10 Knowledge and Skills Required
To learn medical thoracoscopy/pleuroscopy (MT/P), a pulmonologist needs to know the exact topographical anatomy of the thorax, the pathophysiology and pathology of respiratory diseases, their diagnostic approach and their management options, in particular of pleural diseases, as well as the clinical prerequisites, the contraindications, and the complications that have been described in detail in the preceding chapters. He or she must also know the details of the technique of medical thoracoscopy/pleuroscopy including all instruments used, the different options of access to the pleural space, the technique of coagulation, and so on, as outlined in the following chapters. In addition, he or she should already have adopted certain skills in the diagnosis and treatment of respiratory diseases, particularly pleural diseases (Lamb et al. 2010).
Knowledge of Respiratory Diseases
• The diagnostic approach, the differential diagnosis, and the management options of the respective diseases are described in detail in Chapter 3, pp. 22–52.
• Typical pathological changes are demonstrated in the Atlas part of this book.
Knowledge of Thoracic Anatomy
• The interior anatomical topography of the left and right hemithoraces is shown in Figures 10.1 and 10.2.
• How to find the exact orientation during the endoscopic exploration of the pleural cavity is described in Chapter 11, p. 86 ff. and p. 91 ff.
Several important anatomical landmarks of the chest cage must be kept firmly in mind:
• The anteromedial end of the second intercostal space is located by palpating the angle formed by the manubrium and the body of the sternum.
• The ribs can then be counted from top to bottom.
• In the axillary hollow, the second intercostal space is the highest space that can be felt in a nonobese patient.
• The ribs can also be numerated in the back, using the dorsal spinous processes. The reference point here is the prominent C7 spine, from which the vertebrae and ribs may easily be counted.
• The ribs of a patient in the lateral position can be counted along the mid-axillary line: the lowest rib that can be felt is the tenth; the eleventh and twelfth, floating ribs, are behind. The ribs can then be counted from the bottom upward.
• The male nipple is generally situated near the level of the fourth rib.
• If an anterior point of entry is selected, remember that the internal mammary artery and vein pass just posterior to the ribs some 16-18 mm lateral to the sternal margin.
• When erect, the liver is very high within the thorax: reaching as far as the fourth intercostal space during forced exhalation. However, in the left lateral decubitus position, gravity pulls the liver away from the chest wall and there is little possibility of injuring it. Avoiding the liver should be a simple matter once the insertion levels of the diaphragm and the dimensions of the costophrenic angle are appreciated radiographically. Lateral decubitus films or, preferably, fluoroscopy/ultrasonography “on the table,” provide an extra margin of safety when a low entry site is planned.
• Radiographic review is mandatory in each patient. One should keep the typical diaphragmatic anatomy in mind: the diaphragm is more or less symmetrical on both sides; it starts anteriorly just below the sixth costal cartilage at about the same height as the xiphoid process, slopes downward toward the side, and reaches its lowest point level with the end of the eleventh rib and the second lumbar vertebra, approximately in the mid-axillary line. Then it rises again toward the back, crossing the twelfth rib 8-9 cm from the spine and joins the upper edge of the first lumbar vertebra.
• Remember that the major fissure crosses the mid-axillary line at the fourth intercostal space on the right.
• The minor fissure begins at this point and at the fifth intercostal space on the left.
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