Chapter 72 Thoracoscopy (medical)

Thoracoscopy is the procedure of examining the chest wall, parietal pleura, visceral pleura, and diaphragm with a thoracoscope and taking biopsies. Chemical pleurodesis can also be performed. Performed by chest physicians using sedation and local anaesthetic.

There needs to be an adequate space into which the thoracoscope is inserted without damaging the underlying lung. Patients suitable for thoracoscopy are therefore those who have an underlying pleural effusion or a pneumothorax, where the lung is away from the instrument insertion site.

• • Undiagnosed pleural effusion—usually an exudate (diagnostic sensitivity of medical thoracoscopy is 95%)
• • Suspected mesothelioma
• • Staging of pleural effusion in lung cancer
• • Treatment of recurrent pleural effusions with pleurodesis
• • Pneumothorax requiring chemical pleurodesis, as an alternative to surgery, e.g. the patient unfit for surgical thoracoscopy.

• • Obliterated pleural space
• • Pleural adhesions, as these may tear when pneumothorax is induced
• • Bleeding disorder
• • Hypoxia <92% on air
• • Unstable cardiovascular disease
• • Persistent uncontrollable cough.

Mortality rates are low (<0.01% of cases)

• • Haemorrhage—may need diathermy in the pleural space. Rare
• • Pulmonary perforations. Rare
• • Air or gas embolism during pneumothorax induction. Rare <0.1%
• • Local wound infection
• • Empyema
• • Fever, ARDS with talc poudrage (see [link]).

• • Patient should have written information >24 h before the procedure. Written consent taken by doctor performing procedure
• • Check recent CXR and any CT scans available
• • Check FBC, coagulation, U&E
• • Send blood for group and save
• • Nil by mouth for 4 h pre-procedure
• • IV cannula in arm on the same side as the thoracoscopy to make repeated sedative administration during the procedure easy
• • Premedication with analgesia, such as a single dose of oral ibuprofen 800 mg, 1–2 h before. Also antibiotics, such as cefuroxime 1.5 g IV, for infection prophylaxis
• • Baseline oxygen saturations, pulse, BP, temperature. Measure oximetry throughout.

The patient is placed in the lateral decubitus position, with the side of the pleural effusion uppermost. Sedation is administered and allowed time to work. Oxygen (2–4 L/min) is administered via nasal cannulae. The skin is cleaned and local anaesthetic inserted, in the same way as for a chest drain. The aspiration of fluid or air from the pleural space confirms it is safe to proceed to thoracoscopy. An incision is made and blunt dissection performed through the parietal pleura. The thoracoscope port is then inserted. The pleural effusion is drained via a suction tube through the thoracoscope port. Air is allowed to enter the pleural space through this port so the lung does not re-inflate, and effectively a pneumothorax is created. The thoracoscope, with its light source, can then be inserted through the port and the chest cavity inspected. A second smaller incision allows forceps or other instruments to be inserted and biopsies taken.

Thoracoscopic biopsies are usually large and yield good diagnostic results. If the pleural surfaces have appearances consistent with malignancy, pleurodesis can be performed at the end of the procedure, using talc inserted via an insufflator. There is no evidence that pleurodesis performed at thoracoscopy is more efficacious than pleurodesis performed via chest tube, but it may save the patient having a further procedure.

• • Monitor oxygen saturations, pulse, blood pressure, and temperature
• • The patient will have a chest drain in situ. This should be on free drainage initially, but continuous suction is required when the drain stops bubbling
• • Analgesia as required, such as IV diamorphine 2.5 mg, dihydrocodeine 30–60 mg PO, paracetamol 1 g
• • DVT prophylaxis with subcutaneous heparin (increased coagulopathy with talc pleurodesis)
• • Mobile CXR on the morning after thoracoscopy
• • Remove chest drain when the lung is re-inflated on CXR with minimal fluid or air drainage. Trapped lung occurs if the visceral pleura is too thick to allow lung re-inflation (see [link])
• • If mesothelioma is diagnosed, refer for radiotherapy to thoracoscopy and chest drain tract sites.

Daniel T. Diagnostic thoracoscopy for pleural disease. Ann Thorac Surg 1993; 56: 639–40[Abstract]

Loddenkemper R, Boutin C. Thoracoscopy: present diagnostic and therapeutic indications. Eur Respir J 1993; 6: 1544–55[Abstract]