Combined lipiodol marking and video-assisted thoracoscopic surgery in a hybrid operating room

Advances in high-resolution computed tomography (CT) imaging and the availability of low-dose CT screening for lung cancer detection in asymptomatic patients are increasing the detection rate of small pulmonary nodules (SPNs) in the peripheral lung parenchyma (1,2). SPNs or nodules with ground-glass opacity (GGO) are difficult to localize because they are not visible, and manual palpation is sometimes needed during examination of pulmonary lesions. With the current shift toward minimally invasive surgery, video-assisted thoracoscopic surgery (VATS) has become common for resection of SPNs because of its minimal postoperative morbidity and mortality, along with less pain and a better quality of life, compared to open thoracotomy (3,4). Successful VATS for resection of SPNs largely relies on the ability to identify lesions intraoperatively by direct visualization or palpation. However, if the target nodule is <10 mm in diameter and the distance to the pleura is >10 mm, the failure rate of lung nodule localization during VATS is 100%, and this is the most common reason for conversion to open thoracotomy (5)