Stanzi Alessia, Mazza Federico, Lucio Francesco, Ghirardo Donatella, Grosso Maurizio, Locatelli Alessandro, Melloni Giulio
Department of Thoracic Surgery, Santa Croce e Carle General Hospital, Cuneo, Italy.
Medical Physics Department, Santa Croce e Carle General Hospital, Cuneo, Italy.
Clin Respir J. 2018 Apr;12(4):1661-1667. doi: 10.1111/crj.12725. Epub 2017 Oct 26.
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.
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.
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.
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.
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.
当肺部病变无法被识别时，电视辅助胸腔镜手术（VATS）楔形切除术可能需要转为开胸手术。混合手术室（HORs）提供实时图像采集功能，可在术中放置标记物，以利于在VATS期间切除不可触及的结节。
根据肺病变的位置，介绍我们基于两种不同标记物交替使用的工作流程，并报告我们的初步结果。
所有连续的需要进行VATS楔形切除术的不可触及病变患者在HOR中进行目标定位。如果病变较小（<1厘米）、较深（距表面>1厘米）、为亚实性或位于营养不良区域，则认为病变不可触及。麻醉后的患者取侧卧位。进行锥形束CT（CBCT）检查，并使用西门子iGuide针引导系统规划针道。根据我们的工作流程，将金属钩丝或线圈放置在病变附近，并通过CBCT或荧光透视检查其位置。
10例患者共进行了11例VATS楔形切除术，有12个不可触及的病变。使用7根钩丝和4个线圈在30分钟内（范围17 - 56分钟）完成了定位。估计总有效剂量中位数为11.6毫希沃特（范围1.9 - 24.7毫希沃特）。11个病变通过VATS切除，1个深部结节需要开胸手术。未观察到并发症。
我们的经验证实，HOR适用于“困难”肺部病变的同时定位和VATS切除。在每种临床情况下，采用通用方法使用不同设备来切除目标似乎是可取的，可降低VATS转换率。
