Diagnostic Thoracic Surgical Procedures

Chapter 74 Diagnostic Thoracic Surgical Procedures

Despite the ever-increasing sensitivity of noninvasive diagnostic modalities, especially in diagnostic imaging, diagnostic thoracic surgical procedures add critical information to the diagnostic workup of patients with diverse thoracic diseases. To provide definitive tissue diagnosis and to assess stage and resectability of chest tumors, the general thoracic surgeon is vital in the diagnostic evaluation of patients.

Common thoracic surgical procedures used for diagnosis include, in order of invasiveness, bronchoscopic, cervical, scalene, and supraclavicular lymph node, pleural, mediastinal, and pulmonary biopsy procedures that involve endoscopic, thoracoscopic, or open surgical approaches. There is a spectrum of invasiveness to these procedures, with exploratory thoracotomy representing the most invasive of these diagnostic techniques. The choice of procedure is guided by the particular clinical question to be answered, as well as specific patient characteristics and, at times, the individual surgeon’s preference and experience. Overall, these procedures provide a high diagnostic yield, with low morbidity and mortality. Complications, although rare, do occasionally occur, and it is therefore incumbent on referring physicians to understand the nature of these procedures, the level of invasiveness, and the relative risk/benefit ratios.

Clinical Application of Diagnostic Thoracic Procedures

The diagnostic thoracic surgical procedures discussed in this chapter have varied applications, with relative advantages and disadvantages (Table 74-1) and are typically used in the following three broad areas:


In 1968, Ikeda introduced the first flexible bronchoscope, and over the decades, flexible bronchoscopy has largely supplanted rigid bronchoscopy for diagnostic procedures. Previously, rigid bronchoscopy was the only way to visualize and access the tracheobronchial tree directly. Now, however, the flexible bronchoscope provides access to a greater extent of the airway, can be performed with minimal sedation, and can be routinely performed in the intensive care unit (ICU) as well as the regular patient ward in many hospitals.

Rigid Bronchoscopy

Rigid bronchoscopy is mostly used for therapeutic airway interventions such as airway dilation, laser debridement, tumor debulking, placement of airway stents, or foreign body retrieval (Figure 74-1). The use of the rigid bronchoscope continues to be an important diagnostic tool in special circumstances, such as those requiring a better tactile sense when assessing for possible extrinsic tumor invasion of the airway, or when larger biopsies are sought. It is also indispensable when airway control is in question because of hemoptysis or tumor invasion.

Rigid bronchoscopy requires general anesthesia with a muscle relaxant and specific ventilatory strategies. The options most often used include jet ventilation and continuous or intermittent insufflation. In patients with airway control as an overwhelming concern because of an obstructing airway lesion, muscle relaxants are avoided to maintain spontaneous breathing.

Jun 12, 2016 | Posted by in RESPIRATORY | Comments Off on Diagnostic Thoracic Surgical Procedures

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