title: Image-guided thoracoscopic surgery with dye localization in a hybrid operating room.
abstract: BACKGROUND
  The rate of detection of small pulmonary nodules (SPNs) has increased. Thoracoscopic resection following image-guided localization had been a reliable alternative in their treatment. We present our experience with image-guided dye localization using robotic C-arm computed tomography (CT) followed by immediate video-assisted thoracoscopic surgery (VATS) for SPNs in a hybrid operating room (OR).
  
  
  METHODS
  From July 2015 to July 2016, 25 consecutive patients with SPNs smaller than 2 cm underwent robotic C-arm CT-guided blue dye tattooing followed by immediate VATS in a hybrid OR. Their medical records were retrospectively reviewed to evaluate the feasibility and safety of this novel procedure.
  
  
  RESULTS
  Robotic C-arm CT-guided dye localization was successfully performed in 23 patients (92%). Wound extension was required for nodule identification in the remaining two patients. The median size of the nodules was 1.0 cm (range, 0.6-2.0 cm). The median needle localization time and surgery time were 46 and 109 min, respectively. All 25 patients had successful resection of their lesions. The pathological diagnoses were primary lung adenocarcinoma in 18 (72%), benign tumors in 5 (20%), and metastatic lesions in 2 (8%). There was no operative mortality. The median length of the postoperative stay was 3 days (range, 2-8 days). Complications were noted in two patients (8%). One patient had a penetrating injury of the diaphragm during needle localization. The other had pneumonia postoperatively. Both patients were managed conservatively.
  
  
  CONCLUSIONS
  Our experience showed that robotic C-arm CT-guided dye localization followed by immediate thoracoscopic surgery in a hybrid OR is safe and feasible. It may become an effective and attractive alternative in managing SPNs.
authors.affiliation: Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan;; Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: Shun-Mao
authors.initials: SM
authors.lastname: Yang
authors.affiliation: Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: Wei-Chun
authors.initials: WC
authors.lastname: Ko
authors.affiliation: Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: Mong-Wei
authors.initials: MW
authors.lastname: Lin
authors.affiliation: Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: Hsao-Hsun
authors.initials: HH
authors.lastname: Hsu
authors.affiliation: Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: Chih-Yang
authors.initials: CY
authors.lastname: Chan
authors.affiliation: Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: I-Hui
authors.initials: IH
authors.lastname: Wu
authors.affiliation: Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: Yeun-Chung
authors.initials: YC
authors.lastname: Chang
authors.affiliation: Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan;; Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan.
authors.forename: Jin-Shing
authors.initials: JS
authors.lastname: Chen
keywords: Computed tomography (CT); hybrid operating room; localization; pulmonary nodules; video-assisted thoracoscopic surgery (VATS)