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Thoracoscopy and Video-Assisted Thoracoscopic Surgery

By Noah Lechtzin, MD, MHS, Associate Professor of Medicine and Director, Adult Cystic Fibrosis Program, Johns Hopkins University School of Medicine

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Thoracoscopy is introduction of an endoscope into the pleural space. Thoracoscopy can be used for visualization (pleuroscopy) or for surgical procedures.

Surgical thoracoscopy is more commonly referred to as video-assisted thoracoscopic surgery (VATS).

Pleuroscopy can be done with the patient under conscious sedation in an endoscopy suite, whereas VATS requires general anesthesia and is done in the operating room. Both procedures induce a pneumothorax to create a clear view.


Thoracoscopy is used for

  • Evaluating exudative effusions and various pleural and lung lesions when noninvasive testing is inconclusive

  • Pleurodesis in patients with recurrent malignant effusions

  • Breaking up loculations in patients with empyema

The diagnostic accuracy for malignant and tuberculous disease of the pleura is 95%.

Indications for VATS include

  • Correction of spontaneous primary pneumothorax

  • Bullectomy and lung volume reduction surgery in emphysema

  • Wedge resection

  • Lung parenchymal biopsy

  • In some medical centers, lobectomy and even pneumonectomy

Less common indications for VATS are excision of benign mediastinal masses; biopsy and staging of esophageal cancer; sympathectomy for severe hyperhidrosis or causalgia; and repair of traumatic injuries to the lung, pleura, and diaphragm.


Contraindications are the same as those for thoracentesis.

An absolute contraindication is

  • Adhesive obliteration of the pleural space

Biopsy is relatively contraindicated in patients with highly vascular cancers, severe pulmonary hypertension, and severe bullous lung disease.


Although some pulmonologists do pleuroscopy, VATS is done by thoracic surgeons. Both procedures are similar to chest tube insertion; a trocar is inserted into an intercostal space through a skin incision, through which a thoracoscope is inserted. Additional incisions permit the use of video cameras and accessory instruments.

After thoracoscopy, a chest tube is usually required for 1 to 2 days.


Complications are similar to those of thoracentesis and include

  • Postprocedural fever (16%)

  • Pleural tears causing air leak (2%) and/or subcutaneous emphysema (2%)

Serious but rare complications include

  • Hemorrhage

  • Lung perforation

  • Gas embolism

Patients are also at risk of the complications of general anesthesia.