Join thoracic surgeon Dr. Raffaele Marchigiani as he demonstrates the use of Indocyanine Green (ICG) Fluorescence Imaging during a thoracic wedge resection. This advanced imaging technique enhances surgical precision by providing real-time, clear visualization of tissue, improving outcomes and minimizing risk. In this case, Dr. Marchigiani showcases how ICG fluorescence aids in identifying critical structures and ensuring optimal resection margins, leading to safer, more effective thoracic procedures.
My name is Ralph Markajani. I'm a thoracic surgeon at Centera Lee, and I do my procedures out of Centera Lee Main OR, uh, and today we're gonna be reviewing a case, uh, lung cancer case that we used. A special dye called ICG and a soaked coil that was placed within the lung before surgery. We're gonna show how it was removed and using a special camera lens to do that. So this is the patient's preoperative X-ray. You can see the coil in the left upper lung field or this view right upper lung field. This is the left lung and you can see the nodule. Uh, the fiduci was placed 2 weeks before surgery. This is also the picture here in the, uh, kind of upper right or upper left lung. This is another view of the same area. It's a little bit difficult to see it. It's difficult to find, which is why we had this fiducial placed ahead of time or coil placed ahead of time. This is, uh, obviously in the operating room we're making our initial incisions to get into the chest. This patient did have a prior bypass, so she had a sternotomy, so you'll see as we get in that she does have some adhesions that took some time to take down. But these type of lesions called ground glass they're very difficult to feel they're not true nodules and when they're deeper in the lung they're almost impossible to feel. So we tend to use ways to find these, and this is a newer way we've been doing here. It's actually a vascular coil and the coil is soaked in ICG before implantation. That ICG will last up to 14 days. The procedure is done anytime between. A few days up to 14 days, uh, after 14 days, the diet will go away, so we try to perform surgery within 7 to 10 days following implantation of the coil. As you can see here, because of her prior coronary artery bypass grafting, she had some significant adhesions along the kind of chest wall and the anterior mediastinum there where her bypass and her her lima takedown was at, so we're being very careful. To stay away from the vessel that they use for her for her heart bypass. Now we're here trying to see if we can feel anything. Uh, unfortunately it was not uh a a good way to feel it. There is some scar there. Her lung is thick and again it wasn't a nodule, more of a ground glass. So I'm trying to get an idea based on a CAT scan if I could feel anything, uh, but really couldn't feel much. So here's where we switched over the cameras to the special light. That green dye is what we're talking about. That's the ICG soaked in this coil that's nearby the lesion. The type of camera lens we use will show that light. Those other two sites you're seeing is probably just spread. Those aren't spread from the dye, not from the cancer. Those do not concern me. It's more of the, the, the area that's the most saturated. So here I am using the camera on and off just to make sure I'm grabbing the right place in the lung, and as you can see there I'm grabbing the area with the dye. So now I know I have the lesion as I continue to kind of re-grab and readjust my, my grasper I'm able to get the nodule within my grasper and then I come well below it in order to get a good margin on my surgical resection. So here you can see again grabbing well below it. I now check again. So there's my grasp where there's a lesion. I see I have a good gross negative margin from what I can tell at this point we began our resection, so this is a surgical stapler we use again. I know my grasper is well below the lesion, but I also want to take my stapler even more below my grasper. That's additional margin. I wanna make sure I have in order to have a good cancer resection again, I keep checking the lesion. Keep checking my grasper, making sure we're in a good plane. We continue on with our resection, uh, again, checking, make sure that we have the lesion within the specimen. I'm overall happy with where it's at. I could see the dye. I could see my grasp or I could see my resection point. Continues to look good. You'll see that as I continue to grab the lung, that dye will spread a little bit. That's normal, um, as you put more pressure on it, it'll tend to diffuse a little bit. Now here we are removing the specimen. This is on the back table. This is out of the body and you can see that we have within our specimen and it looks to be far away from our staple line so there you go this is us palpating it again we can't really feel anything. It's all based on the dye knowing that we have the lesion and now I take a marker and I'm marking the margin so when they cut it open and look under a microscope they can actually see the purple ink and figure out how far away it is from the actual margin itself.
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