VATS intraoperative tattooing to facilitate solitary pulmonary nodule resection

Abstract

IntroductionVideo-assisted thoracic surgery (VATS) has become routine and widely accepted for the removal of solitary pulmonary nodules of unknown etiology. Thoracosopic techniques continue to evolve with better instruments, robotic applications, and increased patient acceptance and awareness.Several techniques have been described to localize peripheral pulmonary nodules, including pre-operative CT-guided tattooing with methylene blue, CT scan guided spiral/hook wire placement, and transthoracic ultrasound.As pulmonary surgeons well know, the lung and visceral pleura may appear featureless on top of a pulmonary nodule.Case descriptionThis paper presents a rapid, direct and inexpensive approach to peripheral lung lesion resection by marking the lung parenchyma on top of the nodule using direct methylene blue injection.MethodsIn two patients with peripherally located lung nodules (n = 3) scheduled for VATS, we used direct methylene blue injection for intraoperative localization of the pulmonary nodule. Our technique was the following: After finger palpation of the lung, a spinal 25 gauge needle was inserted through an existing port and 0.1 ml of methylene blue was used to tattoo the pleura perpendicular to the localized nodule.The methylene blue tattoo immediately marks the lung surface over the nodule. The surgeon avoids repeated finger palpation, while lining up stapler, graspers and camera, because of the visible tattoo. Our technique eliminates regrasping and repalpating the lung once again to identify a non marked lesion.ResultsThree lung nodules were resected in two patients. Once each lesion was palpated it was marked, and the area was resected with security of accurate localization. All lung nodules were resected in totality with normal lung parenchymal margins. Our technique added about one minute to the operative time. The two patients were discharged home on the second postoperative day, with no morbidity.ConclusionVATS with intraoperative tattooing is a safe, easy, and accurate technique to streamline and efficiently resect solitary pulmonary nodules.

CT-guided microcoil VATS resection of lung nodules: a single-centre experience and review of the literature

“…In one series, there was a delay up to one day after contrast injection until VATS resection, although this time lag did not affect the success of the procedure (47). The sole use of methylene blue, India ink, lipiodol and barium have also be reported in a few small series (48)(49)(50)(51)(52). Similar to the microcoil technique described above, most series involve the percutaneous placement of the contrast material yet some recent reports are using bronchoscopic guidance for pleural dye marking (53,54).…”

Video-assisted thoracoscopic solitary pulmonary nodule resection after CT-guided hookwire localization: 43 cases report and literature review

“…There are several techniques to locate SPN, such as preoperative or intraoperative injection of methylene blue dye at the site of an SPN [14,15], intraoperative ultrasound, or radioguided detection and CT-guided positioning of a metal wire [16][17][18][19][20]. Each of these localization methods has its own advantages and drawbacks.…”

A Simple and Safe Technique for CT Guided Lung Nodule Marking prior to Video Assisted Thoracoscopic Surgical Resection Revisited

“…Surgical techniques using methylene blue have been described with the surgeon palpating more superficial nodules with a finger through the port site incision and marking the palpated area before continuing with VATS resection [ 14 ]. A technique using radiological guided methylene blue for marking prior to breast microdochectomy has also been shown to have equal diagnostic accuracy compared to wire marking [ 15 ].…”