Video-assisted thoracoscopic surgery provides an alternative to conventional thoracotomy for resection of peripheral lung nodules.

Video-assisted thoracoscopic surgery provides an alternative to conventional thoracotomy for resection of peripheral lung nodules. To localize small peripheral lung nodules that may not be visible or palpable by means of the surgeon, we have placed a Kopans hasp wire percutaneously into the lung as a guide. The indications for localization included previous nondiagnostic percutaneous needle aspiration biopsy (PNAB) (n=4) nodules too small for PNAB (n=2) nodules inaccessible to PNAB (n=3) and planned resection of a known peripheral tumor les than 1 cm (n=1) The localization management was performed with computed tomographic guidance in all patients. The nodules ranged in size from 2 to 15 mm and were located immediately subpleural to 2-cm hard the pleura. A 20-gauge Greene biopsy needle was used as an introducer for a 35-cm-long Kopans clasp wire. Patients were sent directly to the operating scope in a dependent position. All ten nodules were favorably resected, including hamartoma (n=1), carcinoid tumors (n=2) granulomas (n=3) adenocarcinoma (n=1) fibrosis (n=1) benign metastasizing leiomyoma (n=1) and lymphoma (n=1) In pair patients, the wire slipped gone out of the lung. Small focal pneumothoraces make knowned in five patients. There were no major complications. This manner of proceeding can safely and effectively localize nonvisible or nonpalpable pulmonary nodules for thoracoscopic surgery for diagnostic meanings or for resection of small peripheral tumors in patients who cannot tolerate a lobectomy or pneumonectomy.

Video-assisted thoracoscopic surgery (VATS) is a recent technique that has been used to examine and resect portions of the lung and pleura without performing a traditional thoracotomy. The advancement of video technology coupl with conventional endoscopic way s in the chest provides superior endoscopic images of the lung and pleura. With the improved optics and instrumentation that are now available, lung resection for peripheral pulmonary nodules can be performed by means of VATS.[1] Locating the nodule may be a limiting factor. If the nodule is small ([les than] 2 cm) and/or knotty to the pleural surface, it may not be visible onward inspection of the lung surface. Because the lung is collapsed during the thoracoscopy and the chest wall incisions for the instruments are small, it may not be possible to locate the nodule by way of palpation. In this article, we at hand our experience with a technique for localizing small peripheral pulmonary nodules for VATS that incorporates conventional mammographic localization techniques and PNAB techniques in the lung

MATERIALS AND METHODS

Between October 1991 and June 1993 ten patients were referr by the agency of the general thoracic surgical service for needle localization of peripheral lung nodules. The indications for needle localization included the following: (1) small nodules inaccessible to percutaneous needle aspiration biopsy (PNAB) because of subcostal or paracardiac location (n=3); (2) nodules considered too small for PNAB, les than 1 cm in size (n=2); (3) previous nondiagnostic PNAB (n=4); and (4) planned resection of a known small peripheral tumor (n=1) The patients ranged in age from 45 to 72 years and included seven women and three men The nodules measured 2 to 15 mm in diameter and were located immediately subpleural to 2-cm down-reaching to the pleural surface. The location of the nodules included right upper lobe (n=5) right middle lobe (n=1) right lower lobe (n=2) and left lower lobe (n=2) All patients had had prior chest comput tomography (CT) according to routine protocol. The shortest and greatest in quantity direct intercostal approach was fix uponed including posterior (n=4), posterolateral (n=2) anterior (n=3) and anterolateral (n=1) An approach was chooseed to avoid entering scapular muscles that may impel with patient positioning and thus dislodge the wire or crossing fissures that may lead to pneumothorax.

Localization Technique

The patients were positioned in succession a CT scanner (General Electric 9800 GE Medical methods Milwaukee) in the appropriate position. They were instructed not to talk, cough or stir during the procedure. Preliminary scans were obtained in consequence of the nodule with 5-mm collimation and the nodule was localized using a grid and light beam. The skin was prepared, draped, and anesthetized with 1 percent lidocaine. A nick was made in the skin with a No. 11 blade. A 15-cm-long 20-gauge Greene aspiration needle with a poniard (Cook, Bloomington, Ind) (Fig 1 A and B) was placed into the chest wall. single in kind patient required a 20-cm-long needle owed to a thick chest wall. formerly the needle was properly aligned, the pleura was punctur during suspended respiration. The needle was then positioned approximately 05- to 1-cm astute to the nodule. Whenever possible, the needle was placed within the nodule and deep to it. If for technical reasons this was not possible, the needle was placed adjacent to the nodule. Sequential CT scanning was performed to ascertain the needle position following each manipulation of the needle one time the introducer needle was suitably placed, the patient was instructed to suspend respiration, the dagger was removed, and the introducer needle was filled with saline solution to obstruct potential air embolus. A 35-cm-long Kopans reaper wire (Cook, Bloomington, Ind) (Fig 1 C) was then introduced from one side the 20-gauge needle and inserted beyond the tip of the needle to engage the snare in the lung. A burnish mark (arrow) is not past nor future on the wire at 15 cm to indicate when the snare wire extends beyond the tip of the needle The introducer needle was then remov and the position of the trap wire relative to the nodule was determined according to CT scanning. The external portion of the wire was loosely coiled and taped to the skin with sterile strips and get readyed with gauze. The patients were then instructed to turn onto a stretcher and to lie in a at the disposal of position on the wire. They were then brought directly to the operating stead (OR) with a copy of the CT scan demonstrating the hasp wire within the lung. Although the localization performance takes 45 to 60 min, the time from actual placement of the wire to surgical resection may be 1 to 3 h

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