Thoracoscopy is the procedure of examining the parietal pleura, visceral pleura, and diaphragm with a thoracoscope and taking biopsies. Chemical pleurodesis can also be performed. Performed by chest physicians using conscious sedation and local anaesthetic. Either a rigid or a ‘semi-rigid’ flexible thoracoscope (similar to a bronchoscope) is used, dependent on local availability.
There needs to be an adequate space into which the thoracoscope is inserted without damaging the underlying lung. Patients suitable for thoracoscopy are therefore usually those who have an underlying pleural effusion or a pneumothorax where the lung is away from the instrument insertion site (although experts may induce a pneumothorax using a Boutin pleural needle, designed to avoid injuring the visceral pleura).
• Undiagnosed pleural effusion—usually an exudate (sensitivity for malignancy >92% and TB ~100%; similar to VATS)
• 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. patient unfit for surgical thoracoscopy.
Contraindications/proceed with caution
• Obliterated pleural space
• Mature pleural adhesions
• Bleeding disorder
• Hypoxia <92% on air or hypercapnia
• Unstable cardiovascular disease
• Persistent uncontrollable cough
• Severe obesity (thoracoscopy ports not long enough to reach pleura)
• Obstructing central airway tumour.
Risks associated with thoracoscopy
Mortality rates low (0% for diagnostic thoracoscopies; 0.69% when talc also used—but studies included ungraded talc). Major complications <2%.
• 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
• Fever, ARDS with talc poudrage (see p. [link])
• Port site tumour seeding.
Preparation of patient and consent
• Patient should have written information >24h before the procedure. Written consent taken by doctor performing procedure
• Check recent CXR and any CT scans available
• Check FBC, U&E, and APTT
• Nil by mouth for solids 6h and liquids 2h pre-procedure
• IV cannula in arm on the same side as the thoracoscopy to make repeated sedation/analgesia administration during the procedure easy
• Premedication with analgesia, such as single doses of oral paracetamol and ibuprofen, 1h before. Some centres give a single dose of IV antibiotic as infection prophylaxis (e.g. co-amoxiclav or, if allergic, vancomycin)
• Baseline O2 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 (IV midazolam) is administered and allowed time to work. O2 (2–4L/min) is administered via nasal cannulae
• Pleural US is used to define pleural anatomy and optimize location for thoracoscope port insertion
• The skin is cleaned and local anaesthetic inserted, in the same way as for a chest drain. Aspiration of fluid or air from the pleural space confirms it is safe to proceed to thoracoscopy
• An incision is made, and a horizontal mattress suture is inserted (for wound closure post-drain removal). Blunt dissection is performed through the parietal pleura, and the port is inserted
• The pleural effusion is drained via a suction tube through the thoracoscope port. Air is simultaneously allowed to enter the pleural space through this port, and effectively a pneumothorax is created
• The thoracoscope, with its light source, can then be inserted through the port and the pleural cavity inspected. A separate second smaller incision allows forceps or other instruments to be inserted and biopsies taken
• An opioid (e.g. IV fentanyl) is given immediately prior to taking biopsies, as these can be intensely painful
• At the end of the procedure, one port is replaced with a 24F drain, and any further ports are removed and sutures tied
• Thoracoscopic biopsies are usually large and yield good diagnostic results
• If the pleural surfaces have appearances consistent with malignancy, pleurodesis can be performed prior to removing the port, using 4–5g talc administered via an insufflator (poudrage). Talc poudrage efficacy is at least as good as talc slurry via a chest drain, and insufflation during thoracoscopy reduces the number of procedures required.
• Monitor O2 saturations, pulse, BP, and temperature
• Chest drain on free drainage initially, but suction is started when bubbling stops, incrementing to –20cmH2O over 2h, as tolerated
• Analgesia, as required, such as IV diamorphine 2.5mg, codeine 30–60mg PO, paracetamol 1g
• DVT prophylaxis with LMWH (increased coagulopathy with talc pleurodesis)
• Mobile CXR the morning after thoracoscopy
• If mesothelioma is diagnosed, refer for radiotherapy to thoracoscopy and chest drain tract sites.