Intraoperative localization techniques for pulmonary nodules.

Video-assisted thoracoscopic resection has emerged as a safe procedure for diagnosis and treatment of peripheral pulmonary nodules. Its role alone or with adjuvant radiotherapy in the management of high-risk patients with T1 peripheral lung cancer is currently under evaluation. Most often, inspection of the lung with imaging will reveal surface changes indicative of tumor location (erythema, puckering, scarring), and gentle instrumental probing will allow both visual and tactile discrimination of normal and tumor boundaries. With experience, most lesions can be identified this way. However, when experience is limited, in particular circumstances where lesions are very small, located posteromedially or basomedially, or when there is underlying lung disease (eg, lung fibrosis, radiation changes, adhesions), intraoperative identification of peripheral nodules can be difficult. Computed tomography of the chest helps in planning the operative procedure, the position of the patient, and the ideal ports. Methylene blue injection and insertion of a guidewire into the lung nodule facilitates its identification intraoperatively. We found ultrasound probes to be helpful in defining the tumor's margins and its relation to bronchovascular structures, and thus in planning the strategy of resection whether by stapling devices, cautery, or laser dissection.