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The Use of Robotic Bronchoscopy for Visceral Pleural Marking Prior to Surgical Resection of Pulmonary Nodules

Abstract

Chhaya Ronak*, Lam Geoffrey T, Egan John P and Cumbo-Nacheli Gustavo

Introduction: Pulmonary nodules suspicious for malignancy may require surgical biopsy. Options include wedge resection using video-assisted thoracoscopic surgery (VATS) or open thoracotomy. Nodules may be identified by visual inspection or digital palpation. Recent localization technical advancements have included preoperative hook wire placement, percutaneous dye injection and electromagnetic navigational bronchoscopy. Intraoperative conversion of VATS to open thoracotomy may stem from unsuccessful nodule localization. We hereby describe a novel approach to preoperative marking of the visceral pleura in order to assist with intraprocedural nodule localization. We present a series of patients who underwent visceral pleural marking by robotic bronchoscopy.

Materials and Methods: This study was performed at a single institution by two interventional pulmonologists and one cardiothoracic surgeon. Seventeen patients who required wedge resection of pulmonary nodules and underwent preoperative visceral pleural marking were studied. An electromagnetic navigational robotic bronchoscopy platform was utilized for dye marking, with fluoroscopy to facilitate needle placement. The primary objective was to advance the bronchoscope within close proximity of the suspicious nodule and mark the visceral pleura. A Wang needle was used to inject indocyanine green and methylene blue dyes. The robotic scope was then retracted to allow for surgical intervention. Wedge resection via robot-assisted VATS was subsequently performed.

Results: Seventeen patients underwent wedge resection for known or suspected malignancy: 13/17 were positive for malignancy, most commonly from extra thoracic metastasis; 6/17 proceeded to completion lobectomy following confirmation of non-small cell lung carcinoma (NSCLC) from intraoperative frozen section examination. There were no reported complications, including pneumothorax, bleeding or dye-related side effects.

Conclusion: Robotic bronchoscopy can be a safe and effective technique for visceral pleural marking prior to VATS resection of pulmonary nodules. Theoretically, this approach may reduce the conversion of VATS to open thoracotomy in selected cases. Further studies are needed to determine statistical differences in outcomes among different techniques for nodule localization, e.g. percutaneous vs robotic bronchoscopy. Limitations of the study include sample size, operator dependence and limited length of follow up.