Narrative review: preoperative localization techniques for small lung nodules

Abstract

Abstract: Minimally invasive surgery, both video-assisted and robotic-assisted, are increasingly used as the approach for surgical biopsy of small indeterminate pulmonary nodules. As the use and resolution of computed tomography (CT) scans increases, the need for surgical biopsy is rising concurrently. The combination of small nodules and minimally invasive surgical approaches can lead to difficulty in localizing these nodules intraoperatively. This results in a negative biopsy or conversion to open surgery for manual localization. In order to mitigate these issues, thoracic surgeons should be familiar with the available techniques for preoperative or peri-operative localization, as well as their respective advantages and disadvantages. Pre-operative localization options often require working closely with interventional radiology; specifically they can help with the placement of metallic markers or injection of tracers and dyes to assist with palpation or visualization of otherwise hard to locate nodules. Newer, non-radiologic, options for peri-operative localization are also available. These include navigational bronchoscopy with indocyanine green (ICG) injection which is then visualized by a special intraoperative camera or image guided video-assisted thoracic surgery (iVATS) with placement of a marker in the same room and position used for resection. This paper will describe the most common techniques, their success rates and common complications, as well as the equipment needed for each approach. The decision regarding which described technique is ideal should be based on surgeon preference and familiarity with the procedure, as well as the available interventional radiologists and equipment at the institution.