Image-guided thoracoscopic lung resection using a dual-marker localization technique in a hybrid operating room

Background: We sought to describe the feasibility and safety of a dual-marker technique—based on a combination of near-infrared (NIR) marking and microcoil localization—before image-guided video-assisted thoracoscopic surgery (iVATS) of small and/or deep pulmonary lesions in a hybrid operating room (HOR). Methods: We retrospectively reviewed the clinical records of consecutive patients who underwent iVATS resection in a HOR using the proposed dual-marker localization technique. Patients were initially imaged with cone-beam CT, and the needle trajectory was subsequently planned with the Syngo iGuide Needle Guidance software. Using a coaxial needle technique, a microcoil was initially deployed either in the immediate proximity or within the lesion of interest followed by injection of diluted indocyanine green (ICG; quantity: 0.3–0.5 mL; dye concentration: 0.125 mg/mL) at the pleural surface. A NIR thoracoscopic camera and a C-arm portable fluoroscopic system were used to guide the subsequent resection. Results: A total of 11 patients were examined. The median lesion size was 6 mm, with a median distance from the pleural surface of 4 mm. Three nodules were solid, whereas the remaining eight were GGOs. All lesions were identifiable on intraoperative cone-beam CT images. The median time required for localization was 19 min. No conversion to thoracotomy or a multi-port approach was required, and there were no clinically significant adverse events after ICG injection or microcoil placement. Conclusions: Our study indicates that iVATS with a dual-marking approach (NIR marking and microcoil localization) is safe and useful to localize difficult-to-identify pulmonary nodules.