Background: The rate of detection of small pulmonary nodules (SPNs) has increased. Thoracoscopic resection following image-guided localization had been a reliable alternative in their treatment. We present our experience with image-guided dye localization using robotic C-arm computed tomography (CT) followed by immediate video-assisted thoracoscopic surgery (VATS) for SPNs in a hybrid operating room (OR). Methods: From July 2015 to July 2016, 25 consecutive patients with SPNs smaller than 2 cm underwent robotic C-arm CT-guided blue dye tattooing followed by immediate VATS in a hybrid OR. Their medical records were retrospectively reviewed to evaluate the feasibility and safety of this novel procedure. Results: Robotic C-arm CT-guided dye localization was successfully performed in 23 patients (92%). Wound extension was required for nodule identification in the remaining two patients. The median size of the nodules was 1.0 cm (range, 0.6–2.0 cm). The median needle localization time and surgery time were 46 and 109 min, respectively. All 25 patients had successful resection of their lesions. The pathological diagnoses were primary lung adenocarcinoma in 18 (72%), benign tumors in 5 (20%), and metastatic lesions in 2 (8%). There was no operative mortality. The median length of the postoperative stay was 3 days (range, 2–8 days). Complications were noted in two patients (8%). One patient had a penetrating injury of the diaphragm during needle localization. The other had pneumonia postoperatively. Both patients were managed conservatively. Conclusions: Our experience showed that robotic C-arm CT-guided dye localization followed by immediate thoracoscopic surgery in a hybrid OR is safe and feasible. It may become an effective and attractive alternative in managing SPNs.

The broad application of low-dose computed tomography screening has resulted in the detection of many more cases of early lung cancer than ever before in modern history. Recent advances in the management of early-stage non-small cell lung cancer have focused on making therapy less traumatic, enhancing recovery, and preserving lung function. In this review, we discuss several new modalities associated with minimally invasive surgery for lung cancer. Firstly, less lung parenchyma resection via sublobar resection has become an acceptable alternative to lobectomy in patients with tumors less than 2 cm in size or with poor cardiopulmonary reserve. Secondly, thoracoscopic surgery using a single-portal or needlescopic approach to decrease chest wall trauma is becoming common practice. Thirdly, less invasive anesthesia, using nonintubated techniques, is feasible and safe and is associated with fewer intubation- and ventilator-associated complications. Fourthly, preoperative or intraoperative image-guided localization is an effective modality for identifying small and deep nodules during thoracoscopic surgery.

Background: The Da Vinci robotic system has been used to enhance the surgeon’s visualization and agility in lung cancer surgery, and thus facilitate refined dissection, knot tying and suturing. However, only a few case reports exist on performing a sleeve lobectomy with a robotic-assisted thoracoscopic surgery (RATS) technique. Here we describe our early experience performing RATS sleeve lobectomies. To our knowledge, this is the first study reporting a series of RATS sleeve lobectomies. Methods: The six consecutive NSCLC patients who underwent a RATS sleeve lobectomy between November 2013 and July 2015 at the National Taiwan University Hospital were enrolled in this study. The lobectomies were all performed by the same surgeon using a three-arm robotic system with an additional utility incision made for assistance and specimen retrieval. Results: Five patients were diagnosed with squamous cell carcinoma, while the sixth was diagnosed with a carcinoid tumor. The mean operation time was 436.7 [255–745] minutes. The mean postoperative intensive care unit (ICU) stay and hospital stay were 3.7 [1–11] and 11.3 [3–26] days, respectively. Two (33.3%; 2/6) morbidities were noted, including one pneumonia and one anastomosis stricture. There were no cases of mortality or of conversion to thoracotomy. Conclusions: Our experience performing a RATS sleeve lobectomy in the six patients demonstrated the feasibility of RATS in complex lung cancer surgeries. The three-dimensional vision and articulated joint instruments made robotic-assisted bronchial anastomosis easier under the endoscopic setting. Our experience suggests that RATS offers specific advantages with regard to accuracy and safety when performing sleeve lobectomies.