Over the last few years there has been a significant increase in the number of small pulmonary nodules detected by low-dose computed tomography (LDCT) in the context of lung cancer screening programs. However, their excision by video-assisted thoracoscopic surgery (VATS) is frequently challenging. A key requirement for successful intraoperative identification of small lung nodules is their precise lesion localization during the preoperative phase.

The advent of hybrid operating rooms (HORs) – in which sophisticated imaging devices are combined with surgery procedures in a single room – has allowed the localization and removal of small lung nodules to be performed in a single session [i.e., image-guided video-assisted thoracoscopic surgery (iVATS)].

The first report on tumor localization in the HOR dates back to 2015 and several studies have subsequently confirmed the clinical usefulness of this approach. However, lesion localization within the HOR was reported to be more time-consuming and associated with a significant learning curve.

The Chang Gung memorial hospital iVATS team was established since 2016 and, remarkably, we have established our novel standardized iVATS workflow. Specifically, localization was performed through different marking approaches (single- vs. double-marker) and access routes [percutaneous technique with Dyna-computed tomography (DynaCT) imaging vs. electromagnetic navigation bronchoscopy (ENB), either with or without DynaCT]. Importantly, the technique is performed with the patient in a lateral decubitus position for localization, which allows accomplishing localization and surgery without patient repositioning.

To date, far in the lead, the CGMH team have performed more than 500 procedures with a success rate of 98.5% at the center.