A case report of uniportal video-assisted thoracic surgery left lower lobe wedge resection: guided by negative fluorography based on pre-block of watershed pulmonary arteries

Abstract

Background: Accurate intraoperative localization of the nodules was the key point of sub-lobectomy resection. Percutaneous computed tomography (CT)-guided hook-wire was the most widely used method to locate pulmonary nodules, however, it was associated with high rates of pneumothorax and parenchymal hemorrhage. In recent years, surgeons were continuously seeking innovative approaches to cover the limitations of CT-guided hook-wire. In this article, we introduced an innovative approach that based on topographic anatomy of pulmonary segments. Case Description: After identifying and blocking the target arteries with the guide of three-dimensional (3D) reconstruction based on the CT images, indocyanine green (ICG) fluorescence was injected via peripheral vein, the fluorescence was invisible in the watershed of the target arteries by using infrared thoracoscopy. Then, a wedge resection along the border of fluorescence was completed. We demonstrated a case underwent wedge resection of a pulmonary nodule in left lower lobe, the 3D reconstruction revealed the 2 cm margin involved the subsegment a of LS8 (LS8a) and subsegment b of LS6 (LS6b). the nodule was successfully resected along the border of LS8a and LS6b displayed by this method after blocking the arteries of LS8a and LS6b. Conclusions: wedge resection guided by negative fluorography based on pre-block of watershed pulmonary arteries is a safe and flexible alternative method for nodules localization in video-assisted thoracic surgery (VATS).