A novel intra-operative navigation system for resection of small lung nodules by video-assisted thoracoscopic surgery (VATS) using three-dimensional image construction in real time and on site with a tablet computer

Precise imaging modalities are necessary during pulmonary resection to assess nodules that are otherwise difficult to diagnose. Studies have demonstrated that partial lung resection can completely cure adenocarcinoma in situ and minimally invasive adenocarcinoma. The important considerations for partial lung resection are: (I) to accurately identify the location of a small tumor intraoperatively and (II) to ensure a sufficient resection margin and preserve the remaining lung function. Hence, precise detection of hardly palpable or invisible tumors is essential. Although some reports describe methods for marking tumor locations, these processes are both invasive and complicated. Here, we describe a novel intraoperative navigation system that easily feeds image information to the operator on-site and evaluated its feasibility in three cases of partial lung resection. Implementing the software developed by Amin Inc. allowed three-dimensional scaling, rotation, transparency display, and calculation of tumor volumes in real time using a tablet computer (TC) interfaced with a hand tracking and voice control device. The surgeon, assistant, and digital imaging assistant can preoperatively verify the image using a TC by simulating the virtual resection line and insertion angle of the endoscopic stapler. During surgery, the tumor was assessed with a thoracoscope in comparison with the constructed three-dimensional image. Partial resection was successfully performed and pathological excision margins were negative in all cases. Other than prolonged air leakage in one case, no other complications were encountered. This novel navigation system appears to be safe and effective for less invasive partial lung resection.