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Medical thoracoscopy (pleuroscopy): Equipment, procedure, and complications

Medical thoracoscopy (pleuroscopy): Equipment, procedure, and complications
Author:
Hans Lee, MD
Section Editor:
Henri G Colt, MD
Deputy Editor:
Geraldine Finlay, MD
Literature review current through: Jan 2024.
This topic last updated: Jun 12, 2023.

INTRODUCTION — Thoracoscopy (pleuroscopy) involves passage of an endoscope through the chest wall for direct visualization of the pleura. Medical thoracoscopy is most commonly used for pleural fluid drainage, pleural biopsy, and pleurodesis. Although the equipment and some applications are similar to those used in video-assisted thoracoscopic surgery (VATS), it is typically more limited in its diagnostic and therapeutic functions and performed by pulmonologists, thus the term "medical" thoracoscopy.

The technique, instruments used, and complications of medical thoracoscopy are reviewed here. The diagnostic and therapeutic uses are discussed separately. (See "Medical thoracoscopy (pleuroscopy): Diagnostic and therapeutic applications".)

INSTRUMENTS — Rigid and semirigid thoracoscopes are commonly used; choosing among them is typically operator-dependent.

Rigid instruments — The rigid thoracoscope is probably still the most common instrument used for medical thoracoscopy (figure 1). It is cheap and provides both excellent optical quality and maneuverability within the pleural space [1-5]. Multiple diameter and angle-viewing instruments are available [6]:

Most instruments contain a light source, working channel, and video port all in a single device, allowing for a single point of entry procedure. Other instruments fulfill just one of these needs which necessitates a multi-port procedure. (See 'Choosing a point of entry' below.)

Some thoracoscopes are 0-degree telescopes used for direct viewing while oblique 30- and 50-degree, and 90-degree telescopes offer a panoramic view of the pleural cavity.

An array of accessories for probes for palpation, needles for aspiration biopsy, and forceps for electrocautery or biopsy are available.

Rigid scopes are generally placed through cannulas into the thoracic cavity. A trocar is a solid blunt device placed inside a cannula and both the trocar and cannula are placed together into the chest cavity; the trocar is then removed and the scope placed through the cannula. Multiple diameter cannulas/trocars (3 to 10 mm) are available to accommodate thoracoscopes of varying sizes. While larger instruments may offer improved views of the pleural cavity, there is concern that they may compress the intercostal nerve and cause discomfort during the procedure.

Semi-rigid instruments — Semi-rigid ("flexi-rigid") fiberoptic video-pleuroscopes are currently no longer available in the United States (figure 1) [7-12]. Similar to a rigid bronchoscope, the proximal portion (handle and shaft) is stiff, while similar to a flexible bronchoscope, the distal end is smaller in diameter and flexible so that the tip can be flexed or extended two-dimensionally. The handle, suction, and a working channel can, similar to a flexible bronchoscope, accommodate accessories such as a biopsy forceps. In addition, the semi-rigid endoscope is compatible with flexible bronchoscopic light sources and video processors, thereby, allowing this instrument to be readily adapted for use in the endoscopy suite.

In general, comparable diagnostic results and safety profiles have been reported between rigid and semi-rigid thoracoscopy, but similar to flexible equipment, adhesions or loculations may impact negatively on the success of semi-rigid thoracoscopy [13,14].

Others

Flexible fiberoptic instruments — Flexible bronchoscopes are rarely used since they are difficult to manipulate within the pleural cavity, are subject to equipment damage from the manipulation and from adhesions, and have been supplanted by the semirigid scope which offers biopsies of similar size [15,16]. They are not approved for this indication.

Autofluorescent instruments — Autofluorescent videothoracoscopy uses the same technology as fluorescent bronchoscopy. Areas of malignancy appear a different color changing from white or pink (under white light) to red using a fluorescent light. (See "Detection of early lung cancer: Autofluorescence bronchoscopy and investigational modalities".)

Three-dimensional instruments — Most pleuroscopes provide two-dimensional views of the thoracic cavity. Newer pleuroscopes that have three-dimensional imaging capacity are available but are not widely used [17].

TECHNIQUE — Medical thoracoscopy should only be performed by properly trained personnel, usually an interventional pulmonologist or thoracic surgeon. Since most cases are performed using local anesthesia and procedural sedation, medical thoracoscopy is generally performed in an endoscopy suite and less commonly in the operating room [16]. More complex cases are performed under general anesthesia in the operating room. Pleuroscopy is performed using standard surgical sterile technique and drapes, gowns, and gloves.

Choosing a point of entry — The patient is placed in the lateral position with the affected side up. A point of entry is then generally chosen using ultrasound, although the history and examination and prior chest imaging (typically computed tomography) also facilitate the selection of the appropriate entry site. In the past, when a pneumothorax was induced prior to sedation, a chest radiograph was taken before thoracoscopy to decide the most appropriate interspace through which the thoracoscope should be introduced. However, this practice has waned since the introduction of ultrasonography which can readily detect fluid and septae within the pleural cavity at the time of the procedure. Ultrasound-guided selection of the entry point into the pleural cavity may optimize the chance for success by avoiding adhesions and may reduce trocar access failures and pneumothorax rates [18-20]. Identifying fluid by ultrasound is discussed separately. (See "Ultrasound-guided thoracentesis", section on 'Technique'.)

When choosing a point of entry the following should also be taken in to consideration [18,21-23]:

For pleural inspection, the mid-axillary line of the 4th or 5th intercostal space is preferred since it allows optimal inspection of the pleura. Care should be taken to avoid the lateral thoracic artery (high in the axilla).

For lesions that have a predilection to the lower regions or diaphragm (eg, metastatic tumor or mesothelioma) these lesions may be more easily accessed through the lower intercostal spaces. However, care should be taken to avoid puncturing the diaphragm.

The clinician should decide in advance whether a single point or two points of entry will be needed. Although the single puncture technique is the most commonly employed method of diagnostic thoracoscopy [4,24-27], some physicians use a double puncture method [1,2,28]. With this latter technique, either prior to or during the procedure, the second site of entry is made under direct video guidance (ie, with the telescope inside the pleural cavity) to simplify visualization or sampling of difficult to reach areas such as the costovertebral angle, mediastinal pleural surfaces, and the lung apex. Two punctures may also be necessary for more complex procedures to facilitate adhesiolysis, drainage of complex fluid collections, sampling of lesions close to the first entry site, or for accessing difficult to reach posterior or mediastinal regions, although the flexi-rigid scope may be optimal for the latter.

Anesthesia — Most cases are performed using local anesthesia and procedural sedation.

Local anesthesia plus procedural sedation — Once a point(s) of entry is chosen, patients are sterilely draped and the skin can be anesthetized (unless the patient is having a general anesthetic) at the point of entry. Following local anesthesia, sedation is administered.

Thoracoscopic procedures typically performed under local anesthesia are inspection of the pleural space, removal of pleural fluid, biopsy of parietal pleura, and pleurodesis.

Following cleaning of the skin with sterile antiseptic, 1 or 2 percent lidocaine is infiltrated into the skin, soft tissue, intercostal muscles, and periosteum of the rib, similar to that described for thoracentesis (see "Ultrasound-guided thoracentesis", section on 'Site preparation and local anesthesia'). Some experts provide additional topical anesthesia (via a second cannula/trocar or through the working channel of the scope) to the pleura when planning pleurodesis (eg, 1 or 2 percent lidocaine via spray catheter; maximum 3 mg per kg) just prior to sclerosant administration [29].

For procedural sedation, we use a combination of intravenous narcotic, commonly either morphine or fentanyl, plus a benzodiazepine, usually midazolam, for analgesia, sedation, and amnesia. Occasionally, propofol is used instead of a benzodiazepine, requiring the presence of an anesthesiologist or a nurse anesthetist. Typical dosing is provided separately. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

General anesthesia — General anesthesia is typically reserved for more complex or high risk medical thoracoscopic procedures (eg, lung biopsy or sympathectomy), or it is anticipated that significant deflation of the lung or conversion to video assisted thoracoscopic surgery (VATS) is likely (eg, complicated pleural space, lobectomy) (table 1). There is no need for local anesthesia if general anesthesia is being used.

Thoracoscopy under general anesthesia can be performed with or without selective bronchial intubation for the ventilation of one lung. Single lung ventilation is preferable when video assisted thoracoscopic surgery (VATS) is performed, because selective contralateral lung ventilation permits complete ipsilateral lung deflation, although techniques for nonintubated thoracoscopic surgery (NITS) are also feasible and described separately. (See "One lung ventilation: General principles" and "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection".)

Intercostal dissection and lung deflation — Once the patient is adequately positioned, sedated, monitored (vital signs, oxygen level), sterilely draped and local anesthetic applied to the point of entry, intercostal dissection occurs as follows:

A wet pleural space – Since in most patients, pleuroscopy is being done for pleural fluid drainage/biopsy, the lung can be deflated by accessing the pleural space and allowing deflation to occur with spontaneous respiration. A 10 mm incision is made above the superior rib margin parallel with the rib. Simple dissection is then performed with a hemostat through the subcutaneous tissue to the intercostal muscles. Some experts reinject the parietal pleura at the level of the intercostal muscles with local anesthetic at this point. The hemostat is used to bluntly enter the pleural space by placing pressure on the hemostat and slowly moving through the intercostal space until it "pops through" the intercostal muscle-parietal pleura complex. Fluid will automatically emerge. A probing finger may be placed into the pleural space to check for adhesions. Air enters the chest cavity with inspiration. The lung will deflate slightly using this method.

A dry pleural space – If a dry pleural space is suspected or known, some experts use the same approach while occasionally, others will induce a pneumothorax before intercostal dissection, to limit the risk of lung puncture. This can be done using a Boutin needle (2 to 3 mm diameter) or an angiocatheter (picture 1), which can be used to access the pleural space and drain pleural fluid (if present); a pneumothorax is induced by leaving the needle/angiocatheter open to air (air enters the pleural space naturally during respiration). Once a pneumothorax is induced, the intercostal space can be dissection as described in the above bullet. In the past, clinicians used to check for a pneumothorax using a chest radiograph after pneumothorax induction, but this is no longer done since the introduction of bedside ultrasonography [30].

The blunt-tip trocar and cannula together are then introduced into the pleural space, taking care to avoid lung injury. The trocar is removed and the thoracoscope is passed through the cannula (passage through the cannula ensures that no tissue residue covers the camera) [1,2,28].

During the procedure if the distance between the lung and the chest wall is small and felt to be impairing visualization of the pleura, additional air can be cautiously introduced to collapse the lung further and enlarge the pleural space. When using a rigid scope, the cannula has a sealed sideport which can be transiently opened to introduce air. Alternatively, in spontaneously breathing patients air can be introduced by allowing the patient to breath spontaneously through an open cannula. Care must be taken to avoid iatrogenic tension pneumothorax when insufflating air into the pleural cavity under general anesthesia.

Procedure — Inspection of the pleural cavity is accomplished by maneuvering the telescope in a methodical manner (movie 1). The cannula is held in place at the skin surface to avoid crushing soft tissue, ribs, and nerves. The scope is slowly maneuvered from apex to diaphragm and medially towards the hilum so that the entire pleural surface is examined (movie 1 and picture 2).

Other interventional instruments such as a probe, a needle for aspiration, or a biopsy forceps may be introduced through the working channel or via another entry site, the choice of which depends upon the operator and thoracoscope used. Procedures commonly performed include:

Pleural fluid removal – Fluid may be removed via a suction port on the thoracoscope.

Adhesiolysis – Adhesions, which may interfere with complete examination of the pleural cavity, can be lysed with either a blunt probe or cautery forceps or the thoracoscope, with caution to avoid vascularized adhesions and tearing of visceral pleura or lung. If cautery is available, then vascular adhesions may be cauterized before lysing.

Parietal pleural biopsy – Biopsies of suspicious areas are obtained under direct visualization (picture 2). The forceps is used to probe the rib avoiding the neurovascular bundle on the inferior aspect. The forceps are opened, abnormal tissue grasped and forceps closed. The forceps should be withdrawn in a "stripping" or "tearing" motion rather than a grab and pull motion (movie 2); this can be achieved by slightly angulating the scope after the tissue has been grasped and then withdrawing the forceps (like peeling dead skin) (movie 3). Other methods include using an insulated tip diathermic knife (via a semi-rigid thoracoscope) and cryobiopsy [31,32]. (See "Bronchoscopic cryotechniques in adults", section on 'Cryobiopsy'.)

Chemical pleurodesis – Various delivery devices for sclerosant are available such as spray atomizer, bulb syringe, or spray catheters (picture 3) that can be administered via the working channel, through the cannula, or through a second port if a multi-port technique is used; some experts use a second port so that the delivery of sclerosant can be directly visualized by the pleuroscope. (See "Chemical pleurodesis for the prevention of recurrent pleural effusion".)

Other procedures that are less frequently performed include visceral pleural and lung biopsy, blebectomy, and sympathectomy. These procedures are highly specialized, generally carry increased risk, and are unlikely to be performed in the endoscopy suite. (See "Medical thoracoscopy (pleuroscopy): Diagnostic and therapeutic applications".)

Once the pleura have been inspected, samples taken (pathology and/or microbiology), and/or therapies administered, the thoracoscope and trocars are removed and a chest tube is inserted for re-inflation of the lung and fluid drainage. Extra holes may be placed in the intrathoracic component of the chest tube to ease fluid drainage after pleurodesis. Chest radiographs are typically routinely performed after thoracoscopy. Assuring there is no air leak clinically and radiographically, the chest tube can be removed within a few hours when thoracoscopy does not involve a lung biopsy or pleurodesis, longer if patients undergo a pleurodesis. Management of chest tubes and indications for removal are described separately. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children".)

Inpatient stay is not mandatory but is typically required when chest tubes need to remain in place, particularly for more invasive procedures including lung biopsy and pleurodesis or when complications occur [33-35]. However, for more minor procedures including pleural inspection and/or parietal pleural biopsy, where chest tube removal occurs within hours, the patient may be managed as an outpatient [33].

COMPLICATIONS — Medical thoracoscopy is a relatively safe procedure with most complications due to sedation/anesthesia and/or the associated diagnostic or therapeutic procedure.

Sedation or anesthesia-related — Many of the complications associated with thoracoscopy are sedation or anesthesia-related (eg, hypotension, hypoxemia, respiratory arrest, arrhythmias), the details of which are discussed separately. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications", section on 'Anticipating and mitigating Complications' and "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection", section on 'Complications'.)

Procedure-related — Procedure-related complications are mostly minor and range from 2 to 6 percent [1,36-40]. The following complications have been noted occurring in less than 2 percent of cases:

A persistent air leak (>7 days) – Air leaks are more likely to occur when the visceral pleura or lung is torn or biopsied. Bronchopleural fistula is unusual.

Subcutaneous emphysema – This occurs due to pneumothorax or insufflation of air and typically resolves once a chest tube is in place.

Fever – Fever is not infrequent particularly after talc pleurodesis and usually resolves within 48 hours.

Hemorrhage – Hemorrhage is unusual since local hemostasis is achieved during the procedure but may be noted with chest tube drainage. It rarely necessitates re-exploration.

Infections – Wound infection, pneumonia, and empyema are unusual but may be more common in those with malignancy.

Rare complications include:

Air embolism – Air embolism is a serious complication. Some surgeons use carbon dioxide during video assisted thoracoscopic surgery since it diffuses rapidly and is thought to be less likely to result in air embolism. However, most pulmonologists use air without any apparent increased risk of air embolism, in our experience. (See "Air embolism".)

Re-expansion pulmonary edema – Although large volumes of fluid can be removed, re-expansion pulmonary edema is rare, possibly due to the equilibration of pleural pressures when the pleural space is open to air. (See "Large volume (therapeutic) thoracentesis: Procedure and complications".)

Tumor seeding at the port of entry – This is a possibility particularly when thoracoscopy is used in patients with mesothelioma. There is no consensus on the use of radiation after thoracoscopy to prevent this complication.

Death is rare, ranging from 0.09 to 0.34 percent [1,41-43], which is comparable to that of transbronchial biopsy (0.22 to 0.66 percent) [44,45] and mediastinoscopy (0.17 percent) [46]. Deaths are rarely attributable to the procedure itself.

Repeat medical thoracoscopy can be performed without significant mortality or morbidity [47]. Contraindications to medical thoracoscopy are discussed separately. (See "Medical thoracoscopy (pleuroscopy): Diagnostic and therapeutic applications", section on 'Contraindications'.)

SUMMARY AND RECOMMENDATIONS

Thoracoscopy (pleuroscopy) involves passage of an endoscope through the chest wall for direct visualization of the pleura. Medical thoracoscopy is most commonly used for pleural fluid drainage, pleural biopsy, and pleurodesis. Although the equipment and some applications are similar to those used in video-assisted thoracoscopic surgery (VATS), it is typically more limited in its diagnostic and therapeutic functions and performed by pulmonologists, thus the term "medical" thoracoscopy. (See 'Introduction' above.)

The rigid thoracoscope is probably still the more common instrument used for medical thoracoscopy (figure 1). The semi-rigid fiberoptic video pleuroscope combines rigid and flexible thoracoscope features with a tip that can be flexed or extended resulting in improved maneuverability. The choice between the rigid and semi-rigid instruments is based on the procedure and preference of the operator. Accessories are available for both instruments including probes for palpation, needles for aspiration, and forceps for coagulation or biopsy. (See 'Instruments' above.)

The number of entry points and their location need to be chosen in advance, typically using pre-procedure imaging (eg, computed tomography) and bedside ultrasonography. Most cases are performed under local anesthesia and procedural sedation. The intercostal space is dissected and the lung partially collapsed to safely introduce the thoracoscope into the pleural space. The pleural cavity is inspected, and if indicated, fluid is drained, samples taken, and sclerosant administered. (See 'Technique' above.)

Medical thoracoscopy is a relatively safe procedure. Most complications are minor, occur in 2 to 6 percent of cases and are due to sedation/anesthesia. Procedure-related complications include persistent air leak, subcutaneous emphysema, fever, hemorrhage, and infections. Air embolism, re-expansion pulmonary edema, and death are rare. (See 'Complications' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Francis Sheski, MD, who contributed to earlier versions of this topic review.

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