Name: electromagnetic navigation transthoracic nodule localization for minimally invasive thoracic surgery
Uploaded: 2022-05-04T14:00:00
Description: Watch this Scientific Journal Video about Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery at JoVE.com

This work is supported by T32HL007106-41 (to Sohini Ghosh).

The procedure is performed in accordance with standard of care expectations and follows the guidelines of the human research ethics committee at the University of North Carolina at Chapel Hill.
1. Pre-operative Preparation
<ol>
	<li>Review prior chest computed tomography (CT) imaging to ensure that the patient undergoing nodule localization has a peripheral pulmonary nodule suitable for minimally invasive thoracic surgery (MITS).</li>
	<li>On the day of or a day prior to the procedure, perfo...

<ol>
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A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meta-analysis+of+guided+bronchoscopy+for+the+evaluation+of+the+pulmonary+nodule.">Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule.</a> Chest. 142 (2), 385-393 (2012).</li><li>Khandhar, S. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Electromagnetic+navigation+bronchoscopy+to+access+lung+lesions+in+1,000+subjects:+first+results+of+the+prospective,+multicenter+NAVIGATE+study.">Electromagnetic navigation bronchoscopy to access lung lesions in 1,000 subjects: first results of the prospective, multicenter NAVIGATE study.</a> BMC Pulmonary Medicine. 17 (1), 59 (2017).</li><li>Munoz-Largacha, J. A., Ebright, M. I., Litle, V. R., Fernando, H. 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H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+Effectiveness+and+Safety+of+Preoperative+Lung+Localization+for+Pulmonary+Nodules:+A+Systematic+Review+and+Meta-analysis.">Comparative Effectiveness and Safety of Preoperative Lung Localization for Pulmonary Nodules: A Systematic Review and Meta-analysis.</a> Chest. 151 (2), 316-328 (2017).</li><li>Kleedehn, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preoperative+Pulmonary+Nodule+Localization:+A+Comparison+of+Methylene+Blue+and+Hookwire+Techniques.">Preoperative Pulmonary Nodule Localization: A Comparison of Methylene Blue and Hookwire Techniques.</a> AJR. 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R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Image-guided+video+assisted+thoracoscopic+surgery+(iVATS)+-+phase+I-II+clinical+trial.">Image-guided video assisted thoracoscopic surgery (iVATS) - phase I-II clinical trial.</a> Journal of Surgical Oncology. 112 (1), 18-25 (2015).</li><li>Bolton, W. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Electromagnetic+Navigational+Bronchoscopy+Reduces+the+Time+Required+for+Localization+and+Resection+of+Lung+Nodules.">Electromagnetic Navigational Bronchoscopy Reduces the Time Required for Localization and Resection of Lung Nodules.</a> Innovations (Phila). 12 (5), 333-337 (2017).</li><li>Hartwig, M. G., D'Amico, T. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracoscopic+lobectomy:+the+gold+standard+for+early-stage+lung+cancer?.">Thoracoscopic lobectomy: the gold standard for early-stage lung cancer?.</a> The Annals of Thoracic Surgery. 89 (6), S2098-S2101 (2010).</li><li>Veronesi, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+lobectomy+and+segmentectomy+for+lung+cancer:+results+and+operating+technique.">Robotic lobectomy and segmentectomy for lung cancer: results and operating technique.</a> Journal of Thoracic Disease. 7 (Suppl 2), S122-S130 (2015).</li><li>Wei, B., Eldaif, S. M., Cerfolio, R. 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Peri-operative transthoracic nodule localization under EMN guidance is a novel application of a recently introduced EMN platform. The critical steps in the performance of EMTTNL are a proper point cloud registration of the device and attentiveness to the percutaneous insertion site and the angulation of the needle. Visualization and maintenance of the angle of entry on multiple planes of the CT scan (HUD, oblique 90, and oblique) are crucial to the success of the procedure.
Some of the followi...

With the increasing use of CT scans of the chest for diagnostic and screening purposes1, there is an increased detection of subcentimeter pulmonary nodules requiring diagnostic evaluation2. Percutaneous and/or transbronchial biopsy have been successfully used to sample indeterminate and high-risk nodules. These lesions often make for challenging targets due to their distal parenchymal location and small size3. When indicated, surgical excision of these lesions should be performed, using a lung-sparing resection via minimally invasive thoracic surgery (MITS), such as video- or robot-assisted thoracoscopic surgery (VATS/RATS)4. Even with advances in surgical technique, there remain intra-operative challenges to resection, despite direct visualization of the lung parenchyma during MITS. These challenges are primarily related to difficulties with nodule localization, especially with ground-glass/semisolid nodules, subcentimeter lesions, and those more than 2 cm from the visceral pleura5,6. These challenges are exacerbated during MITS due to a loss of tactile feedback during the procedure and can lead to more invasive surgical methods, including diagnostic lobectomy and/or open thoracotomy5. Many of these issues with intra-operative nodule localization can be mitigated by the use of adjunct nodule localization methods via electromagnetic navigation (EMN) and/or CT-guided localization (CTGL). This protocol will first highlight the benefits of using electromagnetic transthoracic nodule localization (EMTTNL). Secondly, it will delineate in a step-by-step fashion how to replicate the process prior to MITS.
Electromagnetic navigation helps to target peripheral pulmonary lesions by overlapping sensor technology with radiographic images. EMN first consists of using available software to convert CT images of the airway and parenchyma into a virtual roadmap. The patient&#39;s chest is then surrounded by an electromagnetic (EM) field within which the exact location of a sensory guide is detected. When a guide instrument (e.g., magnetic navigation [MN]-tracked needle) is placed within the patient&#39;s EM field (endobronchial tree or skin surface), the location is superimposed on the virtual roadmap, allowing for navigation to the target lesion identified on the software. EMN can be performed via either transthoracic needle approach or bronchoscopy. EMN bronchoscopy has previously been described for use in both biopsy and fiducial/dye localization7,8,9,10,11. A number of other localization techniques have been developed with varying success rates, including CT-guided fiducial placement, CT-guided injection of dye or radiotracer, intraoperative ultra-sonographic localization, and EMN bronchoscopy12. A recently introduced EMN platform has incorporated an electromagnetically guided transthoracic approach into its workflow. Using the CT roadmap, the system allows the user to define a point of entry on the chest wall surface through which they will pass a tip-tracked EMN-sensed needle guide into the lung parenchyma and lesion in question. Through this needle guide, biopsies and/or nodule localization can then be performed7.
Prior to the EMN localization of nodules for MITS, CTGL using dye marking or fiducial (e.g., microcoils, lipoidal, hook-wire) placement was the primary method employed. A recent meta-analysis of 46 studies of fiducial localization showed high success rates among all three fiducials; however, pneumothorax, pulmonary hemorrhage, and the dislodgement of fiducial markers remained significant complications13. A CT-guided tracer injection with methylene blue has had similar rates of success, but with fewer complications when compared with hook-wire fiducial placement14. One of the primary limitations of using dye for lung nodule localization has been diffusion over time15. Patients undergoing CTGL with dye marking have the localization performed in the radiology suite, followed by transport to the operating room, during which time dye diffusion can occur, making this technique less attractive. Some centers have mitigated this time lapse with the use of hybrid operating rooms with robotic C-arm CTs16,17; however, radiation exposure can be higher with the repeated images and use of fluorosocope15. The use of EMN bronchoscopy allows for peri-operative nodule localization. This, however, has been plagued by prolonged bronchoscopy times and an inability to navigate to those lesions without airway access. EMTTNL allows for a rapid percutaneous nodule localization followed by MITS in one location (i.e., the operating room), therefore decreasing time between the localization and the surgery18. In addition to EMN bronchoscopy, Arias et al. described using EMN for percutaneous biopsy7. An adaptation of this procedure for nodule localization is described below.
A 79-year-old male with a 40 pack-year history of tobacco use and bladder cancer was found to have a new PET fluorodeoxyglucose-avid lung nodule of size 1.0 cm x 1.1 cm in the left lower lobe by surveillance imaging (Figure 1). Given the lesion&#39;s size and position, wedge resection was considered challenging and the patient&#39;s pulmonary reserve made him a less than ideal candidate for diagnostic lobectomy. It was decided that he would undergo EMTTNL to aid in the MITS resection of the lung nodule.

<table>
	<tbody>
		<tr>
			<td>Computed Tomography Scanner</td>
			<td></td>
			<td></td>
			<td>64 - detector (or greater) CT scanner</td>
		</tr>
		<tr>
			<td>SPiN Thoracic Navigation System</td>
			<td>Veran Medical Tecnologies</td>
			<td>SYS 4000</td>
			<td></td>
		</tr>
		<tr>
			<td>SPiN Planning Laptop Workstation</td>
			<td>Veran Medical Tecnologies</td>
			<td>SYS-0185</td>
			<td></td>
		</tr>
		<tr>
			<td>SPiN View Console</td>
			<td>Veran Medical Tecnologies</td>
			<td>SYS-1500</td>
			<td></td>
		</tr>
		<tr>
			<td>Always-On Tip Tracked Steerable Catheter</td>
			<td>Veran Medical Tecnologies</td>
			<td>INS-0322</td>
			<td>3.2 mm OD, 2.0 mm WC</td>
		</tr>
		<tr>
			<td>View Optical Probe</td>
			<td>Veran Medical Tecnologies</td>
			<td>INS-5500</td>
			<td></td>
		</tr>
		<tr>
			<td>vPAD2 Cable</td>
			<td>Veran Medical Techologies</td>
			<td>INS-0048</td>
			<td></td>
		</tr>
		<tr>
			<td>vPAD2 Patient Tracker</td>
			<td>Veran Medical Techologies</td>
			<td>INS-0050</td>
			<td></td>
		</tr>
		<tr>
			<td>SPiNPerc Biopsy Needle Guide Kit</td>
			<td>Veran Medical Techologies</td>
			<td>INS-5600</td>
			<td>Includes INS 5029 (Box of 5)</td>
		</tr>
		<tr>
			<td>ChloraPrep applicator</td>
			<td>Beckton Dickinson</td>
			<td>260815</td>
			<td>26 mL applicator (orange)</td>
		</tr>
		<tr>
			<td>Provay/Methylene Blue</td>
			<td>Cenexi/American Regent</td>
			<td>0517-0374-05</td>
			<td>50 mg/10 mL</td>
		</tr>
		<tr>
			<td>Sterile gloves</td>
			<td>Cardinal Health</td>
			<td>2D72PLXXX</td>
			<td></td>
		</tr>
		<tr>
			<td>Blue X-Ray O.R. Towels</td>
			<td>MedLine</td>
			<td>MDT2168204XR</td>
			<td></td>
		</tr>
		<tr>
			<td>Scope Catheter</td>
			<td>DSC</td>
			<td></td>
			<td>3.2 mm outer diameter, working channel 2.0</td>
		</tr>
	</tbody>
</table>

electromagnetic navigation transthoracic nodule localization for minimally invasive thoracic surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

The patient was prepared per the protocol noted above. Following this, EMTTNL was performed with an injection of a total of 1 mL of a 1:1 methylene blue:patient blood mixture. Upon removal of the needle, the patient was prepped and draped for MITS. Robot-assisted thoracic surgery was performed using the four-arm technique with a robotic surgical system using five total ports. Four ports are placed along the eighth intercostal space (each 9 cm apart) anteriorly from the midclavicular line ...

Watch this Scientific Journal Video about Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery at JoVE.com

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

The main advantage of this technique is that it aids in the perioperative localization of small, deep, and/or sub-solid pulmonary nodules during minimally invasive lung resection. Before beginning the procedure, review prior chest computed tomography or CT imaging to ensure that the patient undergoing the nodule localization has a peripheral pulmonary nodule suitable for minimally invasive thoracic surgery. Then perform a non-contrast chest CT scan with the patient in the lateral decubitus position and the lung ipsilateral to the nodule positioned up to mimic the position during the dye injection.Obtain both expiratory and inspiratory images to account for nodule movement. On the day of the procedure, use the navigation system planning software to digitally segment the target lesion. If the target lesion is radiographically pure ground glass in nature, the segmentation software may fail to properly identify the lesion.If that is the case, place a virtual target in the center of the target lesion. Once the target lesion has been successfully marked, use the planning software to delineate the percutaneous site for needle entry. With the patient in the lateral decubitus position, attach three electronic reference point pads on the ipsilateral chest wall to the nodule and at least five centimeters away from the chosen point of entry.Plug the pads into the electromagnetic navigation system and position the electromagnetic navigation field generator over the reference pads to register the patient within the system. Then use the prompts provided by the electromagnetic navigation system to fine tune the calibration. Once the field generator is in position, use the electromagnetic navigation transthoracic nodule localization platform to take a virtual snapshot of the reference pads.To generate a data point cloud delineating the extent of the main airways, first insert the proprietary electromagnetic navigation tract disposable scope catheter into the right lumen of the double lumen endotracheal tube. Align the catheter on the main carina and slowly pull back into the trachea until prompted by the system to stop. Then drive the disposable scope catheter into the right lower lung lobe until prompted to stop with another green check mark.Once the data point collection is halted, transfer the disposable scope catheter from the right lung lumen of the double lumen endotracheal tube into the catheter of the left lung lumen of the tube. Then drive the disposable scope catheter into the left main stem bronchus two to three centimeters proximal to its bifurcation into the left upper and lower lobes. Resume the data collection driving the disposable scope catheter into the left lower lobe until prompted to stop.Once the full data point cloud has been collected, align a tract percutaneous needle at the chest wall skin entry site using the electromagnetic navigation platform for guidance. Mark the skin at the entry point to the chest cavity taking care that the entry point is just superior to the rib and avoiding any known vasculature or osseus structures. Clean the skin with the 2%chlorhexidine solution for a minimum of 15 seconds and allow the solution to dry for a minimum of 30 seconds.Drape the field using sterile technique and don sterile gloves and a sterile gown. Subcutaneously inject one to two milliliters of 1%lidocaine at the entry point for local anesthesia. Use a number 10 blade surgical scalpel to make a five millimeter superficial skin incision at the entry site through the epidermis.Place a sterile 19 gauge electromagnetic needle on the marked entry point. Use the transverse and coronal views on the electromagnetic system screen to adjust the angle of entry so that it lines up with the center of the target lesion. Once the angle of entry is confirmed, stabilize the electromagnetic navigation tract needle against the chest wall.Firmly advanced the needle through the chest wall while the anesthesia team holds the patient in exhalation. It is critical that the operator properly align the needle with the target lesion in at least two of the three views provided by the electromagnetic navigation system before stabilizing and advancing the needle in a straight downward thrust. Upon reaching the distal side of the target lesion from the chest wall, remove the tract stylet and cover the needle hub with a finger without dislodging the needle.Next, connect a syringe containing two to three milliliters of the appropriate concentration of methylene blue to the needle and inject 0.5 milliliters of the solution into the target lesion. Then gradually and continuously deposit another 0.5 milliliters of the solution while slowly withdrawing the needle to create a track. When all of the dye has been delivered, use the dye marking to localize and resect the lung nodule by minimally invasive thoracic surgery.After electromagnetic navigation transthoracic nodule localization as just demonstrated, the localization dye marking can be identified in the deflated lung and diagnostic wedge resection can be undertaken. While attempting this procedure, it is important to remember to ensure a proper registration and needle chest wall placement. This technique will hopefully pave the way for improvements in small nodule resection using minimally invasive surgical methods and in exploring this method's effects on the rate of diagnostic lobectomy and/or conversion to open thoracotomy.

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Ischemia-reperfusion injury is the main cause of flap failure in reconstructive microsurgery. The rat is the preferred preclinical animal model in many ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...