on the contrary, provides an easier tool to perform an anatomical sublobar resection using a minimally invasive method, improving the quality of the surgery and radicality during lymph-node dissection. The robotic availability of infrared light camera can be of help in reducing the risk of marginal resections, thanks to the better visualization of intersegmental plane with EV ICG injection during the procedure (3,13).…”

“…Surgical treatment offers the best chance of cure for early-stage NSCLC (1), but adequate oncological principles are imperative to offer positive long-term outcomes together with reduced surgical trauma. Today, this is possible thanks to modern minimally invasive surgical techniques (2,3).…”

The Utility of Near-Infrared Fluorescence and Indocyanine Green During Robotic Pulmonary Resection

“…We have recently published our own institutional experience with NIF localization using ICG when administered both via ENB and intravenous injection (16). In our series of patients who underwent planned robotic segmentectomy, 93 were selected for ENB localization with ICG due to small nodule size and/or challenging anatomic location (between segments or deep to the visceral pleural surface).…”