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THORACOSCOPYTHORACOSCOPY

Amr Badreldin Hamdy MD Amr Badreldin Hamdy MD FCCPFCCP

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Medical thoracoscopy is an Medical thoracoscopy is an invasive technique that should invasive technique that should be used only when other, simpler be used only when other, simpler procedures are not helpful.procedures are not helpful.

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The procedure provides a The procedure provides a ““windowwindow toto thethe pleuralpleural spacespace andand thethe lung”lung” through which the through which the physician can visualize and physician can visualize and biopsy the parietal pleural biopsy the parietal pleural surface.surface.

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It is an old technique invented in It is an old technique invented in 1910 by a Swedish physician named 1910 by a Swedish physician named Jacobaeus.Jacobaeus. Its principal use in Its principal use in earlier years was to allow the earlier years was to allow the operator to divide pleural operator to divide pleural adhesions, by cutting or electro-adhesions, by cutting or electro-cautery (pneumolysis), so that an cautery (pneumolysis), so that an artificial pneumothorax could be artificial pneumothorax could be induced in the pre –antibiotic era induced in the pre –antibiotic era for TB therapy.for TB therapy.

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Until 1955 thoracoscopic Until 1955 thoracoscopic pneumolysis was widely used pneumolysis was widely used throughout Europe and the USA throughout Europe and the USA to divide pleural adhesions in to divide pleural adhesions in patients with TB.patients with TB.

It is now included to the core It is now included to the core curriculum for the training of curriculum for the training of pneumologists in Europe and in pneumologists in Europe and in the USA.the USA.

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Around 1990, instruments such Around 1990, instruments such as endoscopic stapler devices, as endoscopic stapler devices, scissors, grasping and biopsy scissors, grasping and biopsy forceps were developed for forceps were developed for surgical interventions by means surgical interventions by means of thoracoscopy in the thorax.of thoracoscopy in the thorax.

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The development of endoscopic The development of endoscopic video systems and video systems and instrumentation lead to the wide instrumentation lead to the wide spread use, the (thoracic) spread use, the (thoracic) surgeons, of therapeutic surgeons, of therapeutic thoracoscopy for a wide variety thoracoscopy for a wide variety of major thoracic procedures of major thoracic procedures (VATS).(VATS).

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Medical thoracoscopy can be Medical thoracoscopy can be performed by a respiratory performed by a respiratory physician in an endoscopy suite or physician in an endoscopy suite or operating room using local operating room using local anesthesia or conscious IV anesthesia or conscious IV sedation; usually only one (or at sedation; usually only one (or at most two) port of entry is needed most two) port of entry is needed and simple, non-disposable and simple, non-disposable equipment, including video camera equipment, including video camera facilities, is employed.facilities, is employed.

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In contrast, In contrast, VATSVATS is described as is described as a keyhole surgical procedure in a keyhole surgical procedure in the operating room, under the operating room, under general anesthesia with one-lung general anesthesia with one-lung ventilation using disposable ventilation using disposable instruments, generally for instruments, generally for therapeutic purposes.therapeutic purposes.

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INDICATIONSINDICATIONS

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1. Pleural effusions of unknown 1. Pleural effusions of unknown origin.origin.

2. Pleural thickening.2. Pleural thickening.

3. Recurrent pleural effusion 3. Recurrent pleural effusion (pleurodesis).(pleurodesis).

4. Complicated parapneumonic 4. Complicated parapneumonic effusions.effusions.

5. Empyema.5. Empyema.

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Advantages of Advantages of Diagnostic Diagnostic

ThoracoscopyThoracoscopy

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1. Fast and accurate biopsy 1. Fast and accurate biopsy diagnosis, including tuberculosis diagnosis, including tuberculosis culture.culture.

2. Biopsies from chest wall pleura, 2. Biopsies from chest wall pleura, diaphragm and potentially the diaphragm and potentially the mediastinum.mediastinum.

3. Possible staging in lung cancer 3. Possible staging in lung cancer and mesothelioma.and mesothelioma.

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4. Exclusion of malignancy and 4. Exclusion of malignancy and tuberculosis with reasonable tuberculosis with reasonable probability (90%).probability (90%).

5. Therapeutic chemical 5. Therapeutic chemical pleurodesis may be performed pleurodesis may be performed after the diagnosis procedure.after the diagnosis procedure.

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Relative Relative Contraindications Contraindications

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1. Poor general health of the 1. Poor general health of the patient.patient.

2. Fever.2. Fever.

3. Uncontrolled cough.3. Uncontrolled cough.

4. Unstable cardiovascular status.4. Unstable cardiovascular status.

5. Unable to lie flat for a minimum 5. Unable to lie flat for a minimum of one hour.of one hour.

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Absolute Absolute ContraindicationsContraindications

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1. Comatose or unresponsive patient.1. Comatose or unresponsive patient.2. Lack of pleural space.2. Lack of pleural space.3. End-stage pleural effusions.3. End-stage pleural effusions.4. Type II respiratory failure.4. Type II respiratory failure.5. MV or nasal intermittent PPV.5. MV or nasal intermittent PPV.6. Uncorrectable bleeding disorders.6. Uncorrectable bleeding disorders.7. Pulmonary arterial hypertension.7. Pulmonary arterial hypertension.8. Superior vena cava obstruction.8. Superior vena cava obstruction.

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Rule of ThumbRule of Thumb

An absolute pre-requisite is the An absolute pre-requisite is the presence of an adequate pleural presence of an adequate pleural space, which should be at least space, which should be at least 6-10 cm in width. If not present, 6-10 cm in width. If not present, a pneumothorax is induced a pneumothorax is induced under fluoroscopic or under fluoroscopic or radiographic/sono- graphic radiographic/sono- graphic control, immediately or the day control, immediately or the day before thoracoscopy.before thoracoscopy.

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The optimal point of entry is The optimal point of entry is localized in the midaxillary line, localized in the midaxillary line, because there are no large because there are no large muscles to be passed by the muscles to be passed by the trocar in this area.trocar in this area.

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Choosing the most suitable Choosing the most suitable anesthetic technique includes the anesthetic technique includes the following:following:

1. The mental status of the patient.1. The mental status of the patient.

2. The suspected duration and type 2. The suspected duration and type of thoracoscopy, e.g. when a of thoracoscopy, e.g. when a procedure is suspected to long or procedure is suspected to long or painful with chronic empyema, painful with chronic empyema, multi-lobar emphysema.multi-lobar emphysema.

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The use of flexible and semi-rigid The use of flexible and semi-rigid thoracoscopes has the thoracoscopes has the disadvantages of flexible disadvantages of flexible instruments:instruments:

1. Reduced mobility.1. Reduced mobility.

2. High costs.2. High costs.

3. Vulnerability.3. Vulnerability.

4. Difficulty in sterilization.4. Difficulty in sterilization.

5. Small size of biopsies.5. Small size of biopsies.

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Recently, Recently, mini-thoracoscopymini-thoracoscopy was was developed as an alternative for developed as an alternative for diagnostic thoracoscopy under diagnostic thoracoscopy under local anesthesia. It consists of rigid local anesthesia. It consists of rigid equipment with smaller sizes than equipment with smaller sizes than standard ones. But it is always standard ones. But it is always necessary to create a second port necessary to create a second port of entry when taking biopsies with of entry when taking biopsies with the mini-thoracoscpe.the mini-thoracoscpe.

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Early Early ComplicationsComplications

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1. Vagal syncope.1. Vagal syncope.

2. Pain.2. Pain.

3. Pleural pain, cough and 3. Pleural pain, cough and dyspnea when fluid is rapidly dyspnea when fluid is rapidly suctioned off the cavity).suctioned off the cavity).

4. Hypoxia.4. Hypoxia.

5. Subcutaneous/mediastinal 5. Subcutaneous/mediastinal emphysema. emphysema.

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Intermediate Intermediate ComplicationsComplications

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1. Wound and intercostal tube site 1. Wound and intercostal tube site discomfort.discomfort.

2. Wound infection.2. Wound infection.

3. Persistent air leaks of more 3. Persistent air leaks of more that eight days’ duration ( 2%).that eight days’ duration ( 2%).

4. Post-operative fever (16%).4. Post-operative fever (16%).

5. Pleural infection.5. Pleural infection.

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Late ComplicationsLate Complications

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1. Failed pleurodesis.1. Failed pleurodesis.

2. Empyema.2. Empyema.

3. Pleura-cutaneous fistula.3. Pleura-cutaneous fistula.

4. Late tumor seeding at 4. Late tumor seeding at thoracoscopy port and thoracoscopy port and intercostal tube site.intercostal tube site.

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THANK YOUTHANK YOU