Role of medical thoracoscopy

The use of thoracoscopy is not widespread in the UK despite its clear benefits. A survey in 2004 showed only 6% of respiratory physicians had performed more than 10 procedures. Alternatives to the traditional rigid scope have recently been developed to try to improve the utility of this valuable tool. This chapter focuses on the semi‐rigid thoracosocpe.

A step‐by‐step guide to semi‐rigid thoracoscopy

Semi‐rigid medical thoracoscopy refers to the inspection of the pleural cavity through a semi‐rigid camera similar in design to the well‐known bronchoscope, including the bi‐directional tip. It is performed in a non‐intubated patient under conscious sedation without the need for general anaesthesia. An illustrated guide to the procedure is described:

• The patient is positioned in the lateral decubitus position (disease side up) and a thoracic ultrasound performed to confirm the presence of fluid and a suitable puncture site (usually in the mid axillary line).
  
• Following local anaesthesia infiltration and confirmation of the presence of pleural fluid with needle aspiration, blunt dissection through the intercostal space into the pleural cavity is performed (Figure 11.11).
  
• Once the pleural space is entered a trocar and/or cannula is inserted into the tract (Figure 11.12).
  
• The semi‐rigid thoracoscope is inserted into the pleural cavity through the cannula and the pleural fluid suctioned under continual direct visualisation.
  
• As pleural fluid is removed air can enter the pleural space through the port to keep the lung deflated, preventing rapid re‐expansion of the lung.
  
• The pleural surfaces are inspected and biopsies taken at appropriate sites (Figures 11.13, 11.14, 11.15 and 11.16).
  
• Talc poudrage is performed if malignant aetiology is strongly suspected (Figures 11.17, 11.18 and 11.19).
  
• The thoracoscope is removed and a chest drain inserted through the tract and sutured in place. This allows removal of air from the pleural space and complete re‐expansion of the underlying lung (Figures 11.20 and 11.21).