Precision in Deep Lung Nodules Resection: Navigational Bronchoscopy and ICG-Guided Robotic Surgery – A Case Report

 

Objective: 

Deep Lung Nodules pose a challenge as they cannot be palpated nor seen, often leading to unnecessary lobar resections when a segmental approach may suffice. Recent studies support sublobar resection for peripheral non-small lung cancers(NSCLC)≤2 cm with node-negative disease, showing comparable disease-free survival to lobectomy. This case report highlights the combined use of intraoperative navigational bronchoscopy and indocyanine green(ICG) for robotic Deep Lung Nodules localization, enabling a sublobar resection.

 

Methods:

The ION robotic-assisted bronchoscopy system(Intuitive Surgical, Inc.) utilized the patient's computed tomography(CT) scan to localize the lesion. After confirming the biopsy needle's location in the lesion through CT, ICG was injected into Deep Lung Nodules. The da Vinci Xi Surgical System(Intuitive Surgical) employed the Xi Firefly system to detect fluorescence from the ICG injected into the tumor, localizing the Deep Lung Nodules and facilitating the resection.

 

Results:

Our patient was a 78-year-old female, diagnosed with biopsy-proven stage IA squamous cell carcinoma(9x13x12mm) in the right upper lobe.(FIGURE 1A,B) We began with navigational bronchoscopy to the lesion, which we injected with ICG for enhanced visibility. Following robotic port placement, the right upper lobe appeared normal under white light.(FIGURE 1C) Switching to Firefly sensitive mode, the lesion fluoresced, confirming its precise location in the posterior segment of the right upper lobe. (FIGURE 1D) Subsequently, a robotic upper posterior segmentectomy was performed. Once resected, Firefly mode was reactivated, revealing no residual disease.

 

Conclusion:

Combining navigational bronchoscopy for tumor localization with ICG and fluorescence-guided surgery may allow for a more parenchymal-sparing resection of Deep Lung Nodules.