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Hybrid DynaCT Scan-Guided Localization Single-Port LobectomyHybrid DynaCT Scan Localization Lobectomy FREE TO VIEW

Calvin S. H. Ng, MD, FCCP; Cheuk Man Chu, MBChB; Micky W. T. Kwok, MBChB; Anthony P. C. Yim, DM, FCCP; Randolph H. L. Wong, MBChB, FCCP
Author and Funding Information

From the Department of Surgery (Drs Ng, Kwok, Yim, and Wong), and the Department of Imaging and Interventional Radiology (Dr Man Chu), Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR.

CORRESPONDENCE TO: Calvin S. H. Ng, MD, FCCP, Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T. Hong Kong, SAR, China; e-mail: calvinng@surgery.cuhk.edu.hk


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(3):e76-e78. doi:10.1378/chest.14-1503
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Published online

Small pulmonary lesions can be difficult to locate intraoperatively. Preoperative CT scan-guided localization, for example with hookwire, is a popular method to help localize such lesions. However, the delay between CT scan localization with hookwire and surgery can lead to risks of pneumothorax and wire dislodgement. We describe a 56-year-old woman who underwent DynaCT-guided hookwire localization of a ground-glass opacity in the hybrid operating room followed immediately by single-port video-assisted thoracic surgery lobectomy. The advantages, disadvantages, and special considerations in adopting this approach are discussed.

Figures in this Article

Small pulmonary lesions < 1 cm or those at a distance from the lung periphery, especially when deeper than 2.5 times the lesion diameter, can be difficult to locate by palpation intraoperatively. Furthermore, lesions with high ground-glass opacity (GGO) percentage are difficult to palpate even if they are sizable. The last decade has seen the increasing use of preoperative CT scan-guided localization, for example with hookwire, as a method to localize pulmonary lesions prior to surgery. However, there remain certain concerns. First, there are the difficult logistics in minimizing the time between the hookwire procedure and the subsequent surgery. Second, there is concern for patient safety, in particular pneumothorax, during transfer to and from the ward to the radiology department and in the frequent delays and waiting in reception areas prior to transfer to operating theaters. Finally, interdepartmental transfers and delays can also increase the risk of hookwire dislodgement. By performing the localization procedure and the lung surgery in the same hybrid operating room environment, these potential risks can be minimized.1 We report a case of single-port video-assisted thoracic surgery (VATS) lobectomy for a right lower lobe 1-cm GGO performed immediately following DynaCT-guided hookwire localization in the hybrid operating room. The advantages, disadvantages, and important considerations of this combined approach are discussed.

A 56-year-old woman, a nonsmoker, was incidentally found to have a 1-cm GGO on CT scan in the right lower lobe. PET-CT scan revealed the lesion to be mildly hypermetabolic, with no signs of other lymph node or systemic involvement. Hookwire (SOMATEX) guided localization was performed in our hybrid operating room equipped with the Siemens Artis Zeego system with DynaCT imaging capabilities. The system provides images equivalent to a 16-slice spiral CT scanner in a single 6-s sweep. The hookwire procedure was accomplished in 30 min, puncturing from anterolateral approach with the patient in a semilateral position (Figs 1A, 1B). The ventilation was stopped during hookwire procedure while keeping the lung inflated. The patient was repositioned into the lateral decubitus position for surgery. With single-lung ventilation, single-port VATS wedge resection2 and frozen section showed adenocarcinoma (Fig 2). We proceeded to perform completion of a right lower lobe lobectomy through the same single-port incision and systematic lymph node dissection using established techniques.3,4 Postoperative course was uneventful; the chest tube was removed on postoperative day 2, and the patient was discharged on the same day without complications. The final pathologic stage was T1aN0.

Figure Jump LinkFigure 1 –  A, DynaCT-guided hookwire placement in right lower lobe 1-cm ground-glass opacity nodule in hybrid operating room. B, Hookwire successfully placed into nodule (right) following planning films (left) on reconstituted CT scan images.Grahic Jump Location
Figure Jump LinkFigure 2 –  Single-port video-assisted thoracic surgery wedge resection of the lung nodule for frozen section-confirmed adenocarcinoma, with subsequent completion right lower lobe lobectomy. (The patient provided written consent for the use of this photograph.)Grahic Jump Location

Both hookwire localization of small lung nodules and single-port VATS major lung resection are popular approaches in the treatment of lung cancer.2,3,5 However, currently the two procedures are done separately, which can pose potential problems as described. Our combined approach is feasible and may reduce risks associated with patient transfer and delays, such as pneumothorax and hookwire displacement. By minimizing waiting in between hookwire placement and surgery, patient discomfort is reduced. There could also be cost benefits with fewer transfers, less porter use, and time savings. The potential cost implications will depend on country- and institution-specific hybrid theater operational costs, manpower costs, interdepartmental transfer times, as well as incidence of hookwire complications. Furthermore, if the hookwire does migrate or dislodge, DynaCT can rapidly and conveniently be done to re-hookwire or relocalize the lesion. It is noteworthy that the hookwire procedure may not be possible if the nodule is too close to a blood vessel or shielded by chest wall structures, such as the scapula.

There are several considerations when performing this combined procedure. First, use of DynaCT to perform hookwire localization of lung nodules requires additional training and familiarization with the Artis Zeego system by the surgeon, radiographer, and radiologist. Training using a mannequin with the DynaCT program for the hookwire placement prior to performing the procedure on the patient can greatly improve accuracy and safety. Prior training can also improve efficiency, thereby significantly reduce the dose of radiation administered to the patient. Second, the current generation of hybrid operating room tables is not designed for thoracic surgery and does not have a hinge joint for bridging. Therefore, bridging needs to be substituted by placing a rolled up pillow under the patient’s mid thorax region to open up the intercostal spaces.4 However, unbridging of the patient during the thoracic procedure may be difficult. An additional problem we noticed is that the operating table stands quite high, with limited lowering capability. Third, to optimize the DynaCT images and avoid collision from the rotating Artis Zeego arm, the anesthetic machine needs to be further away from the patient than usual, possibly requiring extension tubing. Also, any metal object surrounding the patient should be avoided, such as towel clips, which are substituted by adhesive disposable drapes. Furthermore, drip stands and metal bed bars can be substituted by radiolucent bars available from Siemens.

The marriage of radiology and thoracic surgery techniques within the hybrid operating theater1,5 may open doors to new techniques that can be potentially safer, more effective, and more economical for patients. Other evolving approaches to identify lung nodules, such as intraoperative ultrasound, may be synergistically used with DynaCT for nodule localization.5 The combination of single-port VATS with CyberKnife or stereotactic body radiotherapy and electromagnetic navigational bronchoscopy for both marking and catheter-based therapies in the hybrid theater setting may create new therapeutic opportunities.6 Further studies are required to better define the role of this new technology in thoracic surgery.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

GGO

ground-glass opacity

VATS

video-assisted thoracic surgery

Ng CS, Lau KK, Gonzalez-Rivas D, Rocco G. Evolution in surgical approach and techniques for lung cancer. Thorax. 2013;68(7):681. [CrossRef] [PubMed]
 
Ng CS, Hui JW, Wong RH. Minimizing single-port access in video-assisted wedge resection, with a hookwire. Asian Cardiovasc Thorac Ann. 2013;21(1):114-115. [CrossRef] [PubMed]
 
Gonzalez-Rivas D, Fieira E, Mendez L, Garcia J. Single-port video-assisted thoracoscopic anatomic segmentectomy and right upper lobectomy. Eur J Cardiothorac Surg. 2012;42(6):e169-e171. [CrossRef] [PubMed]
 
Ng CS, Wong RH, Lau RW, Yim AP. Minimizing chest wall trauma in single-port video-assisted thoracic surgery. J Thorac Cardiovasc Surg. 2014;147(3):1095-1096. [CrossRef] [PubMed]
 
Ng CS, Rocco G, Wong RH, Lau RW, Yu SC, Yim AP. Uniportal and single-incision video-assisted thoracic surgery: the state of the art. Interact Cardiovasc Thorac Surg. 2014;19(4):661-666. [CrossRef] [PubMed]
 
Eberhardt R, Anantham D, Herth F, Feller-Kopman D, Ernst A. Electromagnetic navigation diagnostic bronchoscopy in peripheral lung lesions. Chest. 2007;131(6):1800-1805. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  A, DynaCT-guided hookwire placement in right lower lobe 1-cm ground-glass opacity nodule in hybrid operating room. B, Hookwire successfully placed into nodule (right) following planning films (left) on reconstituted CT scan images.Grahic Jump Location
Figure Jump LinkFigure 2 –  Single-port video-assisted thoracic surgery wedge resection of the lung nodule for frozen section-confirmed adenocarcinoma, with subsequent completion right lower lobe lobectomy. (The patient provided written consent for the use of this photograph.)Grahic Jump Location

Tables

References

Ng CS, Lau KK, Gonzalez-Rivas D, Rocco G. Evolution in surgical approach and techniques for lung cancer. Thorax. 2013;68(7):681. [CrossRef] [PubMed]
 
Ng CS, Hui JW, Wong RH. Minimizing single-port access in video-assisted wedge resection, with a hookwire. Asian Cardiovasc Thorac Ann. 2013;21(1):114-115. [CrossRef] [PubMed]
 
Gonzalez-Rivas D, Fieira E, Mendez L, Garcia J. Single-port video-assisted thoracoscopic anatomic segmentectomy and right upper lobectomy. Eur J Cardiothorac Surg. 2012;42(6):e169-e171. [CrossRef] [PubMed]
 
Ng CS, Wong RH, Lau RW, Yim AP. Minimizing chest wall trauma in single-port video-assisted thoracic surgery. J Thorac Cardiovasc Surg. 2014;147(3):1095-1096. [CrossRef] [PubMed]
 
Ng CS, Rocco G, Wong RH, Lau RW, Yu SC, Yim AP. Uniportal and single-incision video-assisted thoracic surgery: the state of the art. Interact Cardiovasc Thorac Surg. 2014;19(4):661-666. [CrossRef] [PubMed]
 
Eberhardt R, Anantham D, Herth F, Feller-Kopman D, Ernst A. Electromagnetic navigation diagnostic bronchoscopy in peripheral lung lesions. Chest. 2007;131(6):1800-1805. [CrossRef] [PubMed]
 
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