VATS intraoperative tattooing to facilitate solitary pulmonary nodule resection

The patient is a 66-year-old white male with a past history of end-stage renal disease, hypertension, hyperlipidemia, diabetes, gastroesophageal reflux disease, and anemia. He had two pulmonary nodules on a CT scan of the chest measuring 1.5 and 1.8 cm. A PET scan was performed and showed a high uptake in area of these nodules (maximum SUV 5.2,6.1 respectively). The patient denied tobacco or alcohol use. He had no significant occupational environment exposure. A repeat CT scan three months later showed a decrease in size of the pulmonary nodules (1.1, 1.2 cm) but their etiology remained uncertain (Figures 1, 2). Under general anesthesia with a double-lumen endotracheal tube, the patient was positioned with the right side up. Three 1.5-cm ports were placed in a triangular fashion around the tip of the scapula. The 30-degree 10-mm viewing scope was inserted. The first lesion was palpated (Figure 3). In order to localize the lesion under a featureless lung surface, we injected 0.1 ml of methylene blue dye just underneath the visceral pleura using a spinal needle 25 Gauge through the posterior port under camera guidance (Figure 4). The camera and the operating instruments were then placed in ideal position and exchanged so as to provide a good angle for the stapling device to completely wedge out the lesion. The EZ45/4.8 standard stapling device was utilized to perform a wedge resection of the palpable abnormality (Figure 5). Attention was then turned to the posterior basal segment of the right lower lobe where the second lesion was palpated (Figure 6). After palpation, the area was marked with 0.1 ml of subpleural injection of methylene blue through the port as previously described (figure 7). The tattoo allowed us to remove the camera and exchanged grasper and camera positions and easily identify the lesion upon reentry. The lesion was biopsied in a similar fashion (Figure 8). Both lesions were removed using an EndoCatch bag and sent for frozen section

The second patient is a 63-year-old white female with no significant past medical history. She was a former heavy smoker, having quit 14 years ago. She had an incidentally discovered lung nodule on a chest x ray that was ordered preoperatively for an elective surgery. A chest CT showed a well circumscribed solitary nodule in the left upper lobe measuring 1.5 cm (Figure 9). The patient had general endotracheal anesthesia with a double-lumen tube, and was placed in the lateral position with the left side up. Three 1.5-cm ports were positioned in a triangular fashion around the tip of the scapula. Using 30-degree camera, examination of the left lung by finger palpation revealed a slightly firm area in the left upper lobe (lingular portion) that was approximately 2 cm in dimension (Figure 10). The lesion was marked with 0.1 mL of methylene blue dye just underneath the visceral pleura over the lesion (Figure 11). The camera and the working ports were exchanged and an EZ 45/4.8 standard stapler was then used to perform generous wedge resection of the tattooed area. The entire specimen was retrieved from the chest cavity in an EndoCatch bag.