Page 46 - World Association of Laparoscopic Surgeons - Journal

WJOLS

The Role of Thoracoscopy in Diagnosis and Treatment of Pleural Disease

endostaples, the surgeon can perform a whole host of removal of fibrin deposits or blood clots, and sectioning of
procedures. Recent advances in endoscopic techniques, adhesions that prevent complete inspection of the pleural
surgical instrumentation, and air-tight endostaplers have space and mediastinum. Sometimes these adhesions also
contributed to the resurgence of thoracoscopy as a useful inhibit complete lung expansion; they may also maintain
diagnostic and therapeutic modality. patency of visceral pleural tears in patients with spontaneous
Certain VATS procedures can be performed under local or secondary pneumothorax. In patients with complex
anesthesia, but VATS typically requires general anesthesia pleural effusions, suspected underlying trapped lung
and is performed in an operating room. Operators commonly requiring an attempt at reexpansion using positive pressure
employ the double-lumen endotracheal tube or bronchial ventilation, empyema, and multiloculated pleural effusions
blocker for selective lung ventilation. from infection or malignancy, the pleural space and
Thoracoscopy is usually performed through one or mediastinum can be safely explored using general anesthesia
several small, less than 2 cm skin incisions made along the and multiple access sites. Although comparative studies
intercostal spaces. Patients are placed in the lateral decubitus have not been performed, it is possible that complication
position, involved side up, although some procedures, such rates may be increased in this setting because of the
as a thoracic sympathectomy, are performed with patients increased morbidity of patients undergoing these
in the supine position. Pleural trocars can also be safely procedures, the use of general anesthesia and the invasive
placed in the axilla, so that axillary thoracotomy IV sedation scope of procedures being performed.
and local anesthesia are administered using techniques
similar to those employed when making a chest tube Advantages and Disadvantages of Thoracoscopy
insertion incision. Many operators prefer general anesthesia
Advantages
with single- or double-lumen endotracheal intubation
performed in an operating suite. Certainly, the operating Thoracoscopy offers the several advantages over more
room is the accepted procedural area for diagnostic and conventional techniques; namely, it (1) potentially permits
therapeutic procedures such as lung biopsies, decortication, access to the entire pleural cavity, including both the parietal
or cardiovascular interventions. and visceral pleura, (2) allows for directly visualized
Many procedures limited to removal of pleural fluid, biopsies, certainty of representative tissue for diagnosis, and
visualization, and biopsy of parietal pleura can be performed (3) affords control of bleeding, (4) lysis of adhesions allow
through a single skin incision made in approximately the inspection, (5) recovery time from surgery (shorter hospital
fifth to seventh intercostal space along the lateral chest wall stays and a shorter duration of chest tube drainage compared
42
of the involved hemithorax. When a 5 to 10 mm pleural with thoracotomy) and the level of pain experienced by
trocar and cannula are interted through the incision, the the patient is markedly reduced. Lastly, the small incisions
6
parietal pleura, diaphragm, and lung are well visualized. used are better tolerated than the old larger open
Pleural fluid is evacuated and parietal pleural biopsy thoracotomy incisions.
specimens are obtained from both normal- and abnormal- Potential advantages of thoracoscopy over more
appearing areas. A chest tube is placed through the incision conventional techniques include certainty of representative
site and connected to a suction device, and the lung is gently tissue for diagnosis, reduced requirements for postoperative
reexpanded. Because the duration of chest tube drainage analgesia, shorter hospital stays, and a shorter duration of
can be only a few hours, many patients are discharged the chest tube drainage compared with thoracotomy. 42
same day. In years past, this type of procedure was
commonly referred to as pleuroscopy. Today, because of Disadvantages
the very minimally invasive nature of the procedure, it has
1. Invasive procedure
3
become known as ‘medical thoracoscopy’. Complications
2. Cost
such as bleeding (from parietal pleural biopsy), lung
3. Loss of bimanual palpation of the lung
perforation (during trocar insertion), or infection (from
4. Loss of binocular vision
inadvertently using nonsterile techniques) are extremely
rare. 4 5. Moreover, 20% of VATS procedures require conversion
to thoracotomy, which can add operative time and cost. 7
Advanced diagnostic and therapeutic procedures are
usually performed in an operating suite. Multiple incisions
DIAGNOSTIC THORACOSCOPY
allow the introduction of biopsy forceps, endoscopic
scissors, electrocautery, suction-irrigation instruments, and Pleural effusions: Algorithms for investigating pleural
grasping forceps to allow greater mobilization of the lung, effusion of unknown etiology typically begin with

World Journal of Laparoscopic Surgery, January-April 2012;5(1):4-15 5