title: VATS intraoperative tattooing to facilitate solitary pulmonary nodule resection.
abstract: BACKGROUND
  Video-assisted thoracic surgery (VATS) has become routine and widely accepted for the removal of solitary pulmonary nodules of unknown etiology. Thoracosopic techniques continue to evolve with better instruments, robotic applications, and increased patient acceptance and awareness. Several techniques have been described to localize peripheral pulmonary nodules, including pre-operative CT-guided tattooing with methylene blue, CT scan guided spiral/hook wire placement, and transthoracic ultrasound. As pulmonary surgeons well know, the lung and visceral pleura may appear featureless on top of a pulmonary nodule.
  
  
  METHODS
  This paper presents a rapid, direct and inexpensive approach to peripheral lung lesion resection by marking the lung parenchyma on top of the nodule using direct methylene blue injection.
  
  
  METHODS
  In two patients with peripherally located lung nodules (n = 3) scheduled for VATS, we used direct methylene blue injection for intraoperative localization of the pulmonary nodule. Our technique was the following: After finger palpation of the lung, a spinal 25 gauge needle was inserted through an existing port and 0.1 ml of methylene blue was used to tattoo the pleura perpendicular to the localized nodule. The methylene blue tattoo immediately marks the lung surface over the nodule. The surgeon avoids repeated finger palpation, while lining up stapler, graspers and camera, because of the visible tattoo. Our technique eliminates regrasping and repalpating the lung once again to identify a non marked lesion.
  
  
  RESULTS
  Three lung nodules were resected in two patients. Once each lesion was palpated it was marked, and the area was resected with security of accurate localization. All lung nodules were resected in totality with normal lung parenchymal margins. Our technique added about one minute to the operative time. The two patients were discharged home on the second postoperative day, with no morbidity.
  
  
  CONCLUSIONS
  VATS with intraoperative tattooing is a safe, easy, and accurate technique to streamline and efficiently resect solitary pulmonary nodules.
authors.affiliation: Department of Surgery, Monmouth Medical Center, NJ, USA. ljw898@hotmail.com
authors.forename: Lourens
authors.initials: L
authors.lastname: Willekes
authors.forename: Cherif
authors.initials: C
authors.lastname: Boutros
authors.forename: Michael A
authors.initials: MA
authors.lastname: Goldfarb
mesh_terms: D000368:Aged; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D015552:Injections, Intralesional; D007430:Intraoperative Care / Q000379:methods*; D008297:Male; D008751:Methylene Blue / Q000008:administration & dosage; D008875:Middle Aged; D049268:Positron-Emission Tomography; D003074:Solitary Pulmonary Nodule / Q000175:diagnosis / Q000601:surgery*; D013653:Tattooing / Q000379:methods*; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods*; D014057:Tomography, X-Ray Computed
chemical_list: D008751:Methylene Blue