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  1. 1. THORACOSCOPY Amr Badreldin Hamdy MD FCCP
  2. 2. <ul><li>Medical thoracoscopy is an invasive technique that should be used only when other, simpler procedures are not helpful. </li></ul>
  3. 3. <ul><li>The procedure provides a “ window to the pleural space and the lung” through which the physician can visualize and biopsy the parietal pleural surface. </li></ul>
  4. 4. <ul><li>It is an old technique invented in 1910 by a Swedish physician named Jacobaeus. Its principal use in earlier years was to allow the operator to divide pleural adhesions, by cutting or electro-cautery (pneumolysis), so that an artificial pneumothorax could be induced in the pre –antibiotic era for TB therapy. </li></ul>
  5. 5. <ul><li>Until 1955 thoracoscopic pneumolysis was widely used throughout Europe and the USA to divide pleural adhesions in patients with TB. </li></ul><ul><li>It is now included to the core curriculum for the training of pneumologists in Europe and in the USA. </li></ul>
  6. 6. <ul><li>Around 1990, instruments such as endoscopic stapler devices, scissors, grasping and biopsy forceps were developed for surgical interventions by means of thoracoscopy in the thorax. </li></ul>
  7. 8. <ul><li>The development of endoscopic video systems and instrumentation lead to the wide spread use, the (thoracic) surgeons, of therapeutic thoracoscopy for a wide variety of major thoracic procedures (VATS). </li></ul>
  8. 9. <ul><li>Medical thoracoscopy can be performed by a respiratory physician in an endoscopy suite or operating room using local anesthesia or conscious IV sedation; usually only one (or at most two) port of entry is needed and simple, non-disposable equipment, including video camera facilities, is employed. </li></ul>
  9. 10. <ul><li>In contrast, VATS is described as a keyhole surgical procedure in the operating room, under general anesthesia with one-lung ventilation using disposable instruments, generally for therapeutic purposes. </li></ul>
  11. 12. <ul><li>1. Pleural effusions of unknown origin. </li></ul><ul><li>2. Pleural thickening. </li></ul><ul><li>3. Recurrent pleural effusion (pleurodesis). </li></ul><ul><li>4. Complicated parapneumonic effusions. </li></ul><ul><li>5. Empyema. </li></ul>
  12. 20. Advantages of Diagnostic Thoracoscopy
  13. 21. <ul><li>1. Fast and accurate biopsy diagnosis, including tuberculosis culture. </li></ul><ul><li>2. Biopsies from chest wall pleura, diaphragm and potentially the mediastinum. </li></ul><ul><li>3. Possible staging in lung cancer and mesothelioma. </li></ul>
  14. 22. <ul><li>4. Exclusion of malignancy and tuberculosis with reasonable probability (90%). </li></ul><ul><li>5. Therapeutic chemical pleurodesis may be performed after the diagnosis procedure. </li></ul>
  15. 23. Relative Contraindications
  16. 24. <ul><li>1. Poor general health of the patient. </li></ul><ul><li>2. Fever. </li></ul><ul><li>3. Uncontrolled cough. </li></ul><ul><li>4. Unstable cardiovascular status. </li></ul><ul><li>5. Unable to lie flat for a minimum of one hour. </li></ul>
  17. 25. Absolute Contraindications
  18. 26. <ul><li>1. Comatose or unresponsive patient. </li></ul><ul><li>2. Lack of pleural space. </li></ul><ul><li>3. End-stage pleural effusions. </li></ul><ul><li>4. Type II respiratory failure. </li></ul><ul><li>5. MV or nasal intermittent PPV. </li></ul><ul><li>6. Uncorrectable bleeding disorders. </li></ul><ul><li>7. Pulmonary arterial hypertension. </li></ul><ul><li>8. Superior vena cava obstruction. </li></ul>
  19. 27. Rule of Thumb <ul><li>An absolute pre-requisite is the presence of an adequate pleural space, which should be at least 6-10 cm in width. If not present, a pneumothorax is induced under fluoroscopic or radiographic/sono- graphic control, immediately or the day before thoracoscopy. </li></ul>
  20. 28. <ul><li>The optimal point of entry is localized in the midaxillary line, because there are no large muscles to be passed by the trocar in this area. </li></ul>
  21. 29. <ul><li>Choosing the most suitable anesthetic technique includes the following: </li></ul><ul><li>1. The mental status of the patient. </li></ul><ul><li>2. The suspected duration and type of thoracoscopy, e.g. when a procedure is suspected to long or painful with chronic empyema, multi-lobar emphysema. </li></ul>
  22. 30. <ul><li>The use of flexible and semi-rigid thoracoscopes has the disadvantages of flexible instruments: </li></ul><ul><li>1. Reduced mobility. </li></ul><ul><li>2. High costs. </li></ul><ul><li>3. Vulnerability. </li></ul><ul><li>4. Difficulty in sterilization. </li></ul><ul><li>5. Small size of biopsies. </li></ul>
  23. 31. <ul><li>Recently, mini-thoracoscopy was developed as an alternative for diagnostic thoracoscopy under local anesthesia. It consists of rigid equipment with smaller sizes than standard ones. But it is always necessary to create a second port of entry when taking biopsies with the mini-thoracoscpe. </li></ul>
  24. 32. Early Complications
  25. 33. <ul><li>1. Vagal syncope. </li></ul><ul><li>2. Pain. </li></ul><ul><li>3. Pleural pain, cough and dyspnea when fluid is rapidly suctioned off the cavity). </li></ul><ul><li>4. Hypoxia. </li></ul><ul><li>5. Subcutaneous/mediastinal emphysema. </li></ul>
  26. 34. Intermediate Complications
  27. 35. <ul><li>1. Wound and intercostal tube site discomfort. </li></ul><ul><li>2. Wound infection. </li></ul><ul><li>3. Persistent air leaks of more that eight days’ duration ( 2%). </li></ul><ul><li>4. Post-operative fever (16%). </li></ul><ul><li>5. Pleural infection. </li></ul>
  28. 36. Late Complications
  29. 37. <ul><li>1. Failed pleurodesis. </li></ul><ul><li>2. Empyema. </li></ul><ul><li>3. Pleura-cutaneous fistula. </li></ul><ul><li>4. Late tumor seeding at thoracoscopy port and intercostal tube site. </li></ul>
  30. 38. THANK YOU