Percutaneous Ct Guidance Labeling Of Small Deep Pulmonary Nodules For Sublobar Resection Utilizing Robotic Assisted Thorascopic Surgery (rats)
K A. Lee, Lee Fox, Vincent Turiano, Andrew Hall.
Jupiter Medical Center, Jupiter, FL, USA.
OBJECTIVE: Thorascopic sublobar resection of small deep pulmonary nodules and ground glass opacities/nodules (GGO), are very challenging. The absence of tactile feedback may require greater resection or conversion to thoracotomy to locate the nodule. Percutaneous CT-guided Indocyanine Green (ICG) Injection enables specific localization of these nodules and preserves pulmonary function, maintaining patients’ quality of life.
METHODS: A retrospective study of 62 consecutive patients underwent pre-operative CT-guided localization of solitary pulmonary nodules with ICG. Nodules ≤ 2cm were 28/62 (45%), ≤3cm were 49/62 (79%), ≤4cm were 56/62 (90%). A 25-gauge spinal needle was positioned adjacent or into the nodule with injection of 0.4-0.5cc of Indocyanine Green. The Xi daVinci Robot (Intuitive Surgery, CA) was docked and firefly filter of the 8mm camera was initiated. The nodule illuminated in a fluorescence green color. Wedge or sublobar resections were subsequently performed, lobectomy was completed when indicated.
RESULTS: Percutaneous CT-guidance successfully identified the lesion in 100% of the 62 patients. Success was assessed by illumination of the nodule as visualized by the surgeon upon activation of the Firefly filter and confirmed by pathology. There were no conversions to thoracotomy. Diagnosis was adenocarcinoma in 34 patients (54.8%), squamous in 8 patients (12.9%), carcinoid in 2 patient (3.2%), metastasis in 3 patients (4.8%), lymphoma in 1 patient (1.6%), melanoma in 2 patients (3.2%), and benign in 12 patients (19.3%). There were no 30 or 90 day mortalities. The economic comparison to other modalities of labeling demonstrates ICG cost at $79.58 as compared to a fiducial marker at a cost of $128.00. All institutions have access to CT scanners without an extra cost, whereas electromagnetic navigation systems come with substantial added costs for purchase and $300.00 or greater for disposables.
CONCLUSIONS: Percutaneous CT-guided identification with ICG is an efficient, cost-effective method to localize pulmonary nodules for patients undergoing Robotic Assisted and Video Assisted Thorascopic Surgery (RATS/VATS) resections. This technique may be beneficial in the preservation of pulmonary parenchyma and diminish the need for thoracotomies, maintaining the minimal invasive technique, especially in the absence of tactile response.
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