Image-guided video assisted thoracoscopic surgery (iVATS) and the future of surgical management

The increased utilization of computed tomography for diagnostic imaging has led to an influx of incidentally discovered pulmonary nodules. Both thoracic surgeons and radiologists are burdened with risk stratifying these lesions for observation versus biopsy or resection. The diagnostic accuracy of percutaneous biopsy is dependent on the lesion's size, density, and anatomic location. Nodules that are not amenable to percutaneous biopsy are often referred to surgeons for excisional biopsy. Certain characteristics make some lesions more difficult to resect than others. Small (<1 cm), partially solid, pure ground glass, and central lesions can be difficult to palpate intraoperatively. These lesions can be challenging to resect with thoracoscopic and robotic assisted approaches due to diminished tactile feedback and smaller incisions. Over the past 30 years, techniques have been developed to assist surgeons in locating these lesions with the use of hook wires, fiducials, dyes, and radiolabeled isotopes. These markers are placed preoperatively but are prone to migration or diffusion. In this chapter a new localization and resection technique, image -guided video assisted thoracoscopic surgery (iVATS) is reviewed. iVATS is an attractive option for both patients and surgeons since the localization procedure and parenchymal resection are performed under a single anesthetic. A detailed description of the iVATS technique, success rate, and common complications are reviewed. For pulmonary nodules that are centered within a defined bronchovascular segment, upfront segmentectomy is a reasonable option for obtaining pathologic diagnosis. Since segmentectomy relies on surgeon knowledge and experience with segmental anatomy, non -palpable lesions can be easily treated with this technique. Pearls and pitfalls of the most common segmental resections are addressed. Despite the refinement of localization techniques, small pulmonary nodules continue to present a diagnostic challenge. Ongoing innovation of new clinical tools has generated promising options for the future. In this chapter, we will review some of the tools undergoing development including computer generated algorithms for nodule risk assessment, liquid biopsy, three-dimensional printing, and superselective segmentectomy. Some technologies are focused on creating non-invasive methods to determine if a nodule is benign or malignant, while others seek to improve localization techniques. All of the described tools will need further validation but will potentially streamline the diagnosis and treatment of pulmonary nodules for future clinical practice.