THORACOSCOPY

Thoracoscopy is a procedure that is minimally invasive and traditionally executed for the identification or/and treatment of pleural lung diseases. The practice of thoracoscopy is not new. A Swedish physician, H. C. Jacobeaus performed thoracoscopy for the first time in the year 1910 as an identification technique for patients with exudative pleuritis (1) for inspecting the pleura under local anesthesia (2). Moreover, the thoracoscopic technique is also used to execute certain surgeries and the process is often called video-assisted thoracoscopic surgery (VATS). Over the last twenty years, the management and the approach to the treatment of cardiac and pulmonary diseases have been revolutionized by VATS. Usually, the technique was performed for the assessment and management of pleural effusion in pulmonary tuberculosis patients.

Before VATS, thoracotomy was the standard procedure to treat a thoracic pathology. With the beginning of fiber-optic light, advancement resulted in almost all types of minimally invasive surgeries. There has been an increase in the application of VATS over the decades because of technological developments. Because of these advancements, such techniques have become safer for frail and elderly patients. The multiple advantages of VATS over the traditional technique of thoracotomy include shorter durations of hospital stay, reduced pain after the operation, an overall decrease in cost, and speedy respiratory function recovery in patients especially the elderly or suffering from chronic obstructive pulmonary disease (COPD) (3–5).

INDICATIONS

The use of thoracoscopy is employed for both therapeutic and diagnostic purposes. Pleural effusion is the commonest indication of diagnostic thoracoscopy. The reason behind the development of spontaneous pneumothorax can be identified with thoracoscopy. Pleurodesis which is mostly chemical is the commonest indication for therapeutic thoracoscopy to avoid the reappearance of pleural effusion (6).

Other indications for diagnostic thoracoscopy include pleuroscopy/pleural biopsy, cancer staging, a biopsy of mediastinal lymph node, a biopsy of the chest wall, and a biopsy of lymph node/tissue for lung cancer.

The other indications for therapeutic thoracoscopy include resection of pulmonary bullae/bleb, pulmonary resection that is frequent for lung cancer, pleural drainage in empyema, hemothorax or pneumothorax, thoracic duct ligation, chemical or mechanical pleurodesis, esophagectomy or excision of the esophageal diverticulum, drainage of pericardial effusion, biopsy or excision of mediastinal nodules and masses, drainage of spinal abscess, resection of tumor from the chest wall, sympathectomy, and thoracoscopic laminectomy.

PROCEDURE STEPS

Usually, three to four incisions are made for the standard VATS technique in a triangular conformation for the insertion of scope and instruments (7). As an alternative, there has been a description of VATS having a single port as well (8). The patient is made to lie in the supine position and anesthesia is administered. A DLT opts for most procedures as the preferred airway device. When DTL is placed, a fiber-optic bronchoscope is used to confirm the tube position by way of the DLT lumen. Care should be taken in ensuring the cuff positioning. When the placement of the cuff and tube is confirmed, the placement of the patient is made lateral decubitus with the arm of the patient over the head. The operation table is arched to permit satisfactory exposure to the surgical site. DLT placement is again checked after the patient is finally positioned to start the procedure.

The surgeon makes three cuts for the frontal approach. The cuts are formed to make a triangular conformation such that the utility incision is positioned at the triangle’s apex. Through this incision, the surgeon introduces the camera to make other entry ports safe. The camera is accommodated through the creation of another port in the auscultatory triangle. The surgeon creates a third port at the utility port incision in the mid-axillary line. A video thoracoscope is used to do the assessment after making 3 ports. The specific procedure that needs to be executed guides the further steps of the process. At the end of the procedure, one or two pleural drains linked with a seal drain underwater are placed depending on the nature of the surgery executed (9).

COMPLICATIONS

Even though the risks associated with VATS are low, it is of utmost importance that necessary precautions should be taken for monitoring hemodynamic and cardiac parameters, and saturation of oxygen during the surgery. However, the frequently occurring severe complications of VATS include transient complications of the cardiovascular system, emphysema, empyema, excessive bleeding, fever, wound infection, atelectasis, air leak after the operation, and air embolism (9–13).  

References

1. Jacobaeus HC. Uber die moglichkeit die zystoskopie bein untersuchung seroser hohlungen anzuwenden. Munich Med Wochensche. 1910;40:2090.
2. Luh S ping, Liu H ping. Video-assisted thoracic surgery–the past, present status and the future. J Zhejiang Univ Sci B. 2006 Feb;7(2):118–28.
3. Bravo Iñiguez CE, Armstrong KW, Cooper Z, Weissman JS, Ducko CT, Wee JO, et al. Thirty-Day Mortality After Lobectomy in Elderly Patients Eligible for Lung Cancer Screening. Ann Thorac Surg. 2016 Feb;101(2):541–6.
4. Villamizar NR, Darrabie MD, Burfeind WR, Petersen RP, Onaitis MW, Toloza E, et al. Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J Thorac Cardiovasc Surg. 2009 Aug;138(2):419–25.
5. Paul S, Altorki NK, Sheng S, Lee PC, Harpole DH, Onaitis MW, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg. 2010 Feb;139(2):366–78.
6. Rodriguez-Panadero F, Janssen JP, Astoul P. Thoracoscopy: general overview and place in the diagnosis and management of pleural effusion. Eur Respir J. 2006 Aug 1;28(2):409–22.
7. Hansen HJ, Petersen RH. Video-assisted thoracoscopic lobectomy using a standardized three-port anterior approach – The Copenhagen experience. Ann Cardiothorac Surg. 2012 May;1(1):70–6.
8. Bedetti B, Scarci M, Gonzalez-Rivas D. Technical steps in single port video-assisted thoracoscopic surgery lobectomy. J Vis Surg. 2016;2:45.
9. Mehrotra M, D’Cruz JR, Arthur ME. Video-Assisted Thoracoscopy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Aug 9]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK532952/
10. Davidson AC, George RJ, Sheldon CD, Sinha G, Corrin B, Geddes DM. Thoracoscopy: assessment of a physician service and comparison of a flexible bronchoscope used as a thoracoscope with a rigid thoracoscope. Thorax. 1988 Apr 1;43(4):327–32.
11. Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med. 1991 Feb 15;114(4):271–6.
12. Enk B, Viskum K. Diagnostic thoracoscopy. Eur J Respir Dis. 1981 Oct;62(5):344–51.
13. De Camp PT, Moseley PW, Scott ML, Hatch HB. Diagnostic thoracoscopy. Ann Thorac Surg. 1973 Jul;16(1):79–84.