Robotic-Assisted Bronchoscopic Dye Marking & VATS Left Lower Lobe Apical Segmentectomy

Peripherally located lung nodules are becoming an increasingly common problem faced by thoracic surgeons because of the rising number of computed tomography scans being performed. With this shift, more suspicious ground-glass opacities (GGO) and suspected early stage adenocarcinomas are being identified and require treatment. But accurate intraoperative localization of these lesions remains a challenge. Along with a resurgence in interest and evidence for parenchymal sparing resections for cases of early stage malignancy, this localization challenge has paved the way for the adoption of various new technologies and techniques to be considered during the treatment process (1–4).

This video depicts a technique of treating a suspicious left lower lobe apical segment GGO in a sixty-three-year-old man. The technique utilizes the Monarch platform robotic-assisted bronchoscopy (5) for localization and triple contrast dye marking (6) to facilitate subsequent VATS left lower lobe apical segmentectomy.

Procedure

The suspicious GGO was first noted on a CT scan approximately one year prior to the act of noting interval enlargement from 1 cm to 1.3 cm on the subsequent follow-up scan. The PET-CT scan revealed no suspicious signs of mediastinal lymphadenopathy. Furthermore, the lesion was non FDG avid. A CT-guided biopsy yielded atypical cells. Early stage malignancy was suspected and thus decided for an apical segmentectomy procedure. Robotic-assisted bronchoscopic dye marking lesion localization was performed to ensure a good resection margin. This was done since the GGO was located deep within the inferior aspect of the apical segment.

A hybrid operating theater (Siemens Healthineer Artis Zeego) (7), equipped with cone beam CT and fluoroscopic overlay capabilities, was used for both localization with the robotic assisted bronchoscopy and the VATS resection. A large bore single-lumen endotracheal tube was used initially to facilitate the robotic bronchoscopy with the Monarch platform. In effect, direct visualization was used during the procedure in addition to electromagnetic navigation to increase accuracy. Next, the inferior aspect of the GGO was marked endobronchially using “triple contrast” dye: methylene blue for intraoperative visualization during VATS, indocyanine green (ICG) for deeper visualization by use of near-infrared imaging technology, and iohexol contrast for easy identification during fluoroscopy and cone beam computed tomography (CBCT) to ensure sufficient visualization of the area of interest (6). Finally, an additional metallic fiducial marker (8) was placed approximately 1 cm from the inferior aspect of the lesion to delineate the resection margin.

Subsequently, a two-port VATS left lower lobe apical segmentectomy procedure was performed following an exchange to a double lumen endotracheal tube. The segmentectomy was done with the aid of near infrared imaging to ensure identification of the dye-marked area. Next, the intersegmental plane was identified using 25 ml of intravenous ICG. Identification was performed after ligation of the segmental pulmonary artery and vein, and the previous endobronchially dye marked area (inferior to the lesion) was seen along the intersegmental plane. This technique ensured a good margin of resection. However, the methylene blue was not evident during VATS exploration. This setback was mitigated by the visualization of ICG fluorescence and the fiducial marker. The combined visualization of these dyes served as a sufficient marker for the resection margin; it also resulted in an effective localization model.

Postoperation

The pathology of the resected specimen showed a 1.4 cm adenocarcinoma with an acinar pattern, clear resection margins, and >1 cm away from the staple line. All resected lymph nodes (stations 9, 11, 12, 13) were benign. The patient enjoyed an uneventful postoperative course. The chest drain was removed on postoperative day two, and the patient was discharged from the facility on postoperative day three.

References

1. Saji H, Okada M, Tsuboi M, et al. West Japan Oncology Group and Japan Clinical Oncology Group. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet. 2022 Apr 23;399(10335):1607-1617
2. Kodama K, Higashiyama M, Okami J, et al. Oncologic Outcomes of Segmentectomy Versus Lobectomy for Clinical T1a N0 M0 Non-Small Cell Lung Cancer. Ann Thorac Surg. 2016 Feb;101(2):504-11.
3. Zhao ZR, Situ DR, Lau RWH, Mok TSK, Chen GG, Underwood MJ, Ng CSH. Comparison of segmentectomy and lobectomy in stage IA adenocarcinomas. J Thorac Oncol 2017 May;12(5):890-896
4. Awais O, Reidy MR, Mehta K, et al. Electromagnetic Navigation Bronchoscopy-Guided Dye Marking for Thoracoscopic Resection of Pulmonary Nodules. Ann Thorac Surg. 2016 Jul;102(1):223-9
5. Chaddha, U., Kovacs, S.P., Manley, C. et al. Robot-assisted bronchoscopy for pulmonary lesion diagnosis: results from the initial multicenter experience. BMC Pulm Med 19, 243 (2019)
6. Ng CSH, Zhao Z, Long H, Lau RWH. Electromagnetic Navigation Bronchoscopy Triple Contrast Dye Marking for Lung Nodule Localization. Thorac Cardiovasc Surg. 2020 Apr;68(3):253-255
7. Zhao ZR, Lau RW, Ng CS. Hybrid theatre and alternative localization techniques in conventional and single-port video-assisted thoracoscopic surgery. J Thorac Dis. 2016 Mar;8(Suppl 3):S319-27.
8. Chan JWY, Lau RWH, Ng CSH. Electromagnetic navigation bronchoscopy fiducial marker margin identification plus triple dye for complete lung nodule resection. JTCVS Tech. 2020 Jul 11;3:329-333. doi: 10.1016/j.xjtc.2020.07.010. PMID: 34317919; PMCID: PMC8304901.

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