Successful resection of multi-focal lung nodules in a 53-year-old male following preoperative 5G-assisted remote robotic bronchoscopy dye marking: a case report

Introduction

The management of early-stage lung cancer, particularly through sublobar resection for ground-glass nodules, demands a high degree of precision in preoperative localization. However, access to the specialized expertise and advanced technology required for optimal nodule marking remains geographically constrained. Thoracic surgical specialists and state-of-the-art robotic platforms are predominantly concentrated in major metropolitan tertiary care centers, creating a significant disparity in care for patients in rural or medically underserved regions (1). This “access gap” underscores a pressing need for innovative solutions that can decentralize and democratize high-precision thoracic interventions.

To achieve precise sublobar resection, secure intraoperative localization of small or subsolid nodules is essential. Currently, computed tomography (CT)-guided percutaneous hookwire or dye marking is the most widely utilized technique. However, it is associated with notable limitations, including a significant risk of complications such as pneumothorax (reported rates of 35%), pulmonary hemorrhage, and rare but serious concerns like air embolism or track seeding (2). These risks, along with patient discomfort and radiation exposure, highlight the clinical demand for safer, less invasive alternative localization methods. Transbronchial approaches, enabled by advanced navigation, present a promising avenue to mitigate these percutaneous risks.

Robotic-assisted bronchoscopy has emerged as a pivotal technological advancement, enhancing the stability, reach, and precision of conventional bronchoscopic navigation for the diagnosis and marking of peripheral pulmonary nodules. Its integration with electromagnetic navigation and shape-sensing technology has demonstrated promising diagnostic yields and an excellent safety profile for preoperative dye marking (3,4). Concurrently, the advent of fifth-generation (5G) telecommunication networks, with their hallmark ultra-low latency and high reliability, has transformed the landscape of telesurgery. 5G has evolved from proof-of-concept demonstrations to initial clinical implementations in various surgical fields, effectively collapsing geographical barriers by enabling near real-time remote manipulation of surgical consoles (5,6).

The convergence of these two technologies—robotic bronchoscopy for precise transbronchial access and 5G for real-time remote operation—creates a potential paradigm shift. Herein, we report the first clinical application of a 5G-enabled remote-controlled robotic bronchoscopy system for preoperative dye localization of pulmonary nodules, demonstrating a novel approach designed to address the dual challenges of procedural precision and equitable access. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0031/rc).

Case presentation

Clinical data

A 53-year-old male was admitted to our department for surgical management of incidentally detected pulmonary nodules. The patient was entirely asymptomatic with the pulmonary nodules discovered during a routine health examination three months ago. He reported no cough, chest pain, hemoptysis, dyspnea, fever, or weight loss. The patient had no significant past medical or surgical history. He was a lifelong non-smoker and denied any known occupational exposure to asbestos or other respiratory irritants. There was no relevant family history of malignancy. On admission, his vital signs were within normal limits. Cardiorespiratory auscultation revealed clear breath sounds bilaterally with no added sounds, and normal heart sounds. There were no signs of digital clubbing, lymphadenopathy, or cyanosis. Routine laboratory investigations, including complete blood count and coagulation profile, were within normal limits. Preoperative pulmonary function tests demonstrated normal lung volumes and capacities, with a forced expiratory volume in 1 second (FEV₁) of 3.61 L (108.7% predicted) and a diffusing capacity for carbon monoxide (DLCO) of 91.4% predicted, confirming adequate respiratory reserve for surgery.

A follow-up chest CT scan obtained in September 2025 confirmed the persistence of two dominant ground-glass nodules (GGNs): a 14 mm × 9 mm ground-glass nodule in the apical segment of the right upper lobe (RUL), exhibiting a pleural indentation sign; a 7 mm ground-glass nodule in the posterior basal segment of the right lower lobe (RLL), showing a vacuole sign (Figure 1). The case was reviewed by our hospital’s multidisciplinary team (MDT) for pulmonary nodules, which included specialists from thoracic surgery, pulmonology, radiology, and pathology. The MDT consensus was that, based on the persistence of the nodules and their suspicious morphological characteristics—notably the pleural indentation and vacuole sign—there was a high probability of malignancy. Surgical resection was strongly recommended for definitive diagnosis and curative treatment, a decision consistent with established guidelines for the management of persistent nodules with high-risk feature. To facilitate precise sublobar resection, preoperative localization was deemed necessary. To mitigate the risks of pneumothorax and hemorrhage associated with CT-guided percutaneous transthoracic needle localization, dye marking via a transbronchial route was selected. Robotic-assisted bronchoscopy was specifically chosen for this task due to its enhanced stability and navigational precision in accessing peripheral airways, offering a potentially safer and more accurate alternative for targeting these GGNs.

Figure 1 Preoperative CT images of the two target pulmonary nodules. (A) A 14 mm × 9 mm ground-glass nodule in the RUL. (B) A 7 mm ground-glass nodule in the RLL. CT, computed tomography; RLL, right lower lobe; RUL, right upper lobe.

Robotic-assisted bronchoscopy system and remote localization

The Artificial Intelligence Agent Robotic Assisted Bronchoscopy (aaRAB) system, developed by LungHealth MedTech Company and featuring the Polaris^TM robotic bronchoscopy navigation platform, represents a significant technological advancement in flexible interventional robotics. Approved by China’s National Medical Products Administration in 2023, it integrates multimodal sensing and therapeutic capabilities. After acquiring thin-slice chest CT images, the aaRAB system performed three-dimensional airway reconstruction and navigation path planning. Its artificial intelligence (AI)-assisted software automatically identified the target lesion and generated an optimal navigation route to the segmental bronchi. A simulated path preview allowed for the preoperative assessment of key anatomical branches.

The remote-control system was supported by the Beacon-based 5G network. Leveraging this high-bandwidth, low-latency infrastructure, the remote master console transmitted the surgeon’s navigation commands, facilitating near-real-time synchronization with the robotic arm’s movements in the operating room (Figure 2A). Throughout the procedure, the network signal delay during the procedure was measured and maintained within an excellent range of 21 to 24 milliseconds (ms), thus ensuring real-time control and high precision. Patients were placed supine under general anesthesia in the operation room (Figure 2B). The surgeon monitored and guided the entire process remotely from the control station. The catheter was successfully navigated to the immediate vicinity of both the RUL and RLL target nodules. Once in position, a small amount of indocyanine green (ICG) was injected trans-bronchially by the assistant in the operation room.

Figure 2 Setup for the remote control robotic-assisted bronchoscopy. (A) The surgeon operated the console from the separate control room. (B) The intraoperative scene in the operating room, showing the patient in a supine position under general anesthesia. These images are published with the participants’ consent.

Surgical procedure

Following successful localization, the patient underwent uniportal video-assisted thoracic surgery (VATS). Intraoperative fluorescence imaging was utilized, which clearly confirmed the pre-marked nodules in both the RUL and RLL, presenting as distinct purple foci (Figure 3). Subsequently, precise wedge resections of both lesions were performed using a surgical stapler, ensuring an adequate macroscopic margin. The resected specimens were immediately sent for intraoperative frozen section analysis. The frozen section pathology report indicated: (I) the RUL nodule showed focal alveolar epithelial hyperplasia with mild inflammatory cell infiltration and hemosiderin deposition in the stroma; (II) the RLL nodule was diagnosed as adenocarcinoma in situ (AIS). The entire procedure was completed successfully with negligible estimated blood loss.

Figure 3 Intraoperative fluorescence imaging. (A) The marked nodule in the RUL. (B) The marked nodule in the RLL. RLL, right lower lobe; RUL, right upper lobe.

Postoperative recovery and pathological results

The patient’s postoperative course was uneventful and followed a standardized enhanced recovery after surgery (ERAS) pathway. A bedside chest X-ray on the day of surgery confirmed well-expanded lungs with no signs of pneumothorax or air leak. The chest tube was removed on postoperative day (POD) 2 following satisfactory clinical and radiological assessment. The patient was discharged on POD 3 in a stable condition. A follow-up chest X-ray at 28 days post-operation showed continued excellent pulmonary status with no abnormalities (Figure 4).

Figure 4 The follow-up chest X-ray.

The final histopathological examination of the resected specimens provided a definitive diagnosis that correlated closely with the preoperative imaging characteristics. The nodule in the RUL was confirmed as focal atypical adenomatous hyperplasia (AAH), with stromal fibrosis, scattered lymphocyte infiltration, and hemosiderin deposition, consistent with its pre-invasive, low-density radiological appearance. The target nodule in the RLL, which appeared as a 7 mm GGO with a central vacuole sign, revealed a more complex histology. The lesion was predominantly composed of bronchiolar adenoma. However, a focal area of non-mucinous AIS was identified upon extensive sampling; this AIS component measured approximately 0.2 cm in diameter on the frozen section slides. The transition to a focal invasive pattern or the presence of a fibrotic focus was not identified. The presence of the vacuole sign on CT corresponded to the architecturally complex glandular proliferation seen in the AIS focus. Critically, the following features were negative: spread through air spaces (STAS), lympho-vascular invasion, perineural invasion, and pleural invasion. All surgical margins were confirmed to be uninvolved by the tumor.

Patient perspective

As someone who had never undergone a major procedure before, the idea of surgery was daunting. However, the medical team thoroughly explained the innovative plan to use a robotic-assisted bronchoscopy for the dye marking, emphasizing how the 5G technology would allow a specialist to perform the procedure with precision from a separate console. While the concept seemed futuristic, their confidence and clarity helped build my trust. Knowing that experts were leveraging advanced technology to minimize invasiveness and maximize accuracy was incredibly reassuring.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

This report describes the first successful application of 5G remote-controlled robotic bronchoscopy for preoperative dye localization, culminating in precise sublobar resection using the Polaris^TM Bronchoscope Robotic System.

The procedure of electromagnetic navigation bronchoscopy (ENB)-guided localization is inherently modular, comprising distinct phases such as planning, registration, navigation, marking, and confirmation. This modularity allows it to be conducted within a standardized protocol, ensuring reproducibility and providing a clear workflow for robotic implementation. Recent studies underscore the potential of robotic platforms for preoperative dye marking. Chan et al. reported an 80% success rate for ICG localization using the Monarch^TM platform combined with cone-beam CT, achieving successful navigation in all five patients (7). Our experience shares the goal of precise transbronchial access but pioneers a distinct operational paradigm: remote execution via 5G, without concurrent cone-beam CT for real-time correction. This shift decouples procedural expertise from geographic location, offering a potential solution for resource distribution.

While establishing initial technical and procedural feasibility, a deeper analysis of the underlying mechanisms, comparative context, and practical challenges is warranted to translate this proof-of-concept into a reliable clinical tool. A paramount challenge in any image-guided bronchoscopic procedure is “CT-to-body divergence”, where differences in lung inflation or patient position between preoperative CT and the operative setting can cause navigation errors (8). The Polaris^TM system’s AI-enhanced 3D planning provided an optimal virtual roadmap. Crucially, the stable, ultra-low latency (21–24 ms) transmission of the high-definition video bronchoscopy feed via the 5G network enabled the remote surgeon to perform continuous, real-time visual correlation between the live anatomy and the virtual map. This capacity for dynamic intraoperative visual registration and manual trajectory correction represents a key mechanism by which the integrated system mitigates the limitations of purely plan-dependent navigation.

The 5G network was the fundamental enabler for remote telemanipulation. The achieved latency is within the acceptable range for precise control. However, the clinical scalability of telesurgery necessitates a candid discussion of its vulnerabilities, primarily network instability. Latency jitter or packet loss exceeding certain thresholds (e.g., >200–300 ms) could severely impair controllability and safety. In this inaugural case, we implemented a dedicated, Beacon-based 5G network ensured bandwidth priority; and a trained assistant was physically present in the operating room as an immediate failsafe.

Powered by 5G technology, telesurgery has advanced from proof-of-concept to initial clinical implementation, with demonstrated feasibility across multiple surgical specialties. The core advantage is the near real-time transmission of high-definition visuals and control signals, providing immersive experience for surgeons. Furthermore, 5G-enabled multi-console systems facilitate remote collaboration, real-time guidance, and surgical training, demonstrating significant potential for optimizing medical resource allocation and cross-regional academic exchange. Standardized workflow must include a mandatory pre-procedure checklist verifying network latency (<30 ms) and stability. Procedural safety hinges on continuous latency monitoring and the immediate availability of a locally proficient operator. Ultimately, the promising feasibility demonstrated here must be followed by prospective, multi-center trials. These trials are essential to definitively establish the diagnostic yield, safety profile, and cost-effectiveness of 5G remote robotic localization against the current standard of care, paving the way for its evidence-based integration into thoracic surgical practice.

Conclusions

This case report preliminarily indicates the technical feasibility of 5G remote-controlled robotic bronchoscopy for preoperative nodule localization. The approach demonstrates potential to expand access to specialized thoracic surgery, but its efficacy and safety must be further validated through multi-center clinical trials.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0031/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0031/prf

Funding: This study was supported by the National Natural Science Foundation of China (No. 82372855), Interdisciplinary Program of Shanghai Jiao Tong University (No. YG2023ZD04), and Novel Interdisciplinary Research Project from Shanghai Municipal Health Commission (No. 2022JC023).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0031/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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