Eastern Cardiothoracic Surgical Society

The Role of Navigational Bronchoscopy in Localization of Lung Nodules for Robotic Resection
Sagar Kadakia, Stefanos Boukovalas, Vishnu Ambur, Cherie Erikmen, Larry Kaiser, Abbas Abbas, Temple University School of Medicine, Philadelphia, PA

OBJECTIVE: Localizing small and deep lung nodules for sublobar resection may be difficult during thoracoscopic surgery and often requires larger resections or conversion to thoracotomy. Also, with robotic surgery, there is lack of tactile feedback. Electromagnetic navigational bronchoscopy (ENB) may provide a tool to help in localizing these nodules.

METHODS: This is a single institution retrospective study of all patients (20) who underwent ENB for intraoperative localization of pulmonary nodules that were deeper than 1 cm and smaller than 2 cm from May 1, 2013 to May 31, 2014.   Localization was done by ENB-guided transbronchial injection of different agents that included methylene blue, methylene blue plus a fiduciary or methylene blue plus indocyanine green. Immediately following localization, the patients underwent thoracoscopy followed by either robotic assisted thoracoscopic surgery (RATS) or video assisted thoracoscopic surgery (VATS).

RESULTS: ENB successfully localized the nodules for initial sublobar resection in 95% (19 of 20) patients. It failed to identify the nodule in 1 patient, who had a visible marker and initially underwent a wedge resection. However, intraoperative pathology did not identify the nodule and a robotic assisted right lower lobe basilar segmentectomy was then performed, which successfully resected the nodule. Minimally invasive thoracoscopic surgery was successfully performed in 18 of 20 (90%) patients. Sublobar resection was performed by RATS in 16 of 20 (80%) and by VATS in 4 of 20 (20%) patients. Of the 4 patients who underwent VATS, 2 patients required a thoracotomy secondary to extensive adhesions. There were no 90 day mortalities. A pneumothorax requiring chest tube reinsertion was seen in 5% (1/20) of patients. Home oxygen was required in 10% (2/20) of patients. Discharge with a Heimlich valve for persistent pneumothorax was required in 10% (2/20) of patients.

CONCLUSIONS: This study shows that ENB allows accurate localization of small and deep pulmonary nodules for sublobar resection during thoracoscopic surgery. This technique may help avoid the need for conversion to open surgery or for requiring larger resections. In robotic surgery, it may help compensate for the lack of tactile palpation.