Video-assisted thoracoscopic surgery for pulmonary nodules: rationale for preoperative computed tomography-guided hookwire localization

Objectives: Video-assisted thoracic surgery (VATS) provides a minimally invasive means to resect pulmonary nodules (PN). Deep localization of PN may jeopardize VATS lung resection. The aim of this study was to establish the utility of preoperative computed tomography (CT)-guided hookwire localization of PN. Methods: Between January 1993 and September 2001, we performed 151 VATS resections for PN. Preoperative CT-guided hookwire localization was not performed in 98 patients (group 1); it was done just before surgery in 53 patients (group 11) when, at CT scan, the distance of PN from the lung surface was > 15 and/or when the size was < 10 mm. Results: Pneumothorax occurred in four patients (7.5%). Hookwire dislodged in four patients, but the hematoma left on the visceral pleura made thoracoscopic localization possible in three of these. Seventeen patients (17%) in group I and 4 (7.5%) in group 11 required conversion to thoracotomy (P ≤ 0.05). The most common reason for conversion was impossibility to localize PN in group I (nine cases) and deep localization requiring local enucleation in group 11 (two cases). In 31 group 11 patients (58%) hookwire positioning led to successful VATS resection that would otherwise have been impossible because PN were neither visible nor palpable. Conclusions: Preoperative CT-guided hookwire localization for pulmonary nodules is an effective technique which allows VATS resection of PN < 10 mm located > 15 mm from the pleural surface. Even when PN are subpleural but < 10 mm, hookwire localization makes VATS resection faster. Apical and diaphragmatic localization of PN are limitations to the procedure. (C) 2003 Elsevier B.V. All rights reserved.