inch of the scope and then it articulates similar to the exible bronchoscope. It is a 0 degree optic with 160 degrees of exion and 130 degrees of extension. The scope has an outer diameter of 6.9 mm and fts through a dedicated 7 mm port. There is a 2.8 mm working channel that is safe for thermal modalities such as electrocautery or laser.

There are several commercially available rigid thoracoscopes on the market. In general, the instruments include a 4 mm optic with a 30-degree angle to be able to fully inspect the pleural space. Many also include an over-tube suction and optical forceps for single port procedures. In some cases, a second port is necessary for pleural intervention and non-optical forceps are available to biopsy the pleura. Dedicated re-useable ports measuring 5–10 mm are available. A dedicated apparatus for pleurodesis consisting of a powder dispenser and a bulb to aerosolize into the pleural space is also available.

A comprehensive list of equipment to perform the procedure is listed in Table 34.1.

A prospective, randomized, pilot study designed to compare the diagnostic yield between the rigid and semi-rigid thoracoscopes determined that there was equipoise between the two instruments with diagnostic accuracies of 100%

Table 34.1  Medical thoracoscopy equipment

Medical Thoracoscopy equipment

 Thoracoscope (rigid or semi-rigid) Biopsy forceps

 Biopsy and suction valves if semi-rigid

 Suction over-tube if rigid Suction tubing

Light source

 HD camera if rigid Port

 Kelly clamp or scissors for blunt dissection Scalpel

 Multiple 10 ml sterile syringes, hypodermic needles and 1% lidocaine

 Talc poudrage apparatus if pleurodesis being performed

Suture material Chest tube Pleurovac

 Chest tube dressing materials

and 97.6%, respectively. The main difference between the two instruments was the size of biopsy specimens derived from the procedure. The average specimen obtained by the rigid thoracoscope was 25 mm versus 12 mm for the semi-rigid scope [31].

Procedure

Pre-procedural Preparations and Considerations

The importance of appropriate patient selection cannot be overstated. A comprehensive history and physical detailing the patient’s medical co-­ morbidities, medications including anticoagulants, cancer history both personal and family, occupational and social histories to determine risk factors for malignancy should be performed. Radiology with a focus on obtaining prior imaging for comparison is very important and should be supplemented with bedside ultrasound to determine optimal site of entry into the thorax. Pertinent, pre-procedural lab investigations are dependent on the patient’s underlying medical comorbidities, that said many centers require a baseline complete blood count (CBC), international normalized ratio (INR), basic metabolic panel, and electrocardiogram (EKG). Informed consent should be obtained with explanation of the reason for the procedure and expected outcomes and a balanced discussion of risks, potential benefts, and common complications.

Procedural Technique [32]

Medical thoracoscopy should be performed in sterile fashion. Proper positioning of the patient is essential to avoid post-procedural neuropathies. The patient is positioned with the unaffected side down in the lateral decubitus position with the arms outstretched and knees bent. An axillary roll may be inserted along with support for the knees (pillow between them), arms, and head. Cardiac, blood pressure, and oxygen saturation monitoring should be performed through-

out the procedure and until the patient is fully recovered from sedation. Our group performs the time out with site and side verifcation immediately after positioning to allow the patient to participate. Transthoracic ultrasound is performed to re-evaluate the pleural space in the procedural position. The hemidiaphragm, lung, liver/spleen, and any pleural-based abnormalities are identifed. In the case of a loculated or complex effusion, the largest pocket of freeowing uid is usually selected for entry into the thorax and the site marked on the skin surface. For pleural effusions, the preferred entry site for uncomplicated effusions is the anterior axillary line in the ffth intercostal space. This allows for ease of visual inspection of the pleural space. On the other hand, the preferred entry site for the management of pneumothorax is the third interspace in the anterior axillary line such that the operator has a comprehensive view of the apex of the lung, particularly if considering thoracoscopic management of blebs.

Once positioned, the patient is draped in sterile fashion and then moderate sedation administered. The patient should continue to breathe spontaneously and caution should be taken to avoid over-sedation. Next, an intercostal block is performed using 1% lidocaine. Generous local anesthesia will minimize the sedation required for patient comfort. A 1-inch superfcial wheel of lidocaine is injected along the entry site just above the lower rib, then extended down along the tract to the pleura. If malignancy is suspected, caution should be taken to not inoculate the tract after breaching the pleura and aspirating pleuraluid. Using a clean needle, the periosteum of the upper and lower ribs is anesthetized. The intercostal space is then also infltrated with lidocaine. A 1-inch incision is made into the skin and blunt dissection with forceps is used to form a tract for the port. Stylistic differences exist, but some physicians prefer to penetrate the pleura with their digit as opposed to with the forceps to avoid accidental injury to the lung and intercostal vessels. Once the pleura is breached, the index fnger is used to perform a sweep of the pleural space to ensure that the lung is not adherent to the pleura. The port is then advanced into the thoracic cavity

and the trocar removed. The thoracoscope is advanced through the port and into the pleural space. Fluid is aspirated to allow for complete inspection of the surfaces of the lung, hemidiaphragm, and chest wall. Once the pleural space has been evaluated and key landmarks identifed, then biopsies may be performed if appropriate. In order to minimize the risk of injury to vascular structures, the tip of the forceps is used to identify the rib. Then the forceps are used to peel off the parietal pleura. It is prudent to biopsy away from vascular structures. In addition, fssures should be avoided whenever possible to limit accidental injury to the vessels or airways.

Simple thin loculations may either be aspirated using the suction or gently broken down using the tip of the thoracoscope. Extreme caution must be taken as thicker bands may be vascularized and bleeding may occur if interrupted accidentally. Cautery may be employed to address potential bleeding from an adhesion. Both rigid and exible cautery probes are available for this purpose. With respect to pleurodesis, specifcally talc poudrage, the procedure depends upon whether there is an integrated channel for pleurodesis. If so (which is the case for many rigid scopes), the scope is advanced into the pleural space and talc insuf ated under direct visualization. A thin layer of talc is applied to all surfaces including the visceral and parietal pleura. It is important to slowly move the thoracoscope anteriorly, posteriorly, apically, and along the hemidiaphragm. Once complete, a chest tube is inserted through the thoracoscopy incision and oriented either basally along the hemidiaphragm or apico-posteriorly depending on the indication ( uid or pneumothorax, respectively). A pressure dressing with Vaseline gauze around the tube is applied and the chest tube connected to suction at −20 cm H2O until the lung is re-in ated. The duration of ongoing chest tube drainage is dependent on the indication and physician preference. For pleural effusions, it is preferable to leave the chest tube on suction when attempting pleurodesis until such time as the volume is minimal to minimize the risk of incomplete symphysis and formation of symptomatic loculations. With respect to pneumothorax, the