Shape-Sensing Robotic Bronchoscopy with Integrated Mobile Cone-Beam CT Guidance for Intraoperative Localization of Lung Tumors Using Indocyanine Green

Background/Objectives: With increasing frequency in sublobar resections, accurate intraoperative localization has become essential to ensure adequate resection margins and spare lung parenchyma. Our study evaluates the efficacy of shape-sensing robotic bronchoscopy (SS-RAB) with integrated mobile cone-beam CT (mCBCT) for intraoperative localization of lung tumors using indocyanine green (ICG). We further aimed to explore the feasibility of a single intubation-single positioning technique for bronchoscopy and surgery. Methods: We retrospectively reviewed patients who underwent SS-RAB with integrated mCBCT for ICG marking, followed by minimally invasive sublobar resection. ICG marking was deemed successful when it allowed the operative team to localize and resect the lesion with adequate pathology margins. Results: A total of 28 patients with 30 pulmonary lesions from a single institution were included. Median tumor size was 10.5 mm (IQR, 8.7–14.6 mm) and distance from pleura 7.8 mm (IQR, 2.45–13.8 mm). Twenty lesions (66.6%) were solid, 5 lesions (16.6%) semi-solid, and 5 lesions (16.6%) ground-glass. ICG localization was successful in 28 lesions (93%). Nineteen patients (68%) were intubated only with a double-lumen endotracheal tube (DL-ETT), used for bronchoscopy and surgery, and in 10 patients (36%) ICG marking and surgery were both performed in lateral decubitus. One patient developed a small pneumothorax during bronchoscopy which did not prevent ICG injection. Conclusions: SS-RAB with integrated mCBCT for ICG marking is successful and safe. Single intubation with DL-ETT and lateral decubitus positioning for both bronchoscopy and surgery are feasible. Further studies are needed to prove a potential increase in efficiency with this technique.