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Pulmonary & Critical Care Bulletin
Vol. VII, No. 3, July 15, 2001
In this issue :

From Editor's Desk

AEROSOL THERAPY
(Dr. Uma Maheswari,)

ONCE - DAILY ASTHMA PREVENTION THERAPY
(R. S. Bedi & U.S. Bedi)

16th Annual Meeting on Pulmonary and Critical Care Medicine
(Dr. S. K. Jindal)



Publihed under the auspices of:
Pulmonary C. M. E. Programme



Editorial Board :


Department of Pulmonary Medecine
Post Graduate Institute of Medical Education & Research (PGIMER) Chandigarh. INDIA-160012


Subscription :


Thoracoscopy and Related Procedures

Thoracoscopy is a surgical procedure to visualise the lung surface using a rigid fiberoptic telescope i.e. thoracoscope.

History

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.

Anaesthesia

- Mostly done under general anaesthesia
- Procedures involving parietal pleura may be done under regional anaesthesia and intravenous sedation.
- Local anaesthesia at incision site - if post operative pain is anticipated.

Intubation

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.

Technique

- Done in an operation theatre
- Position of the patient - Lateral decubitus with the operating side higher up, head in neutral position, pillow in between body and table, arms abducted.
- Table position - Maximally flexed to widen intercostal spaces, may be rotated as required.
- Lung or the segment of the lung of interest is collapsed as mentioned earlier. If necessary, application of positive pressure through chest wall stoma and compression by grasping forceps are done

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.
- Two others - 5th ICS in anterior axillary and 6th ICS in posterior axillary line for insertion of instruments.
Incision size may have to be extended (rib sparing) - extended thoracoscopy or mini thoracotomy.

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.

Complications

- Quite safe even after the age of 70
- A meta-analysis of 145 papers (Europe, 1989 - 1994) showed: mortality rate = 0.3% complication rate = 3.6%; conversion to thoracotomy = 1%
- Anaesthesia related complications
- Pressure injury : A nerve damage due to unsatisfactory posturing
- Pooling of secretion
- Post operative pulmonary edema, aspiration injury
- Hypoxaemia
- Acute respiratory failure
- Instrument related - malfunction, injury to diaphragm, compression of intercostal nerves
- Bleeding - usually minor problems and sepsis
- Persistent air leak beyond 7 days
- Conversion to thoracotomy

Indications, scope and Results

A. Diagnostic

1. Pleural biopsy in :

- Undiagnosed pleural effusion
- Malignant pleural effusion
- Benign pleural lesion

2. Pulmonary : Diffuse Infiltrates : - Failed TBLB - Critically ill patients
- Indeterminate solitary pulmonary nodule
- Safe and 100% certain; serves as therapy as well
- Nodule is not considered for VATS, if ill localized or , high suspicion of malignancy.

3. Mediastinal : Masses, nodes, cysts which are inaccessible otherwise by percutaneous, transbronchial or transesophageal route lymphoma, cancer - staging

4. Others : Biopsy from vertebral lesions

B. Therapeutic

1. Malignant pleural effusion

- When (ICTD) is inadequate or One attempt at ICTD pleurodesis has failed, thoracoscopic pleurodesis is done.
ii. Early empyema: where ICTD is inadequate
iii. Chest trauma
iv. Spontaneous pneumothorax

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
- Bulla with intervening lung tissue : Reinforcement with bovine pericardium or glue
- Diffuse emphysema : LVRS in advanced cases
- Indeterminate pulmonary nodule : Excision biopsy
- Solitary carcinomatous nodule stage / cancer lung : VATS lobectomy s compromise procedure when open lobectomy is not feasible.
- Peripheral lung metastasis - Curative wedge resection

3. Mediastinal Diseases

Removal of Tumours : Thymic tumours - teratoma, bronchogenic cyst
pericardial effusion - Pericardiotomy and transpleural drainage when catheter drainage is inadequate or effusion is detected while doing other procedures. Sympathectomy
Ligation of thoracic duct in chylothorax

4. Spinal Diseases

Drainage of abscess
Discectomy
Release operation for kyphoscoliosis

Dr. Asutosh Ghosh, Senior Resident,
Department of Pulmonary Medicine,
PGI, Chandigarh

Dr. Asutosh Ghosh



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