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Thoracoscopy and Video-Assisted Thoracoscopic Surgery

By

Rebecca Dezube

, MD, MHS, Johns Hopkins University

Last full review/revision May 2021| Content last modified May 2021
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Thoracoscopy is a procedure in which an endoscope is introduced to visualize 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.

Indications

Thoracoscopy is used for

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

  • Pleurodesis in patients with recurrent malignant effusions when chemical pleurodesis is not indicated or has been ineffective

  • Breaking up loculations in patients with empyema

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

Common indications for VATS include

  • Bullectomy and lung volume reduction surgery in emphysema

  • Correction of spontaneous primary pneumothorax

  • Lobectomy and pneumonectomy (in some centers)

  • Lung parenchymal biopsy

  • Wedge resection

Less common indications for VATS are

  • Biopsy and staging of esophageal cancer

  • Excision of benign mediastinal masses

  • Repair of traumatic injuries to the lung, pleura, or diaphragm

  • Sympathectomy for severe hyperhidrosis or causalgia

Contraindications

Contraindications to thoracoscopy and VATS 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.

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 of thoracoscopy and VATS 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.

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