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Sponsored Video: Workflow for One-Stop Image-Guided Surgery of Small Pulmonary Nodules

Friday, March 13, 2015

Worldwide, lung cancer is a leading cause of death. Minimally invasive resection of small pulmonary nodules is an opportunity and a challenge at the same time. The earlier a growing tumor is resected the better the long-term outlook for the patient is in terms of reoccurrence and healthy tissue saved. Furthermore, the patient can benefit from a shorter recovery time through the minimally-invasive approach. However, the smaller the nodule, the more challenging the resection for the surgeon. An efficient solution can be found in intra-operative detection, marking, and resection of the nodule during a single session. This can be accomplished in a hybrid operating room (OR). A hybrid OR is a facility which combines advanced imaging capabilities with the infrastructure of an OR.

Traditionally, detection and needle marking of pulmonary nodules is done in the CT room. From there, the patient is transferred into the OR where the nodule is resected. The video shows a video-assisted minimally invasive resection of small pulmonary nodules using Siemens Artis zeego for intra-operative 3D imaging and syngo iGuide for needle path planning and guidance.

In this case, the patient presented with a suspicious lesion in the lungs. He was scheduled for a video-assisted thoracoscopic surgery of the nodule (VATS) in the hybrid OR. The patient was under general anesthesia and in surgical position when the OR team began with a large volume syngo DynaCT. Artis zeego allows intra-operative imaging in the hybrid OR. Marking and resection of the nodules can be accomplished in one session. The Artis zeego multi-axis robot-supported system provides high flexibility in different positions of the patient and the surgical team.

syngo DynaCT Large Volume is a unique feature of the Artis zeego. Two eccentric syngo DynaCT runs are performed and fused into one 3D image with a larger volume. This allows the visualization of both lungs and the surrounding skin. The representation of the surrounding skin is important for the surgeon to place the needle correctly.

The acquired 3D volume can be analyzed at the table-side and on the syngo X Workplace. The surgeon inspects the lungs in different cross-sectional planes and searches for the suspicious tissue. syngo iGuide supports the surgeon in planning the needle path.

The surgeon is able to mark the nodule in different layers of the image. Then, the path of the needle is planned by marking the entry and the target point of the needle on the screen. The path is verified by turning the image into different 3D views.

The C-arm travels automatically into the Bull’s Eye view, in which the detector and tube are parallel to the needle path. The surgeon activates the laser beam that indicates the entry point and the optimal direction of the needle. Once the needle is inserted into the body, the system can be switched to progression mode to control the penetration from a side view. The final position of the needle is checked by another  syngo DynaCT Large Volume run. This dose is not higher than in a conventional CT scanner. 

During the needle placement, a pneumothorax or a hematothorax should not happen. However, if it happens accidentally, the patient can be treated immediately under optimal conditions. Because the procedure is done in a hybrid OR, the procedural risk is reduced. When the needle is in the target area, the OR team covers the patient in sterile drapes. The surgeon starts the minimally invasive resection with a small intercostal approach to the lungs. When the intercostal ports are placed, the lungs collapse. Due to the small diameter of the port the surgeon cannot use his tactile sense. It is not possible for him to feel centrally located agglomerations. However, in this situation the needle and the video endoscope indicate the location of the tumor and guide him to the previously identified region. Thus healthy tissue can be saved.

Once the tumor is extracted, the tissue can be visually evaluated and send to the pathology laboratory for a detailed diagnosis. The patient benefits from an early minimally-invasive procedure while the surgeon benefits from a more straightforward and less risky workflow.

The statements by Siemens' customers described herein are based on results that were achieved in the customer's unique setting. Since there is no "typical" hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.

On account of certain regional limitations of sales rights and service availability, Siemens cannot guarantee that all products included in this presentation are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and are subject to change without prior notice.


Two points to clarify if you please: 1. How do you feel the position of the marking needle changes with the collapsing of the ipsilateral lung? 2. What do you think of seeding of malignant cells on the needle track? Promising concept, thank you Aristotle D. Protopapas MSc. (DIC) FRCS

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