From
StayCurrentMD
Image Guided Surgery Video Series, Episode 2 - Lung Nodule Localization &...
With Dr. Rajni Dasgupta · hosted by Dr. Rod Gerardo & Dr. Anton Bash & Dr. Denise Liu
Part of
Hepatoblastoma 15 items
Chapter 1 of 5 · Fundamentals
Pre-hybrid workflow
Introduction and Pre-Hybrid OR Workflow
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Pre-hybrid OR, lung nodule localization required moving the patient from CT scan downstairs to an operating room upstairs.
Traditional localization used Copan's breast localization needle and wire plus minus methylene blue blood patch.
Microcoil deployment is technically challenging and requires practice outside the patient beforehand because the coil is smaller than the guide needle and can deliver in the hub if not properly controlled.
Patients undergoing lung localization always have a double lumen ET tube or a bronchial blocker depending on patient size.
In hybrid OR, when possible, the patient is positioned in thoracoscopic position from the beginning, allowing single prep and draping and reducing chance of wire dislodgement.
Cone beam CT is a type of tomography where the C-arm rotates 360 degrees around the patient while capturing multiple images from different angles, essentially functioning like a CT but done with a C-arm.
The most important aspect of chest localization procedures is respiration motion, with anesthesia playing a crucial role in controlling respiration and providing apnea at the precise moment for targeting lung lesions.
The planned path goes directly through the middle of the intercostal space above the ribs to avoid the arteries and nerves that are below the rib.
It is critical to advance the needle quickly after planning; waiting and fiddling around after needle insertion increases risk of pneumothorax and other complications.
The respiratory excursion during cone beam CT imaging must match the respiratory excursion when advancing the needle, otherwise the planned path will be off target because the nodule location changes in 3D space with different respiratory phases.
If pneumothorax occurs, it can be managed by placing a 5 French sheath or pigtail catheter connected to low wall suction.
For lung biopsies in outpatients with moderate sedation, breathing changes make it difficult to maintain consistent breath-holding at the same level, which is why lesions should be at least 1 centimeter.
Cone beam CT spatial and contrast resolution is just as good as traditional CT, possibly slightly better, and can visualize all small lesions seen on diagnostic CT.
Multiple lesions can be localized simultaneously; up to 3 have been done, though multiple localizations increase the chance of pneumothorax.
3D rendering with segmentation coloring of the nodule allows rotation of the image in 3D space to understand spatial relationships, such as the nodule being inferior to the needle tip by a specific distance.
Real-time discussion between interventionalists and surgeons in the room helps confirm anatomical orientation (anterior, posterior, medial) and ensure everyone is on the same page.
Radiologists and surgeons think slightly differently in 3D space, making it valuable to have trusted colleagues from both specialties discussing positioning together.
The goal is to prep and drape the patient once, which saves time and helps ensure the wire stays in place by limiting movement.
Patients are usually positioned in lateral decubitus; supine positioning is rare and only needed based on nodule location.
During needle advancement, methylene blue blood patch should be injected as the needle advances through parietal pleura and punctures visceral pleura toward the target.
For very peripheral nodules, if the needle puncture through visceral pleura is not decisive and fluid is being injected, the visceral pleural surface can be pushed away, resulting in wire deployment outside the lung rather than within it.
More recently, localization has been done with microembolization coils in combination with Copan's wire as backup in case the wire becomes inadvertently pulled out during thoracoscopic resection.
Pre-hybrid OR workflow involved intubating upstairs, transferring down to CT, moving patient onto CT table, performing localization, then transferring back to OR and repositioning for thoracoscopy, creating multiple opportunities for wire dislodgement.
Cone beam CT performs a 360 degree scan of a designated 3D volume, giving cross-sectional images that account for the z-axis and provide 3D spatial information.
To ensure reproducible respiratory effort, patients are fully paralyzed and tubes disconnected from ventilator so the patient exhales naturally to a natural stopping point, which is more reproducible than using CPAP.
Using no positive pressure (natural exhalation) is thought to reduce the chance of pneumothorax.
Peripheral lung lesions carry higher risk of pneumothorax, while more central lesions carry higher risk of pulmonary hemorrhage.
If multiple lesions are in the same lobe, thoracic surgeons can resect them all together; if in different lobes with concern for different etiology, typically the biggest lesion is targeted.
Small nodules are not visible under plain fluoroscopy alone, so without CT guidance and planned graphics, needle advancement would be pushing blindly.
The display monitor shows live X-ray with graphics superimposed and the pre-op CT for comparison during needle advancement.