Medical Thoracoscopy vs VATS
Medical Thoracoscopy vs VATS
Medical Thoracoscopy vs VATS
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Sugamya Mallawathantri<br />
Consultant Respiratory Physician<br />
Poole Hospital NHS Foundation Trust
<strong>Medical</strong><br />
<strong>Thoracoscopy</strong><br />
Examination of<br />
the pleural<br />
cavity using a<br />
rigid/ flexible<br />
scope.<br />
Examination of<br />
the visceral and<br />
diaphragmatic<br />
pleura and the<br />
pericardial<br />
surface.
The Past<br />
Francis Richard Cruise 1865
<strong>Medical</strong> <strong>Thoracoscopy</strong> <strong>vs</strong> <strong>VATS</strong><br />
• Safe<br />
• Simple to set up<br />
• Can be performed under LA, conscious sedation<br />
• Endoscopy unit<br />
• Non disposal rigid instruments<br />
• Less invasive and less expensive than surgical<br />
procedures<br />
• Less inpatient stay
Diagnostic procedure<br />
Indications<br />
Unilateral, exudative pleural effusions<br />
perform pleural biopsies under direct<br />
vision<br />
Therapeutic procedure<br />
Complete drainage of pleural fluid<br />
Talc poudrage
Other indications<br />
• Talc pleurodesis - recurrent pneumothoraces<br />
• Pulmonary biopsy<br />
• Pericardiocentesis<br />
• Sympathectomy<br />
• Treatment of empyema
Contraindications<br />
Patients who require <strong>Thoracoscopy</strong> are usually ill<br />
Absolute:<br />
• Absence of pleural space<br />
• No consent<br />
• Uncooperative patient<br />
• PaO2 < 50mmHg<br />
• Platelet count < 75,000/ Elevated PT<br />
• Temperature >37.5 ºC ( except in the setting of an<br />
empyema)
Types of anaesthesia<br />
• Local anaesthesia - United Kingdom<br />
Premedication – morphine, atropine<br />
Midazolam and alfentanil<br />
• General anaesthesia - Europe, spontaneous<br />
breathing
Patient position<br />
• Lateral decubitus position<br />
• Healthy lung down<br />
• Arm away and strapped and supported<br />
• Patient should face the main operator<br />
• Second operator - either anterior or<br />
posterior to the patient
The patient-Sterile field
Points of entry<br />
• Pleural effusion – 5 th to 7 th intercostal space<br />
Always use pleural ultrasound to locate the<br />
point of entry [avoid damaging the<br />
diaphragm, avoid adhesions]<br />
• Pneumothorax – 3 rd /4 th intercostal space<br />
• Pulmonary biopsy – 4 th or 5 th intercostal<br />
space
Equipment – rigid thoracoscopy
Equipment
Equipment - Rigid <strong>Thoracoscopy</strong><br />
Boutin needle -<br />
create an artificial<br />
pneumothorax<br />
Safe entry into the<br />
cavity
Artificial pneumothorax
Biopsy technique<br />
• No punch biopsies<br />
• Stripp the pleura in lateral direction<br />
• Always start biopsying over a rib<br />
• Always check for bleeding<br />
• Deep biopsies with some deep tissue<br />
specially useful to confirm invasiveness of<br />
mesothelioma
Complications<br />
• Major<br />
significant bleeding<br />
empyema<br />
continuous air leak<br />
pulmonary emboli<br />
TALC PNEUMONITIS - RARE
Complications<br />
• Minor<br />
subcutaneous emphysema<br />
wound infections<br />
pain<br />
fever<br />
arrhythmias
summary<br />
• <strong>Medical</strong> thoracoscopy is a safe procedure<br />
• More cost effective<br />
• Less morbidity and mortality<br />
• Day case procedure if performed for<br />
diagnostic purposes<br />
Trainees – attend courses/more hands on<br />
experience
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