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Thoracoscopy and Video-Assisted Thoracoscopic Surgery

by Noah Lechtzin, MD, MHS

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 to evaluate exudative effusions and various pleural and lung lesions when noninvasive testing is inconclusive. The diagnostic accuracy for malignant and tuberculous disease of the pleura is 95%. The procedure is also used for pleurodesis in patients with recurrent malignant effusions and to break up loculations in patients with empyema.

Indications for VATS include correction of spontaneous primary pneumothorax, bullectomy and lung volume reduction surgery in emphysema, wedge resection, and, in some medical centers, lobectomy and even pneumonectomy. Less common indications 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

Contraindications are the same as those for thoracentesis; adhesive obliteration of the pleural space is an absolute contraindication. Biopsy is contraindicated in patients with highly vascular cancers, severe pulmonary hypertension, and severe bullous lung disease.

Procedure

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

Complications are similar to those of thoracentesis. Postprocedural fever is common (16%); pleural tears causing air leak, subcutaneous emphysema, or both are less common (2% each). Hemorrhage, lung perforation, and gas embolism are serious but rare.

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