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Thoracoscopy: A Concise Guide to History, Types, and Role in Diagnosis
- 1. Thoracoscopy
- 2. History: Developed by Jacobeus in early 1900s to break adhesions in tuberculosis patients Also was used to localize and diagnose benign and malignant lesions of pleura Later it was used extensively to assist in diagnosis of pleural effusion
- 4. TYPES Medical thoracoscopy VATS (Video Assisted Thoracoscopy)
- 5. Medical Thoracoscopy Two methods: Single Puncture and double puncture Single Puncture:A single rigid thoracoscope in a 9mm working channel is used All equipments are used through a single working channel Double Puncture: Two ports 1. a 7 mm rigid thoracoscope 2. 5 mm trocar-biopsy forceps,brushes,needles Single Puncture-easier to perform and preferred by chest physicians
- 6. VATS Medical Thoracoscopy Site Anaesthesia GA Conscious sedation/LA MV Double lumen ETT,Single lung ventilation Spontaneous breaths Ports Multiple Single or Double Indications Resection of Pulmonary Nodule Bullectomy Pneumonectomy Lobectomy Pulmonary Window Pleural biopsy Chest tube insertion Talc pleurodesis Deloculation
- 8. Role in diagnosis 1.Undiagnosed pleural effusion: Mainly to establish a diagnosis of malignancy Used only when less invasive procedures didn’t get any desired results More preferred when : 1)history of more than one month No fever Blood tinged pleural fluid Ct suggestive of malignancy
- 9. 2.Malignant pleural effusions: Mainly for pleurodesis Especially in loculated effusions Ovarian cancer and pleural effusion-because the amount of material in pleural effusion,dictate surgical therapy
- 10. 3.Parapneumonic pleural effusions If not drained by thoracocentesis or ICD CT Scan should be done prior to know the exact location of the empyema and need for intervention If fibropurulent material cannot be drained-convert to a open thoracotomy
- 11. If there is undrained empyema,there are usually four basic alternatives: A)insert one more ICD tube B)Instill fibrinolytics and dna ase intrapleurally C)thoracoscopy D)Thoracotomy
- 12. 4.Pneumothorax Mainly done for two objectives: A)to treat the bullous disease responsible for pneumothorax B)to create a pleurodesis Bullae- treated by endoscopic stapling device Earlier-Electrocoagulation and roeder loops was used Howover using a loop can have high chance of recurrence.
- 13. Mostly VATS is used, But medical thoracoscopy with talc insufflation is also being used ACCP Guidelines : thoracoscopy preferred for primary spontaneous pneumothorax ,usually after an ipsilateral recurrence Bullectomy and parietal pleural ablation also has been recommended Secondary spontaneous pneumothorax-always indicated
- 14. BTS-chemical pleurodesis to be performed only if the patient is unwilling for surgical intervention Indications : A)Secondary ipsilateral pneumothorax B)First contralateral pneumothorax C)Bilateral spontaneous pneumothorax D)Persisitent Air Leaks (5-7 days of tube drainage) E)Professions at risk (pilots,divers)
- 15. 5.Haemothorax Usually thoracotomy is more preferred to thoracoscopy Can be used for removing retained blood clots If retained blood clots are more than 30 percentage usually thoracotomy is preferred
- 16. Complications Prolonged Air Leak – 3.2 percentage Significant bleeding –only in 1 percent Pneumonia-1.1 % Empyema – 0.6 % Complications of medical thoracoscopy is less than VATS