Image Guided Surgery Video Series, Episode 2 - Lung Nodule Localization &...

So we're back with episode 2 of our image guided surgery podcast. This is part 2. This is Rod Gerardo and I'm Anton Bash. We're research fellows at Cincinnati Children's Hospital Medical Center, and we're joined by Denise Liu. I am Denise Liu. I'm one of the interventional radiology residents at the University of Toledo. Previous. Part, we talked about lung nodule localization. We have images for you posted below the media player in the app to see what we're talking about. Today we're gonna talk about something else. What are we talking about, Denise? Today, we're gonna talk about the resection of the lung nodules that we localized on the last episode. Guys, hold on, I have a question first. It's about the last episode. After listening to Part one, I couldn't stop thinking, how long does the localization part take? I know probably if you have more lesions, it takes much longer, but what would you say for the draping and the localization, moving on to the surgery, how long does it take? So, and when we get around to actually doing the CT where we advance the needle to the lung nodule, this part typically doesn't take a very long time. Uh, with everything together from the time the patient gets into the room to the time we localize and be ready for surgery, and that time is about 45 minutes. Still seems pretty quick overall. So, if we're ready for today's episode, let's jump right in. Doctor Dasgupta, once you start, what is your process? Generally, we'll put in our first port. I don't. Other people do it differently. I don't insulate the lung or have the lung brought down. I find the wire while the lung is still inflated and bring it into the chest, primarily to make sure that the wire doesn't get pulled out of the lung after all the work that the interventionalists did. By causing us, you know, when we collapse the lung, the wire can sometimes get stuck within the chest musculature. So, we have the room to operate, and then basically, we find the wire, talk to IR either we see it really wonderfully or we do not see it. If we don't see it, just resect around the area of where the wire is. Making sure that we incorporate our discussions with our IR, uh, colleagues, that's medial or superior to the wire or whatever, and then remove the specimen often. We'll obviously feel the specimen, see if we can feel a nodule. If we put a coil in, we'll X-ray the specimen to make sure that the coil is in place and that the wire has been removed. And then I usually put a little tis seal on my staple lines of chest tube, and then out. Do you usually use 3 throw cards, camera points your working parts, yeah. There's a little detail we forgot to mention. Once we place the wire and check with CT it's in position, then we cut the wire off of the skin. And the reason for that is that the wires are quite long. And so if Rosie has to pull the whole wire through. If we leave the whole wire there, she's got to pull that through into the chest and it gets a bit cumbersome. So we cut the wire off at the chest, at the skin. Would you have cut it at the skin if we were gonna transport it if, if we don't have the hybrid OR, or does it get displaced during the transport, or what are your thoughts? In the old days when we were doing it downstairs on the traditional CT and then transferring, I still cut the wire. I learned to cut the wire because there was one memorable case when we left the wire in place from downstairs. We would pack up the wire with blue towels and then send the kid up to the operating room, and I got pulled to another case. When I went to the operating room, the OR nurses who had not been in the CT downstairs, thought that there's somebody had left a stitch in the chest, and they pulled it. So from that time onwards, I cut the wire, and it's a lot easier for the surgeon to pull that wire through. In the past, we just left the wire super long, and then we That it tends to get bent at the skin surface or it will jam and won't pull through or other times uh when patients are being repositioned the wire would get pulled out so um now we cut the wire short for ease of transport and make sure that nobody is going to uh dislodge it. While we're removing the lesion, we're not necessarily doing it under fluoroscopy or any kind of imaging, right? You just check the specimen. The only reason that you would use fluoro at the, at the, for the resection is if we'd placed the coil, just to assure that the coil has been removed. At the end of the case, we'd wanna use fluoro to make sure that that coil's not in the patient. So here's an example. Let's take a wedge resection with a wire. It looks like somebody is opening it up, potentially to look for ICG which I find really interesting. How would you explain that? How do you use the ICG and how does that process work? Which is just endocyanine green fluorescence. We are using it for all types of lesions, generally not thoracoscopically for looking at one lesion, but we do know that it's metabolized by the liver, so for hepatblastoma metastasis, it's actually very nice and you can actually see them quite well. The enhancement of these pulmonary nodules, depending on what their primary cancer is. Uh, depends on the primary cancer's vascularity. So for sarcoma, for example, it is very, uh, vascular due to the increased angiogenesis. So it will show up as hyper enhancing. It's not specific for a tumor type because there can be multiple hypervascular primary cancers. If you want to learn more about ICG imaging, we're gonna give you a link to an update course rewind where Doctor Chiro Esposito walks. Us through the utilization of ICG for the pediatric surgeon. Click on that link, check it out. I use it open all the time to find lesions that you can't see or palpate as well. The issue with the ICG, particularly thoracoscopically, is its depth of penetration. So you can't really see deep into the lungs. So you can put it in the camera and you really not see very much. You often have to cut open the specimen that you've already localized to prove that you've gotten it. That's why it's really important to do this needle localization for some of these nodules that are not right at the periphery. So once we get the lesion out, we double-check that it's all the way out, and then I assume that we can close up and finish. I'm finding that there's actually two really unique things about the Hybrid OR. One is obviously the technical aspect. You guys are able to do some really awesome things. The resolution of these images, it's absolutely incredible. But the other thing that I don't think we should sweep under the rug is that listening to Doctor Das Gupta and Doctor Ricardo talk. Together like their friends, like these two different departments in a pediatric hospital that get along really well, have the same goals. They want to work together well, they want to work together efficiently. I don't think that's very common in other institutions, and I think it's, it's, it's really amazing here what you guys are doing for the pediatric patient. So we moved interventional radiology from downstairs in radiology up into the operating room in 2000. With the political help of Doctor Eastcon and it made sense. If you look at interventional radiology, we are mechanical people doing mechanical things to patients through small holes with X-ray equipment. So it's actually the surgical process, not the radiology process, and so we moved out of radiology. Everything we do is on the operating room scheduling, the anesthesia, the whole thing. We're part of the operating room. So this is actually a very important thing very few hospitals have been able to achieve this. Some have tried, but it is very hard to get IR physically integrated into the OR so it's not a very common thing for most hospitals. We get rewarded. Children's for team building, not for individuality so much. It's been a very satisfying experience. I think we're really lucky that we have great interventional radiologists that work really well with us and, you know, we ask them for help all the time and it's just great to have them there cause they can come when you need them pretty quickly and it's a really good relationship that we have with them. We sometimes joke that the definition of surgery is interventional radiology with a big scar. Oh, that's cold, Doctor Johnson. Wow. That's fired. It's a pleasure to work with our surgeons. It's really comforting having that relationship knowing if you're doing an interventional case that's on the edge and is risky, we can call the surgeons and say, hey, you know, we're gonna be doing this just so you guys know if something terrible happens, and it's nice to. Feel that support and be able to maybe push the edge a little bit further than you would if you didn't have that support. I think it goes both ways in terms of you all helping the surgeons to localize and make the procedure as invasive as possible for the patient and that surgeons can help you if you need it. Hey Rod, can you summarize what we learned through this episode too? So, you're gonna have 3 ports total, 1 camera, 2 working ports. Doctor Dasgupta doesn't initially insufflate the chest. So first, she's gonna go and find the wire while the lung is inflated and, and pull the wire into the chest, so she can see it within her view, and so it doesn't get. Dislodged or moved or anything from externally. Then she'll insufflate the chest, and then work with anesthesiology to bring down the lung. If she's able to see where the wire is, she can dissect around the wire, obviously, consulting interventional radiology throughout the case to make sure that the localization is correct. Then she will proceed with a wedge resection of the specimen. And this day and age, using a thoracoscopic stapler, and then once they have the specimen removed, depending on wire, coil, whatever it is, they're gonna X-ray the specimen to verify, to seal all over the staple wise to help prevent any bleeding, and then we're out of there. And that's a wrap on episode 2, part 2 of Hybrid OR podcast, lung localization and resection, the steps, the intricacies of two different departments in a pediatric hospital working together for a patient with metastatic lung nodules. Uh, if you Like this episode. If you don't like it, go ahead and leave us a comment, like, or subscribe to our YouTube page. Uh, download the Saur Pediatric Surgery app. It's in the Apple App Store. It's in the Google Play Store. But until then, I'm Rod Gerardo. I'm, I'm Tom Bash, and I'm Denise Liu. And remember, knowledge should be free.