Single-stage localization and removal of small lung nodules through image-guided video-assisted thoracoscopic surgery

This case series illustrates the feasibility of single-stage image-guided video-assisted thoracoscopic surgery for simultaneous localization and removal of small solitary pulmonary nodules (SPNs). The procedure was performed in a hybrid operating room using C-arm cone-beam computed tomography equipped with a laser-guided navigation system. Between October 2016 and January 2017, 12 consecutive patients presenting with SPNs underwent image-guided video-assisted thoracoscopic surgery. The feasibility and safety of the procedure were assessed through a retrospective review of the patients' clinical charts. The median size of SPNs was 5.5 mm [interquartile range (IQR) 4-6 mm], whereas their median distance from the pleural surface was 11.7 mm (IQR 6-11.3 mm). All of the lesions were visible on intraoperative C-arm cone-beam computed tomography images, and localization was successful in 10 patients; thereafter, complete thoracoscopic resection was successfully performed. The median time required for the localization of SPNs was 45.5 min (IQR 36-60 min), whereas the median radiation exposure (expressed through the skin absorbed dose) was 223.2 mGy (IQR 180.3-321.3 mGy). Lesion localization was unsuccessful in 2 cases because to the development of pneumothorax induced by needle puncture. In such cases, a utility thoracotomy was required for the identification of SPNs. There was no operative mortality, and the median length of postoperative stay was 4 days (IQR 3.8-4 days). The results of our case series support the feasibility of image-guided video-assisted thoracoscopic surgery for detection and removal of SPNs. Future efforts should be tailored to decrease localization time and minimize radiation exposure.