Image-guided video-assisted thoracoscopic small lung tumor
resection using near-infrared marking
· Yu‑Yin Liu
· Hsin‑Yueh Fang
· Ming‑Ju Hsieh
· Yin‑Kai Chao
Received: 12 January 2018 / Accepted: 29 May 2018
© Springer Science+Business Media, LLC, part of Springer Nature 2018
Background Localization of non-visible, non-palpable small pulmonary nodules during video-assisted thoracoscopic surgery
(VATS) remains challenging. We sought to investigate the feasibility and safety of image-guided video-assisted thoracoscopic
surgery (iVATS) with near-infrared (NIR) marking in a hybrid operating room (OR).
Methods Both localization and surgery were performed by a single team of thoracic surgeons. Diluted indocyanine green
(ICG; quantity: 0.3–0.5 mL; dye concentration: 0.125 mg/mL) was injected percutaneously to pinpoint the tumor’s location
under cone beam computed tomography (CBCT) guidance using a laser-guided navigation system. Real-time ﬂuorescence
images were intraoperatively obtained using a NIR thoracoscopic camera to guide subsequent resection.
Results Between March and December 2017, 26 patients underwent NIR marking of small pulmonary nodules for iVATS.
The median tumor size was 7 mm (interquartile range [IQR] 5.3–10.8 mm), whereas their median distance from the pleural
surface was 5 mm (IQR 0.3–10.5 mm). Seven nodules (35%) were solid, whereas 17 (65%) were ground-glass opacities. All
lesions were identiﬁable on intraoperative CBCT. The median time required for NIR localization was 13 min. An NIR(+)
“tattoo” was identiﬁed in all cases, and no intraoperative conversion to thoracotomy occurred. The ﬁnal pathological diag-
noses were primary lung cancer (n = 11), metastatic cancer (n = 6), and benign lung tumor (n = 9). Adverse events were not
observed, and the median length of post-operative stay was 4 days (IQR 3–4 days).
Conclusions Our data show that iVATS with NIR marking is useful, has no adverse eﬀects, and can successfully localize
diﬃcult-to-identify small pulmonary nodules.
Keywords Near-infrared · Small pulmonary nodules · Indocyanine green · Imaging-guided video-assisted thoracoscopic
surgery · Hybrid operating room · ARTIS zeego
In recent years, the identiﬁcation of small pulmonary nod-
ules has increased dramatically as a result of low-dose
computed tomography (LDCT) screening for lung cancer
[1, 2]. Unfortunately, small pulmonary nodules are fre-
quently invisible and/or impalpable, ultimately posing
major challenges to their correct localization and removal
via video-assisted thoracoscopic surgery (VATS) . Incor-
rect information about the location of a pulmonary nodule
may lead to excessive parenchymal tissue sacriﬁce or even
unexpected conversion to open thoracotomy .
With the clinical scenario shifting towards an increasing
number of small pulmonary nodules being detected through
LDCT, the optimization of preoperative localization tech-
niques is increasingly crucial for optimal VATS outcomes
and prevention of intraoperative unplanned conversion to
open surgery . The standard method used for localiza-
tion of non-visible, non-palpable lesions is the hookwire
technique . Unfortunately, the associated risk of wire dis-
lodgement (caused by lung collapse during one-lung venti-
lation or surgical manipulation during VATS) remains not
negligible . A number of alternative localization methods
have been devised to circumvent this issue, including the use
and Other Interventional Techniques
Electronic supplementary material The online version of this
article (https ://doi.org/10.1007/s0046 4-018-6252-7) contains
supplementary material, which is available to authorized users.
* Yin-Kai Chao
Division of Thoracic Surgery, Chang Gung Memorial
Hospital, College of Medicine, Chang Gung University,
Department of General Surgery, Chang Gung Memorial
Hospital, Kaohsiung, Chang Gung University, Kaohsiung,