Thoracoscopy
- 1. THORACOSCOPY Amr Badreldin Hamdy MD FCCP
- 2. Medical thoracoscopy is an invasive technique that should be used only when other, simpler procedures are not helpful.
- 3. The procedure provides a “ window to the pleural space and the lung” through which the physician can visualize and biopsy the parietal pleural surface.
- 4. 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.
- 5. Until 1955 thoracoscopic pneumolysis was widely used throughout Europe and the USA to divide pleural adhesions in patients with TB. It is now included to the core curriculum for the training of pneumologists in Europe and in the USA.
- 6. 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.
- 8. 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).
- 9. 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.
- 10. 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.
- 11. INDICATIONS
- 12. 1. Pleural effusions of unknown origin. 2. Pleural thickening. 3. Recurrent pleural effusion (pleurodesis). 4. Complicated parapneumonic effusions. 5. Empyema.
- 20. Advantages of Diagnostic Thoracoscopy
- 21. 1. Fast and accurate biopsy diagnosis, including tuberculosis culture. 2. Biopsies from chest wall pleura, diaphragm and potentially the mediastinum. 3. Possible staging in lung cancer and mesothelioma.
- 22. 4. Exclusion of malignancy and tuberculosis with reasonable probability (90%). 5. Therapeutic chemical pleurodesis may be performed after the diagnosis procedure.
- 24. 1. Poor general health of the patient. 2. Fever. 3. Uncontrolled cough. 4. Unstable cardiovascular status. 5. Unable to lie flat for a minimum of one hour.
- 26. 1. Comatose or unresponsive patient. 2. Lack of pleural space. 3. End-stage pleural effusions. 4. Type II respiratory failure. 5. MV or nasal intermittent PPV. 6. Uncorrectable bleeding disorders. 7. Pulmonary arterial hypertension. 8. Superior vena cava obstruction.
- 27. Rule of Thumb 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.
- 28. 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.
- 29. Choosing the most suitable anesthetic technique includes the following: 1. The mental status of the patient. 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.
- 30. The use of flexible and semi-rigid thoracoscopes has the disadvantages of flexible instruments: 1. Reduced mobility. 2. High costs. 3. Vulnerability. 4. Difficulty in sterilization. 5. Small size of biopsies.
- 31. 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.
- 33. 1. Vagal syncope. 2. Pain. 3. Pleural pain, cough and dyspnea when fluid is rapidly suctioned off the cavity). 4. Hypoxia. 5. Subcutaneous/mediastinal emphysema.
- 35. 1. Wound and intercostal tube site discomfort. 2. Wound infection. 3. Persistent air leaks of more that eight days’ duration ( 2%). 4. Post-operative fever (16%). 5. Pleural infection.
- 37. 1. Failed pleurodesis. 2. Empyema. 3. Pleura-cutaneous fistula. 4. Late tumor seeding at thoracoscopy port and intercostal tube site.
- 38. THANK YOU