From
Dr. Roshni Dasgupta
Thoracoscopic lung nodule resection techniques with wire localization and ICG imaging
With Dr. Denise Liu · hosted by Dr. Rod Gerardo & Dr. Anton Bash
Chapter 1 of 5
Intro & timing
Introduction and localization timing discussion
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What the experts said
The localization procedure from patient entry to surgical readiness takes approximately 45 minutes total.
The surgeon places the first port without initially collapsing the lung, finding and securing the wire while the lung remains inflated to prevent wire displacement through chest wall musculature during lung collapse.
After CT confirmation of wire position, the wire is cut at the skin level rather than left at full length.
Cutting the wire at the skin prevents it from becoming cumbersome during surgical manipulation and reduces risk of accidental removal during patient transport or repositioning.
In one case, OR nurses unfamiliar with the wire localization mistook the wire for a retained stitch and removed it, leading to the practice of cutting wires short.
Fluoroscopy during resection is used only when a coil has been placed, to confirm the coil has been removed with the specimen and is not retained in the patient.
ICG (indocyanine green) is metabolized by the liver, making it particularly useful for visualizing hepatoblastoma metastases to the lung.
Enhancement of pulmonary nodules with ICG depends on the primary cancer's vascularity; sarcomas show hyperenhancement due to increased angiogenesis.
ICG hyperenhancement is not specific for a single tumor type because multiple primary cancers can be hypervascular.
ICG is more useful in open surgery for finding non-palpable lesions than in thoracoscopic approaches.
ICG has limited depth of penetration in thoracoscopic approaches, preventing visualization of deep lung lesions and often requiring specimen opening for confirmation.
Needle localization is important for nodules that are not at the lung periphery, where ICG limitations are more significant.
At Cincinnati Children's Hospital, interventional radiology was moved from the radiology department into the operating room in 2000.
Interventional radiology procedures at Cincinnati Children's are scheduled through the operating room system with OR anesthesia, fully integrated into the OR environment.
Physical integration of IR into the OR is uncommon; few hospitals have achieved this despite attempts.
The standard approach uses three ports total: one camera port and two working ports.
After wire retrieval and chest insufflation, the surgeon works with anesthesiology to collapse the lung for resection.
The surgeon consults with interventional radiology throughout the case to confirm correct localization.
Wedge resection is performed using a thoracoscopic stapler.
The specimen is X-rayed after removal to verify wire or coil removal, and sealant is applied over staple lines to prevent bleeding.