Tailored intraoperative localization of non‐palpable pulmonary lesions for thoracoscopic wedge resection using hybrid room technology

VATS wedge resection can require conversion to thoracotomy when pulmonary lesions cannot be identified. Hybrid operating rooms (HORs) provide real‐time image acquisition capabilities allowing the intraoperative placement of markers to facilitate the removal of non‐palpable nodules during VATS. Objectives To present our workflow based on the alternative use of two different markers according to the location of the lung lesion and report our initial results. Methods All consecutive patients with non‐palpable lesions requiring VATS wedge resection underwent localization of the targets in HOR. Lesions were considered non‐palpable if they were small (<1 cm), deep (>1 cm from surface), subsolid, or located within a dystrophic area. Anesthetized patients were placed in lateral decubitus. Cone‐beam CT (CBCT) was performed, and the needle trajectory was planned using Syngo iGuide Needle Guidance. Metal hook‐wire or coil was placed, according to our workflow, close to the lesion and their position was verified by CBCT or fluoroscopy. Results Eleven VATS wedge resections were performed in 10 patients with 12 non‐palpable lesions. The localization was performed with seven hook‐wires and four coils in 30 minutes (range 17‐56 minutes). The median estimated total effective dose was 11.6 mSv (range 1.9‐24.7 mSv). Eleven lesions were removed by VATS, and one deep nodule required a thoracotomy. No complications were observed. Conclusions Our experience confirms that HOR is suitable for simultaneous localization and VATS resection of ‘difficult’ pulmonary lesions. A versatile approach, using different devices, seems advisable for the removal of targets in every clinical scenario, reducing the VATS conversion rate.