Bronchoscopy-guided intraoperative localization of lung nodules using fiducial Indocyanine green (ICG) dye instillation: A novel aid for surgical resection – First report from India

In cases of malignant solitary pulmonary nodules (SPNs), Video-assisted Thoracoscopy (VATS) or Robotic-assisted Thoracoscopy (RATS)-guided segmentectomy are preferred surgical modalities.Precise intraoperative localization of SPNs, particularly when small, subsolid, or deeply positioned, remains challenging despite advancements in thoracic surgery.Difficulty in localization can compromise surgical precision, prolong operative time, and increase morbidity.We report two female patients, aged 73 and 55 years, each with FDG-avid solitary pulmonary nodules measuring 2.2 x 2.1 cm in LB 1+2 and 1.8 x 1.5 cm in RB 6 segments, respectively.Both nodules were diagnosed as adenocarcinoma on biopsy with a negative staging linear endo-bronchial Ultrasound (EBUS) and no distant metastases on a positron emission tomography(PET) scan (T1N0M0).Both patients were planned for a RATS segmentectomy.Intraoperatively, they underwent bronchoscopy-guided fiducial localization.Navigation planning was performed using Virtual Bronchoscopic Navigation (Lung Point), and lesions were localized using an ultra-thin bronchoscope and radial EBUS.A PeriView FLEX TBNA needle was precisely positioned within the nodules under fluoroscopy.Subsequently, 0.25ml of indocyanine green (ICG) dye solution mixed with distilled water and 20% human albumin was instilled into the nodules.Intraoperative visualization via Firefly near-infrared (NIR) imaging effectively highlighted the fluorescent nodules, facilitating precise, efficient, and complete surgical resection with clear margins.This case series demonstrates that bronchoscopic fiducial localization using ICG dye enhances intraoperative visualization of lung nodules.The technique ensures accurate resections, reduces procedural duration, minimizes morbidity, and decreases the necessity for invasive open thoracotomy.