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Preoperative Localization of Small Pulmonary Lesions with a Short Hook Wire and Suture System: Experience with 168 Procedures¹

¹ From the Departments of Radiology (S.D., S.K., K.Y., H.M., S.A., M.K, Y.H.) and Surgery II (A.A., N.S.), Okayama University Medical School, 2-5-1 Shikatacho, Okayama 700-8558, Japan; and Department of Radiology, Fukuyama National Hospital, Japan (T.H., Y.K.). Received June 11, 2001; revision requested August 3; final revision received February 18, 2002; accepted March 20. Address correspondence to S.K. (e-mail: susumu@cc.okayama-u.ac.jp).

View larger version (24K): [in a new window]   Figure 1a. System and manner of localization shown with model. (a) Introducer system with two concentric cylindric tubes: a 21-gauge 10-cm-long cannula and a 24-gauge 10-cm-long hollow pusher. The central 10-mm-long hook wire is preloaded inside the tip of the cannula, the attached suture (curved arrow) passes through the pusher, and the rim of the pusher is in place immediately after the funnel-shaped end of the hook wire. After a small rotation of the pusher hub (straight arrow) to release the safety stopper from the notch (arrowhead), the hook wire is ejected by means of full advance of the pusher. (b) In this model, gelatin and a 13-mm glass ball are assumed to be the lung and a pulmonary nodule, respectively. The tip of the introducing cannula is inserted close to the targeted nodule. (c) As the hollow pusher is fully advanced from within the cannula, the hook wire is ejected and freed from the cannula. (d) Introducer system of cannula and pusher is withdrawn. (e) Hook wire remains close to the nodule, and the portion of the suture outside the lung can serve as a guide and medium-strength tent during thoracoscopic surgery.

View larger version (76K): [in a new window]   Figure 1b. System and manner of localization shown with model. (a) Introducer system with two concentric cylindric tubes: a 21-gauge 10-cm-long cannula and a 24-gauge 10-cm-long hollow pusher. The central 10-mm-long hook wire is preloaded inside the tip of the cannula, the attached suture (curved arrow) passes through the pusher, and the rim of the pusher is in place immediately after the funnel-shaped end of the hook wire. After a small rotation of the pusher hub (straight arrow) to release the safety stopper from the notch (arrowhead), the hook wire is ejected by means of full advance of the pusher. (b) In this model, gelatin and a 13-mm glass ball are assumed to be the lung and a pulmonary nodule, respectively. The tip of the introducing cannula is inserted close to the targeted nodule. (c) As the hollow pusher is fully advanced from within the cannula, the hook wire is ejected and freed from the cannula. (d) Introducer system of cannula and pusher is withdrawn. (e) Hook wire remains close to the nodule, and the portion of the suture outside the lung can serve as a guide and medium-strength tent during thoracoscopic surgery.

View larger version (74K): [in a new window]   Figure 1c. System and manner of localization shown with model. (a) Introducer system with two concentric cylindric tubes: a 21-gauge 10-cm-long cannula and a 24-gauge 10-cm-long hollow pusher. The central 10-mm-long hook wire is preloaded inside the tip of the cannula, the attached suture (curved arrow) passes through the pusher, and the rim of the pusher is in place immediately after the funnel-shaped end of the hook wire. After a small rotation of the pusher hub (straight arrow) to release the safety stopper from the notch (arrowhead), the hook wire is ejected by means of full advance of the pusher. (b) In this model, gelatin and a 13-mm glass ball are assumed to be the lung and a pulmonary nodule, respectively. The tip of the introducing cannula is inserted close to the targeted nodule. (c) As the hollow pusher is fully advanced from within the cannula, the hook wire is ejected and freed from the cannula. (d) Introducer system of cannula and pusher is withdrawn. (e) Hook wire remains close to the nodule, and the portion of the suture outside the lung can serve as a guide and medium-strength tent during thoracoscopic surgery.

View larger version (73K): [in a new window]   Figure 1d. System and manner of localization shown with model. (a) Introducer system with two concentric cylindric tubes: a 21-gauge 10-cm-long cannula and a 24-gauge 10-cm-long hollow pusher. The central 10-mm-long hook wire is preloaded inside the tip of the cannula, the attached suture (curved arrow) passes through the pusher, and the rim of the pusher is in place immediately after the funnel-shaped end of the hook wire. After a small rotation of the pusher hub (straight arrow) to release the safety stopper from the notch (arrowhead), the hook wire is ejected by means of full advance of the pusher. (b) In this model, gelatin and a 13-mm glass ball are assumed to be the lung and a pulmonary nodule, respectively. The tip of the introducing cannula is inserted close to the targeted nodule. (c) As the hollow pusher is fully advanced from within the cannula, the hook wire is ejected and freed from the cannula. (d) Introducer system of cannula and pusher is withdrawn. (e) Hook wire remains close to the nodule, and the portion of the suture outside the lung can serve as a guide and medium-strength tent during thoracoscopic surgery.

View larger version (65K): [in a new window]   Figure 1e. System and manner of localization shown with model. (a) Introducer system with two concentric cylindric tubes: a 21-gauge 10-cm-long cannula and a 24-gauge 10-cm-long hollow pusher. The central 10-mm-long hook wire is preloaded inside the tip of the cannula, the attached suture (curved arrow) passes through the pusher, and the rim of the pusher is in place immediately after the funnel-shaped end of the hook wire. After a small rotation of the pusher hub (straight arrow) to release the safety stopper from the notch (arrowhead), the hook wire is ejected by means of full advance of the pusher. (b) In this model, gelatin and a 13-mm glass ball are assumed to be the lung and a pulmonary nodule, respectively. The tip of the introducing cannula is inserted close to the targeted nodule. (c) As the hollow pusher is fully advanced from within the cannula, the hook wire is ejected and freed from the cannula. (d) Introducer system of cannula and pusher is withdrawn. (e) Hook wire remains close to the nodule, and the portion of the suture outside the lung can serve as a guide and medium-strength tent during thoracoscopic surgery.

View larger version (131K): [in a new window]   Figure 2a. Transverse CT scans obtained in a 71-year-old man show simultaneous double hook wire placement and lesions with ground-glass opacity. (a) Scan shows a 19-mm-wide lesion with ground-glass opacity and an inserted cannula. The tip of the first cannula is 17 mm from the pleural surface and just beside the lesion. Note another 7-mm-diameter ground-glass opacity (arrowhead) in the same lobe. (b) Scan obtained after withdrawal of the introducer system shows the released hook wire (white arrow) just beside the lesion. Note small pneumothorax (black arrow). (c) Scan shows subsequent insertion of a second cannula (arrow) successfully performed 5 mm from the 7-mm-diameter ground-glass opacity and 15 mm from the pleural surface, despite advancing pneumothorax. (d) Scan obtained after withdrawal of the introducer system shows the newly released hook wire (arrow) 5 mm from the second lesion. The patient was moved to the surgical suite 30 minutes after these procedures were performed and did not need insertion of a drainage tube. The first lesion was faintly visible during thoracoscopy, but the second lesion was neither visible nor palpable. At intraoperative pathologic examination immediately after wedge resection, findings showed that the 19-mm-diameter lesion was well-differentiated adenocarcinoma and the 7-mm-diameter lesion was bronchioloalveolar carcinoma. VATS and lobectomy with lymph node dissection were subsequently performed.

View larger version (132K): [in a new window]   Figure 2b. Transverse CT scans obtained in a 71-year-old man show simultaneous double hook wire placement and lesions with ground-glass opacity. (a) Scan shows a 19-mm-wide lesion with ground-glass opacity and an inserted cannula. The tip of the first cannula is 17 mm from the pleural surface and just beside the lesion. Note another 7-mm-diameter ground-glass opacity (arrowhead) in the same lobe. (b) Scan obtained after withdrawal of the introducer system shows the released hook wire (white arrow) just beside the lesion. Note small pneumothorax (black arrow). (c) Scan shows subsequent insertion of a second cannula (arrow) successfully performed 5 mm from the 7-mm-diameter ground-glass opacity and 15 mm from the pleural surface, despite advancing pneumothorax. (d) Scan obtained after withdrawal of the introducer system shows the newly released hook wire (arrow) 5 mm from the second lesion. The patient was moved to the surgical suite 30 minutes after these procedures were performed and did not need insertion of a drainage tube. The first lesion was faintly visible during thoracoscopy, but the second lesion was neither visible nor palpable. At intraoperative pathologic examination immediately after wedge resection, findings showed that the 19-mm-diameter lesion was well-differentiated adenocarcinoma and the 7-mm-diameter lesion was bronchioloalveolar carcinoma. VATS and lobectomy with lymph node dissection were subsequently performed.

View larger version (130K): [in a new window]   Figure 2c. Transverse CT scans obtained in a 71-year-old man show simultaneous double hook wire placement and lesions with ground-glass opacity. (a) Scan shows a 19-mm-wide lesion with ground-glass opacity and an inserted cannula. The tip of the first cannula is 17 mm from the pleural surface and just beside the lesion. Note another 7-mm-diameter ground-glass opacity (arrowhead) in the same lobe. (b) Scan obtained after withdrawal of the introducer system shows the released hook wire (white arrow) just beside the lesion. Note small pneumothorax (black arrow). (c) Scan shows subsequent insertion of a second cannula (arrow) successfully performed 5 mm from the 7-mm-diameter ground-glass opacity and 15 mm from the pleural surface, despite advancing pneumothorax. (d) Scan obtained after withdrawal of the introducer system shows the newly released hook wire (arrow) 5 mm from the second lesion. The patient was moved to the surgical suite 30 minutes after these procedures were performed and did not need insertion of a drainage tube. The first lesion was faintly visible during thoracoscopy, but the second lesion was neither visible nor palpable. At intraoperative pathologic examination immediately after wedge resection, findings showed that the 19-mm-diameter lesion was well-differentiated adenocarcinoma and the 7-mm-diameter lesion was bronchioloalveolar carcinoma. VATS and lobectomy with lymph node dissection were subsequently performed.

View larger version (126K): [in a new window]   Figure 2d. Transverse CT scans obtained in a 71-year-old man show simultaneous double hook wire placement and lesions with ground-glass opacity. (a) Scan shows a 19-mm-wide lesion with ground-glass opacity and an inserted cannula. The tip of the first cannula is 17 mm from the pleural surface and just beside the lesion. Note another 7-mm-diameter ground-glass opacity (arrowhead) in the same lobe. (b) Scan obtained after withdrawal of the introducer system shows the released hook wire (white arrow) just beside the lesion. Note small pneumothorax (black arrow). (c) Scan shows subsequent insertion of a second cannula (arrow) successfully performed 5 mm from the 7-mm-diameter ground-glass opacity and 15 mm from the pleural surface, despite advancing pneumothorax. (d) Scan obtained after withdrawal of the introducer system shows the newly released hook wire (arrow) 5 mm from the second lesion. The patient was moved to the surgical suite 30 minutes after these procedures were performed and did not need insertion of a drainage tube. The first lesion was faintly visible during thoracoscopy, but the second lesion was neither visible nor palpable. At intraoperative pathologic examination immediately after wedge resection, findings showed that the 19-mm-diameter lesion was well-differentiated adenocarcinoma and the 7-mm-diameter lesion was bronchioloalveolar carcinoma. VATS and lobectomy with lymph node dissection were subsequently performed.