ISMICS 17 Annual Scientific Meeting, 7-10 June 2017, Rome Cavalieri, Rome, Italy
ISMICS 17 Annual Scientific Meeting, 7-10 June 2017, Rome Cavalieri, Rome, Italy
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One Stop Electromagnetic Navigation Bronchoscopy Dye Marking Lobectomy: The Role Of Cone-beam Ct When Navigation Is Deviated
Jacky YK Ho, Simon CY Chow, Peter SY Yu, Rainbow WH Lau, Calvin SH Ng.
Prince of Wales Hospital, Hong Kong, Hong Kong, Hong Kong.

OBJECTIVE: Electromagnetic navigational bronchoscopy (ENB) guided pleural dye marking is an effective technique for small lesion localisation during video-assisted thoracosopic surgery (VATS). We report an interesting case using the novel technique of one-stop hybrid theatre single staged approach for ENB dye marking and VATS lung resection. The importance of hybrid theatre real-time cone beam CT in identifying deviated ENB navigation and guiding correct navigation and marking of the target lesion is highlighted.
METHODS: A 56-year-old gentleman with incidental 1.4 cm peripheral right lower lobe lesion with standardized uptake value of 3.8 on positron emission tomography was scheduled for ENB dye marking and resection.
RESULTS: Under general anaesthesia in hybrid theatre, virtual navigation to the lesion with the locatable guide (SuperDimension 7, Medtronic Inc) to a distance within 0.8cm directly in front of the target was achieved. However, verification by cone-beam CT in the hybrid theatre showed at least 2cm inferior discrepancy between the ENB catheter and lesion. With the 3D-CT airway roadmap under fluoroscopic guidance successful re-navigation to the target lesion was performed. Position was further confirmed with repeat cone-beam CT. Methylene blue was injected in the lesion and at the adjacent pleura. Immediate single staged VATS in the hybrid OR showed pleural dye marking effectively localising the targeted lesion. VATS RLL wedge resection and frozen section showed adenocarcinoma, and completion RLL lobectomy was performed. Postoperative course was uneventful and patient was discharged day 4 following surgery.
CONCLUSIONS: Inaccurate navigation by ENB is a known limitation of the technology and ability to identify such error is paramount. Hybrid theatre cone-beam CT provides best imaging information to confirm failed and successful navigation dye marking, which combined with the one-stop hybrid OR single staged VATS offer superior management for localization resection of lung nodules.

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