Bridging the sensory gap: intraoperative lung ultrasound for deep pulmonary nodule localization in totally endoscopic robotic thoracic surgery

In robotic-assisted thoracic surgery (RATS), the absence of tactile feedback remains a critical limitation for intra-operative localization of small or deeply located pulmonary nodules. This study aimed to evaluate feasibility and safety of intra-operative lung ultrasound (ILU) as a real-time localization tool in this setting. We prospectively enrolled 26 patients undergoing totally endoscopic RATS for solid or part-solid pulmonary nodules located > 1 cm from the visceral pleura between February 2024 and February 2025. A linear extracorporeal ultrasound probe (Esaote LP 4-13) was used via the assistant port to identify the target lesion. Detection rate, localization time, resection margins, histology at frozen section and intra-operative outcomes were recorded. ILU successfully localized the target nodule in 25 out of 26 patients (96.1%). Median nodule diameter was 12 mm (IQR 9-14 mm), and median localization time was 12 min (IQR 10-15 min). All resected nodules had clear margins, with a median tumor-free distance of 11 mm (IQR 9-13 mm). Lobectomy was completed in 23 cases, while remaining patients underwent wedge resection alone due to indolent histology or intolerance to one-lung ventilation. No conversions to thoracotomy or peri-operative complications were observed. ILU proved to be a safe, accurate, and reproducible method for localizing deep pulmonary nodules in totally endoscopic RATS. By restoring the surgeon's spatial perception through imaging, ILU effectively compensates for the lack of tactile feedback in robotic surgery. This technique may allow for broader adoption of upfront robotic resections without pre-operative localization or biopsy.