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Pulmonary & Critical Care Bulletin
Vol. VII, No. 3, July 15, 2001
In this issue :
From Editor's Desk
Thoracoscopy and Related Procedures
Thoracoscopy is a surgical procedure to visualise the lung surface using a rigid fiberoptic telescope i.e. thoracoscope.
The procedure was invented by Jacobeus in 1921 (a Swedish physician), who used it in the collapse therapy for pulmonary tuberculosis (TB). Uptil 1990, it was used in UK and USA, mostly for the purpose of pleurodesis in malignant pleural effusion and pneumothorax and for treatment of traumatic hemothorax.
1990 onwards, with the advent of advanced videotechnology, the procedure is now termed as Video Assisted Thoracoscopy (VAT) or Thoracoscopic Surgery (VATS).
Equipment and Instruments
Used earlier : Rigid bronchoscope, flexible bronchoscope, laparoscope
Currently used : Thoracoscope - a rigid fiberoptic telescope of dia 5, 7, 10 mm.
Accessories : 1. Xenon light source, 2. A camera mounted on the eye piece, 3. Videomonitor - two; one for the operator and another for the assistant, 4. Videorecorder.
Instruments : Pleural trocar and cannula, Irrigation aspiration device, scissors-cum-cauteriser, atraumatic forceps, lung retractors, graspers, surgical clips, stapling devices. Usual thoracic surgical instruments are also used as necessary.
- Mostly done under general anaesthesia
Lung on the operating side is collapsed by selective intubation of opposite lung preferably by using bronchoscope. Double lumen ETT may be used. If necessary, selective bronchial blocking catheter may be used in stead of endotracheal tube; mostly extubated after the procedure is over.
- Done in an operation theatre
CO2 insufflation is not done.
1. Incision : Usually three openings (<2 cm) are made. Number and site may vary according to the procedure
- In midaxillary line at 7th/8th intercostal space (ICS): for insertion of the thoracoscope.
2. Insertion : Through the 1st stoma, pleural trocar followed by cannula are introduced. Through the cannula, thoracoscope is introduced. At the end of the operation, chest tube is inserted to drain air and fluid. Lung is allowed to collapse gently. Skin incision is closed.
- Quite safe even after the age of 70
Indications, scope and Results
1. Pleural biopsy in :
- Undiagnosed pleural effusion
2. Pulmonary : Diffuse Infiltrates : - Failed TBLB - Critically ill patients
3. Mediastinal : Masses, nodes, cysts which are inaccessible otherwise by percutaneous, transbronchial or transesophageal route lymphoma, cancer - staging
4. Others : Biopsy from vertebral lesions
1. Malignant pleural effusion
- When (ICTD) is inadequate or One attempt at ICTD pleurodesis has failed, thoracoscopic pleurodesis is done.
Persistent air leak > 2-3 days
Reccurrence after tube pleurodesis
Parietal pleura is abraded using gauge; talc for older patients
2. Pulmonary Diseases
- Bullous lung disease : Bullectomy
3. Mediastinal Diseases
Removal of Tumours : Thymic tumours - teratoma, bronchogenic cyst
4. Spinal Diseases
Drainage of abscess
Dr. Asutosh Ghosh, Senior Resident,
Dr. Asutosh Ghosh
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