Group C included 22 consecutive patients who undertook CBCT and navigation bronchoscopic VATS marking.

The patient was given general anesthesia in the hybrid OR, and tracheal intubation was performed. Non-contrast CBCT was performed during suspended respiration using an Artis Q device (Siemens Healthcare, Forchheim, Germany). Cross-sectional images were then reconstructed automatically on a dedicated workstation (Syngo X Workplace; Siemens Healthcare, Forchheim, Germany). On cross-sectional images, the target lesion was manually contoured in multiple orthogonal planes using dedicated software (Syngo iGuide Toolbox; Siemens Healthcare, Forchheim, Germany). The contours were displayed live on augmented X-ray fluoroscopy for intraprocedural guidance. A bronchoscope was then inserted through the tracheal tube to the peripheral bronchus. A TBAC needle-guide sheath was led close to the target pulmonary nodule under CBCT-augmented X-ray fluoroscopy guidance. When the TBAC needle was deployed nearby the target contour, the C-arm of the CBCT-augmented X-ray fluoroscopy was tilted from the vertical to the horizontal direction to confirm that the tip of the TBAC needle was placed at the appropriate position three-dimensionally (Figure 4A,B). The VATS marker was then injected into the parenchyma near the target pulmonary lesion in the same manner as that performed in group B (Figure 4C,D). Compared to the first CBCT taken at the beginning of the procedure (Figure 5A), the second CBCT (Figure 5B,C) confirmed that the bronchoscopically injected VATS marker is located adjacent to the target pulmonary lesion. A three-dimensional CT image displaying the target pulmonary nodule(s) and VATS marker(s) in the half-translucent lung was created for intraoperative reference aiding the surgeons (Figure 5D). After inserting a bronchial blocker for isolated lung ventilation, the patient was placed in a lateral position, and VATS was continued.

Bronchoscopic video-assisted thoracic surgery (VATS) marking in the hybrid operating room (OR). (A) After the induction of general anesthesia, the target lesion can be visualized using cone-beam CT (CBCT); the tumor can then be displayed as red nodules or circles on augmented fluoroscopy. Even if the tumor itself is not visible under radiography, the position of the target lesion can be indicated on the monitor throughout the procedure. (B) A flexible bronchoscope is inserted through the intratracheal tube to the peripheral bronchus. The tip of the bronchoscopic needle is guided to the target lesion under both augmented X-ray fluorography and virtual bronchoscopy guidance. (C) A total of 0.05 mL of a VATS marker is injected. (D) A CBCT scan is performed again to confirm that the VATS marker was injected adjacent to the target pulmonary nodule (green-colored lesion). (E) The patient is repositioned into the lateral recumbent position. Thoracoscopic surgery is started, and the position of the target lesion is visualized using fluorescent thoracoscopy.

Examination of the accuracy of VATS marking on CT images. (A) The target pulmonary nodule to be marked by VATS. (B) CT image after the VATS marker (green arrow) is injected near the target pulmonary nodule (red arrow). (C) The distance between the center point of the target lesion and the center point of the VATS marker is measured on the workstation. (D) Three-dimensional chest image from the right lateral direction. The surgeon confirms that the VATS maker (green spot) is placed near the target (red spot).

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