Your SlideShare is downloading. ×
Medical Thoracoscopy
Upcoming SlideShare
Loading in...5

Thanks for flagging this SlideShare!

Oops! An error has occurred.

Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Medical Thoracoscopy


Published on

Talk given by me on Medical Thoracoscopy for Mangalore Chest Association CME

Talk given by me on Medical Thoracoscopy for Mangalore Chest Association CME

Published in: Health & Medicine, Business
  • Be the first to comment

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

No notes for slide


  • 1. Dr Subin Ahmed Dept of Pulmonary Medicine YMCH
  • 2. Thoracoscopy: A window to the pleural space
  • 3. Historical Background
    • Thoracoscopy is not a new technique; H.C.Jacobeus, the Swedish internist, was the first to perform thoracoscopy in 1910, as a diagnostic procedure for exudative pleuritis.
    • H.C.Jacobeus published the first series of thoracoscopy cases in 1921, describing the value of thoracoscopy in the diagnosis of tuberculous and malignant effusions.
  • 4. Historical Background
    • Thoracoscopy was used mainly as a therapeutic tool for adhesiolysis in patients with tuberculosis (TB), in order to obtain a ‘‘therapeutic’’ pneumothorax – Jacobeus Procedure
    • Pioneers like Swierenga et al, Brandt and Boutin et al confirmed its value in publications in the 1970 s
    • Around 1990, instruments such as endoscopic stapler devices, scissors, grasping and biopsy forceps were developed for surgical interventions by means of thoracoscopy
  • 5. Historical Background
    • The development of endoscopic video systems and instrumentation lead to the widespread use, by (thoracic) surgeons, of therapeutic thoracoscopy for a wide variety of major thoracic procedures.
    • Medical thoracoscopy is generally characterized as thoracoscopy performed under local anesthesia in the endoscopy suite with the use of non-disposable instruments, and is generally for diagnostic purposes.
  • 6. Definition
    • Medical thoracoscopy/pleuroscopy is a minimally invasive procedure that allows access to the pleural space using a combination of viewing and working instruments. It also allows for basic diagnostic (undiagnosed pleural fluid or pleural thickening) and therapeutic procedures (pleurodesis) to be performed safely.
    • Interventional pulmonary procedures : Guidelines from ACCP
    • Chest 2003;123:1693-1717
  • 7. VATS vs MEDICAL THORACOSCOPY VATS Medical Thoracoscopy Operator Thoracic surgeon Pulmonologist Site OR Endoscopy suite/ OR Anesthesia GA Conscious sedation/LA MV Double lumen ETT, Single lung ventilation Spontaneous breaths Ports Multiple Single or double Indications
    • Minimally invasive surgery
    • -Resection of Pulm. nodule
    • -Bullectomy
    • Lung Bx/Lobectomy
    • Pneumonectomy
    • Pericardial window
    • Diagnostic/Therapeutic
    • Pleural biopsy
    • Pleural biopsy
    • Chest Tube insertion
    • Talc Pleurodesis
    • Deloculation
  • 8. Indications for Medical Thoracoscopy
    • Diagnostic :
    • – Pleural effusions of unknown origin-
    • Diagnostic Yield is 93-100% ( 44% with closed biopsy & 62% with fliud cytology )
    • – Suspected tuberculous effusions
    • – Suspected malignancy with inconclusive cytology
    • – Evaluating Chest Trauma
  • 9. Indications for Medical Thoracoscopy
    • Therapeutic:
    • 1) For pleurodesis in malignant or recurrent pleural effusion, recurrent pneumothorax
    • 2) To divide adhesions in recurrent/persistent spontaneous pneumothorax
    • 3) To perform pleural toilet in the fibrino-purulent stage of empyema
  • 10. Medical thoracoscopy : steps
  • 11. The Semi-rigid Pleuroscope or the Rigid Pleuroscope
  • 12. Instruments
  • 13. Anesthesia
    • Midazolam (2 mg upto 10 mg) or
    • Neuroleptic Analgeisa (Fentanyl + Droperidol) or
    • Opiods + Benzodiazepines &
    • Local Infiltration with 2% Lidocaine
    • Propofol – be ready with intubation/ventilatory settings
  • 14. Trocar insertion: Access to the pleural space
    • • Vessels to avoid: internal mammary, the subclavian and the lateral thoracic artery
    • Lateral thoracic region between the mid- and anterior axillary line in the fourth to seventh intercostal space
  • 15. The intercostal space
    • 3 muscles, with a neurovascular bundle in the middle and innermost
    • Lies in a grove in the inferior aspect of the rib
    • Posteriorly, the bundle lies in the middle of the intercostal space until 5-8 cm lateral to the spine.
    • *Intercostal vessels may sag in geriatric patients onto the superior costal margin of the adjacent rib
  • 16. STEPS
    • Patient in the lateral decubitus position with the arms placed over the head in order to increase the size of the intercostal spaces.
    • Local anesthesia (intercostal block) with 2% lidocaine and sedation with midazolam drip
    • A small caliber trocar (14F) introduced into the intercostal space after incising the chest – to induce a pneumothorax
    • Increase the pneumothorax by insufflating air with a 60 ml syringe
  • 17. STEPS
    • Larger flexible trocar (10mm) then introduced after enlarging the channel.
    • A rigid thoracoscope 7 mm diameter inserted into the pleural cavity
    • Thoracoscope connected to a video camera and viewed on a screen
    • Biopsy, lysing of adhesion or electrocoagulation or cutting - a second smaller (5 mm) incision was made to enable insertion of a second instrument (usually a biopsy forceps)
  • 18. Pleural Biopsies
    • Most pleural pathology in the posterior costal pleura
    • Biopsy specimens from the parietal pleura over the rib
    • Ideally, specimens should not be taken from the apex, anterior parietal pleura
  • 19. Pleural Pathology – Tuberculous PE
    • Diagnostic yield from closed pleural biopsy is 70-90% (with specimens sent for microbiological analysis)
    • Needs 6 or more specimens
    • Thoracoscopy may offer higher tissue-culture positive rates
  • 20. Pleural Pathology – Tuberculous PE
    • Visualization of grayish-white granuloma (parietal & diaphragmatic pleura esp. costo-vertebral gutter)
    • Multiple biopsies from selected sites (HP Diagnosis 94-98 %)
    • TB cultures more frequently positive (esp. when fibrin production is significant)
    • Diagnosis by MT + Culture+ HPE∼ 100% (> Closed needle Biopsy + Culture of Pleural Effusion)
  • 21. Thoracoscopy in Pleural Malignancies
    • Pleural fluid cytology is only positive in 60-70% of cases of pleural malignancy, with marginal benefit when closed pleural biopsy is added
    • Patchy involvement of pleural cavity, involvement of the visceral pleura, lower hemithorax/diaphragm involvement
    • Allows receptor analysis
  • 22. Thoracoscopy in Pleural Malignancies
    • Thoracoscopy is the recommended procedure in patients with an undiagnosed effusion and negative pleural fluid cytology, who are suspected of having malignancy.
    • The diagnostic yield with thoracoscopy is over 90% in malignant effusions.
    • Pleurodesis can be performed during the same procedure if the biopsy is positive (on-site cytology during thoracoscopy), or if the macroscopic appearance is strongly suggestive of malignancy and adequate biopsies have been taken
  • 23. Malignant Mesothelioma and Thoracoscopy
    • Routine cytology examination of pleural fluid has a sensitivity of only 32%
    • Blind percutaneous needle biopsy specimens gives a diagnosis in less than 50% of cases
    • Thoracoscopy allows complete visualization of the pleural cavity and multiple biopsy samples.
    • Helps in diagnosis of early lesions
  • 24. Malignant Mesothelioma and Thoracoscopy
    • Concern of tumor spread along chest drain and aspiration sites
    • Seeding
    • Irradiation with 7 Gray over 3 days within 15 days of procedure
  • 25. Recurrence prevention in malignant effusions
    • 80% lung, breast , lymphomas, ovarian or Primary pleural malignancies mesothelioma
    • Diagnosis in 95% with thoracoscopy
    • Palliate symptoms
    • Complete evacuation of pleural fluid, maximization of lung expandability by removing adhesions
    • Prevention of fluid reaccumulation: obliterating the pleural space by pleurodesis ( long-term success rates of > 90%)
    • Chemical Pleurodesis:
    • Talc - 7 g (Poudrage)
    • Tetracycline/Doxycycline
    • Bleomycin, Thiotepa
    • Various: Iodopovidine, Silver nitrate
  • 26. Recurrent Pleural Effusion of Benign Etiology & Thoracoscopy
    • Recurrent pleural effusion of benign etiology (heart failure, cardiac surgery, nephrotic syndrome, connective tissue diseases, and other inflammatory disorders)
    • Thoracoscopic pleurodesis is indicated when the recurrent effusion causes symptoms and is not controlled by repeated large-volume thoracocentesis
  • 27. Spontaneous Pneumothorax & Thoracoscopy
    • Persistent or recurrent pneumothorax
    • Recurrence rate of 23-50% after the first episode and higher after recurrence
    • Pleurodesis is achieved in these cases by talc insufflation (1.5 grams)
    • Excellent alternative to repeated chest tube drainage
  • 28. Empyema & Complicated Para-Pneumonic Effusions - Thoracoscopy
    • After failure of chest tube drainage and fibrinolytic treatment
    • Fibrino-purulent stage with pleural peels entrapping the lung
    • Deloculation, Fibrinolysis, chest tube insertion under direct visualization
    • Mechanical removal of infected material and permits lung re-expansion
  • 29. Empyema – Thoracoscopic Drainage
    • Especially in frail patients with high surgical risk
    • Entry site confirmed by USG
    • Aspiration of the liquid
    • Exploration of the thoracic cavity to identify loculations or, rarely, foreign bodies
    • Opening the loculations
    • .
  • 30. Empyema – Thoracoscopic Drainage
    • 4)Removal of fibrinopurulent membranes from the cavity and from parietal and visceral surfaces;
    • 5) Cleansing of the pleural space with saline solution.
    • When the thoracic cavity has been emptied a careful exploration of the pleural surfaces is carried out and, if necessary biopsies performed. Finally a large-bore chest drain ( >28 F) is introduced, possibly under visual control, to remove dense and viscous pus or fibrin debris
  • 31. Chest Trauma - Thoracoscopy
    • Evaluation/Management in blunt/penetrating chest trauma:
    • Diaphragmatic injury
    • Chest wall bleeding
    • Traumatic pneumothorax/ chylothorax/ hemothorax
    • Lung parenchymal lacerations
    • Trapped lung (after prolonged Hemothorax) Removal of fibrous peel + loculations/adhesions  lung re- expansion  pleurodesis
  • 32. Complications of Thoracoscopy
    • One of the safest procedure
    • Desaturation during procedure – <2 %
    • Persistent air-leak (2%)
    • Subcutaneous emphysema (0.5%)
    • Postoperative fever (16%)
    • Empyema (2.5%)
    • Death (0.01%)
    • Negligible – benign cardiac arrhythmias, transient hypotension
    • Colt HG. Chest 108:324-329, 1995
    • Loddenkemper R. J Bronchol 7:207-209, 2000
  • 33. Prevention Of Complications
    • Postpone thoracoscopy for several days if patient is coughing
    • Measure blood gases & monitor cardiac status by simultaneous ECG
    • Oxygenate the patient during thoracoscopy
    • Avoid taking biopsy samples from internal parts of the fissures or from mediastinum
    • Coagulate & ensure hemostasis if hemorrhage exceeds 20ml
  • 34. Prevention Of Complications
    • Insert a chest tube (at least till the lung expands) to prevent subcutaneous emphysema
    • Start physiotherapy on the day of thoracoscopy to exercise the diaphragm & avoid accumulation of secretions & obstruction
    • To prevent invasion in cases of mesothelioma, administer radiation therapy of 7 grays/day for 3 days to the scar area on post operative day 10
  • 35. Contraindications
    • Absolute Contraindication:
    • Absence of a potential pleural space ( < 6-10 cm usually due to extensive adhesions)
    • Relative Contraindications:
    • – Uncorrectable coagulopathy
    • – Multiple pleural adhesions
    • – Unstable cardio-respiratory status
    • – uncontrollable cough
    • – Inability to lie flat for an hour
    • – Severe chest wall deformity
  • 36. Thoracoscopy - Variants
    • Medical Thoracoscopy using Fiber Optic -bronchoscope inserted through a chest tube under L/A
    • -Argyle type 32F chest tube
    • -5mm outside diameter FOB
    • -1.5 mm incision
    • -only 1 trocar entry (biopsy forceps put into the FOB port)
  • 37. Thoracoscopy - Variants
    • Mini Thoracoscopy
    • two 3.8 mm trocars
    • one 3.3 mm telescope
    • one 3.0 mm biopsy forceps
    • Good visibility, Easy maneuverability, Less pain, Less local anesthetic, No stitches, Better cosmetic results
    • Conversion to conventional thoracoscopy sometimes required, lung biopsy specimens can be inadequate, chest drains >8F cannot be inserted
    • Small loculated PE
  • 38. Conclusion
    • Pleuroscopy allows the pleural cavity to be visualized under local anesthesia with sedation/intravenous anesthesia
    • Procedure of choice in the diagnostic workup of patients suspected of a malignant effusion with an indeterminate cytology
    • Allows for pleurodesis in the same setting
    • Physicians performing this procedure should have training requirements vary between institutions, but the operator should have sound knowledge of pleural and thoracic anatomy, and sufficient surgical skill.
  • 39.  
  • 40. “ Once you touch the lungs you should be ready to convert it into a Thoracotomy any time”