Hybrid OR workflow for pediatric lung nodule localization and resection

Pre-hybrid OR, peripheral lung nodules that are deeper require localization in CT suite followed by patient transfer to OR upstairs

Traditional localization uses Copan's breast localization needle and wire plus/minus methylene blue blood patch

Deploying microcoils through Copan's needle is technically challenging and requires practice outside the patient; coil holder must be firmly established in hub or coil will deploy in the hub instead of the target

Patients undergoing lung nodule resection receive double-lumen endotracheal tube or bronchial blocker depending on patient size

Pre-hybrid OR workflow: patient intubated in OR, transferred on stretcher to CT two floors down, moved onto CT table, scanned and localized, moved off CT table with wire protected, transferred back to OR, then repositioned for thoracoscopy

Multiple transfer and repositioning steps create opportunities for wire dislodgement

In hybrid OR, when nodule location permits, patient can be positioned in thoracoscopic position from the start, allowing single prep and drape with less chance of wire dislodgement

Problems with chest procedures have been based on anesthesia staff not understanding the workflow

Positioning patient in same position as thoracoscopy from the start avoids need to re-drape

Trajectory planning is done at workstation by clicking on lesion and skin entry point; system draws the line and can adjust it to go through middle of intercostal space above the rib to avoid arteries and nerves below the rib

After trajectory planning, computer arranges C-arm automatically in exactly the right position

Needle is advanced to pleura and stabilized with blue towels; procedure must be done quickly without waiting or fiddling after needle insertion to avoid pneumothorax or other complications

Same respiratory excursion must be maintained during cone-beam CT imaging and during needle advancement; if respiratory excursion differs, needle will be off target because nodule location in 3D space changes with lung inflation

Apnea without positive pressure (rather than CPAP of 20-25) is most reproducible and may reduce chance of pneumothorax

Cone-beam CT spatial and contrast resolution is just as good as traditional CT, possibly slightly better; every small lesion seen on diagnostic CT has been visible on hybrid OR cone-beam CT

Small nodules are not visible under plain fluoroscopy; without pre-procedure CT and live fluoroscopy superimposed with planned graphics, operator would be pushing blindly

3D rendering with nodule segmentation coloring allows rotation of image in 3D space to understand nodule position relative to needle tip

Having interventional radiologist present in room during surgery for real-time discussion of wire position (anterior/posterior/medial) is helpful for confirming everyone is on same page

Radiologists and surgeons think slightly differently in 3D space; having trusted colleagues from both specialties discuss together makes positioning very clear

Interventional radiologists stay in room during surgery when possible, or return frequently

Goal is to prep and drape patient once; positioning in lateral decubitus for thoracoscopy from the start limits movement and helps keep wire in place while saving time

Rarely, nodule location may require supine positioning that differs from thoracoscopic position

During needle advancement through parietal and visceral pleura, methylene blue blood patch is injected toward target

For very peripheral nodules, if needle advancement is not decisive through visceral pleura and fluid is being injected, the visceral pleural surface can be pushed away; operator may think needle is deep enough when it has not actually punctured visceral pleura, resulting in wire deployment outside the lung