Limits...
VATS intraoperative tattooing to facilitate solitary pulmonary nodule resection.

Willekes L, Boutros C, Goldfarb MA - J Cardiothorac Surg (2008)

Bottom Line: All lung nodules were resected in totality with normal lung parenchymal margins.Our technique added about one minute to the operative time.The two patients were discharged home on the second postoperative day, with no morbidity.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Surgery, Monmouth Medical Center, NJ, USA. ljw898@hotmail.com

ABSTRACT

Introduction: Video-assisted thoracic surgery (VATS) has become routine and widely accepted for the removal of solitary pulmonary nodules of unknown etiology. Thoracosopic techniques continue to evolve with better instruments, robotic applications, and increased patient acceptance and awareness. Several techniques have been described to localize peripheral pulmonary nodules, including pre-operative CT-guided tattooing with methylene blue, CT scan guided spiral/hook wire placement, and transthoracic ultrasound. As pulmonary surgeons well know, the lung and visceral pleura may appear featureless on top of a pulmonary nodule.

Case description: This paper presents a rapid, direct and inexpensive approach to peripheral lung lesion resection by marking the lung parenchyma on top of the nodule using direct methylene blue injection.

Methods: In two patients with peripherally located lung nodules (n = 3) scheduled for VATS, we used direct methylene blue injection for intraoperative localization of the pulmonary nodule. Our technique was the following: After finger palpation of the lung, a spinal 25 gauge needle was inserted through an existing port and 0.1 ml of methylene blue was used to tattoo the pleura perpendicular to the localized nodule. The methylene blue tattoo immediately marks the lung surface over the nodule. The surgeon avoids repeated finger palpation, while lining up stapler, graspers and camera, because of the visible tattoo. Our technique eliminates regrasping and repalpating the lung once again to identify a non marked lesion.

Results: Three lung nodules were resected in two patients. Once each lesion was palpated it was marked, and the area was resected with security of accurate localization. All lung nodules were resected in totality with normal lung parenchymal margins. Our technique added about one minute to the operative time. The two patients were discharged home on the second postoperative day, with no morbidity.

Conclusion: VATS with intraoperative tattooing is a safe, easy, and accurate technique to streamline and efficiently resect solitary pulmonary nodules.

Show MeSH

Related in: MedlinePlus

Chest CT scan. Nodule involving the right lower lobe, laterally, measures 1.1 × .6 cm.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC2278144&req=5

Figure 1: Chest CT scan. Nodule involving the right lower lobe, laterally, measures 1.1 × .6 cm.

Mentions: The patient is a 66-year-old white male with a past history of end-stage renal disease, hypertension, hyperlipidemia, diabetes, gastroesophageal reflux disease, and anemia. He had two pulmonary nodules on a CT scan of the chest measuring 1.5 and 1.8 cm. A PET scan was performed and showed a high uptake in area of these nodules (maximum SUV 5.2,6.1 respectively). The patient denied tobacco or alcohol use. He had no significant occupational environment exposure. A repeat CT scan three months later showed a decrease in size of the pulmonary nodules (1.1, 1.2 cm) but their etiology remained uncertain (Figures 1, 2). Under general anesthesia with a double-lumen endotracheal tube, the patient was positioned with the right side up. Three 1.5-cm ports were placed in a triangular fashion around the tip of the scapula. The 30-degree 10-mm viewing scope was inserted. The first lesion was palpated (Figure 3). In order to localize the lesion under a featureless lung surface, we injected 0.1 ml of methylene blue dye just underneath the visceral pleura using a spinal needle 25 Gauge through the posterior port under camera guidance (Figure 4). The camera and the operating instruments were then placed in ideal position and exchanged so as to provide a good angle for the stapling device to completely wedge out the lesion. The EZ45/4.8 standard stapling device was utilized to perform a wedge resection of the palpable abnormality (Figure 5). Attention was then turned to the posterior basal segment of the right lower lobe where the second lesion was palpated (Figure 6). After palpation, the area was marked with 0.1 ml of subpleural injection of methylene blue through the port as previously described (figure 7). The tattoo allowed us to remove the camera and exchanged grasper and camera positions and easily identify the lesion upon reentry. The lesion was biopsied in a similar fashion (Figure 8). Both lesions were removed using an EndoCatch bag and sent for frozen section


VATS intraoperative tattooing to facilitate solitary pulmonary nodule resection.

Willekes L, Boutros C, Goldfarb MA - J Cardiothorac Surg (2008)

Chest CT scan. Nodule involving the right lower lobe, laterally, measures 1.1 × .6 cm.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2278144&req=5

Figure 1: Chest CT scan. Nodule involving the right lower lobe, laterally, measures 1.1 × .6 cm.
Mentions: The patient is a 66-year-old white male with a past history of end-stage renal disease, hypertension, hyperlipidemia, diabetes, gastroesophageal reflux disease, and anemia. He had two pulmonary nodules on a CT scan of the chest measuring 1.5 and 1.8 cm. A PET scan was performed and showed a high uptake in area of these nodules (maximum SUV 5.2,6.1 respectively). The patient denied tobacco or alcohol use. He had no significant occupational environment exposure. A repeat CT scan three months later showed a decrease in size of the pulmonary nodules (1.1, 1.2 cm) but their etiology remained uncertain (Figures 1, 2). Under general anesthesia with a double-lumen endotracheal tube, the patient was positioned with the right side up. Three 1.5-cm ports were placed in a triangular fashion around the tip of the scapula. The 30-degree 10-mm viewing scope was inserted. The first lesion was palpated (Figure 3). In order to localize the lesion under a featureless lung surface, we injected 0.1 ml of methylene blue dye just underneath the visceral pleura using a spinal needle 25 Gauge through the posterior port under camera guidance (Figure 4). The camera and the operating instruments were then placed in ideal position and exchanged so as to provide a good angle for the stapling device to completely wedge out the lesion. The EZ45/4.8 standard stapling device was utilized to perform a wedge resection of the palpable abnormality (Figure 5). Attention was then turned to the posterior basal segment of the right lower lobe where the second lesion was palpated (Figure 6). After palpation, the area was marked with 0.1 ml of subpleural injection of methylene blue through the port as previously described (figure 7). The tattoo allowed us to remove the camera and exchanged grasper and camera positions and easily identify the lesion upon reentry. The lesion was biopsied in a similar fashion (Figure 8). Both lesions were removed using an EndoCatch bag and sent for frozen section

Bottom Line: All lung nodules were resected in totality with normal lung parenchymal margins.Our technique added about one minute to the operative time.The two patients were discharged home on the second postoperative day, with no morbidity.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Surgery, Monmouth Medical Center, NJ, USA. ljw898@hotmail.com

ABSTRACT

Introduction: Video-assisted thoracic surgery (VATS) has become routine and widely accepted for the removal of solitary pulmonary nodules of unknown etiology. Thoracosopic techniques continue to evolve with better instruments, robotic applications, and increased patient acceptance and awareness. Several techniques have been described to localize peripheral pulmonary nodules, including pre-operative CT-guided tattooing with methylene blue, CT scan guided spiral/hook wire placement, and transthoracic ultrasound. As pulmonary surgeons well know, the lung and visceral pleura may appear featureless on top of a pulmonary nodule.

Case description: This paper presents a rapid, direct and inexpensive approach to peripheral lung lesion resection by marking the lung parenchyma on top of the nodule using direct methylene blue injection.

Methods: In two patients with peripherally located lung nodules (n = 3) scheduled for VATS, we used direct methylene blue injection for intraoperative localization of the pulmonary nodule. Our technique was the following: After finger palpation of the lung, a spinal 25 gauge needle was inserted through an existing port and 0.1 ml of methylene blue was used to tattoo the pleura perpendicular to the localized nodule. The methylene blue tattoo immediately marks the lung surface over the nodule. The surgeon avoids repeated finger palpation, while lining up stapler, graspers and camera, because of the visible tattoo. Our technique eliminates regrasping and repalpating the lung once again to identify a non marked lesion.

Results: Three lung nodules were resected in two patients. Once each lesion was palpated it was marked, and the area was resected with security of accurate localization. All lung nodules were resected in totality with normal lung parenchymal margins. Our technique added about one minute to the operative time. The two patients were discharged home on the second postoperative day, with no morbidity.

Conclusion: VATS with intraoperative tattooing is a safe, easy, and accurate technique to streamline and efficiently resect solitary pulmonary nodules.

Show MeSH
Related in: MedlinePlus