Fluoroscopy-assisted thoracoscopic resection of lung nodules marked with lipiodol

Background. To localize small and deeply situated pulmonary nodules under thoracoscopy with roentgenographic fluoroscopy, we developed a marking procedure that uses both lipiodol and colored collagen. Methods. Pulmonary nodules were marked with 0.4 mL of lipiodol under computed tomography. The visceral pleura near each nodule was marked with 1 mL of colored collagen, ie, a mixture of atelocollagen and methylene blue. Nodules were marked more than 1 day before thoracoscopy. At thoracoscopy, C-arm-shaped roentgenographic fluoroscopy was used to detect the radiopaque nodules. Eighteen nodules in 16 patients were localized by this procedure. The nodules had an average diameter of 7 mm (range: 4 to 10 mm) and were located an average distance of 19 mm (range: 8 to 30 mm) from the pleural surface under computed tomographic measurement. Results. There were no complications from the marking procedure except for pneumothorax in 1 patient who required chest tube drainage for additional marking. All 18 nodules could be easily localized at thoracoscopy. The colored collagen revealed the pleura near the nodules. The lipiodol showed the nodules on the fluoroscopic monitor, which was used to guide the forceps to grasp the nodules. All of the nodules could be resected completely under thoracoscopy without adding minithoracotomy. The pathologic diagnosis was malignant tumor in 9 patients, atypical adenomatous hyperplasia in 3, and benign lesion in 4. Conclusions. A marking procedure that uses both lipiodol and colored collagen can localize small and deeply situated pulmonary nodules under fluoroscopy and facilitate safe and successful thoracoscopic resection.