Objective

To describe a non-invasive guidance procedure, using intraoperative Cone Beam Computed Tomography (CBCT) and augmented fluoroscopy to guide lung resection during video-assisted thoracic surgery (VATS).

Methods

Patients with pulmonary nodules less than 20mm were included. A moderate pneumothorax was created. CBCT acquisition was then performed. A segmentation of the lesion was done, giving a 3D reconstruction. A projection of this 3D reconstruction was then integrated into the digital workspace and automatically registered into the fluoroscopic images, creating an augmented fluoroscopy. Then, with classic video-thoracoscopic vision taking account of the augmented fluoroscopy to locate the targeted mass.

Results

8 patients have been included. Lesion’s mean size was 13±5mm. Mean depth was 21±10mm. 4 patients underwent a wedge resection. 2 patients had a wedge resection followed by lobectomy (primary lung tumor). 1 patient had a wedge resection in the upper lobe and a lobectomy of the inferior. 1 patient underwent a conversion and a bilobectomy (vascular injury). All the nodules have been identified on the CBCT. We have been able to detect all the nodules. The mean localization time was 11.8 ±3.8min.

Conclusion

This work is the first describing a clinical application of CBCT performed during thoracic surgery. Associated with augmented reality, it offers a significant advance to VATS resection of subpalpable lung nodules. This preliminary experience highlights the potential of the proposed CBCT approach to improve the perception of targeted small tumors during VATS.