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 for Thoracoscopy and VATS
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 cancer and tuberculosis of the pleura is about 95% (1, 2).
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 to Thoracoscopy and VATS
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
Severe bullous lung disease
Procedure for Thoracoscopy and VATS
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 and VATS, a chest tube is usually required for 1 to 2 days.
Complications of Thoracoscopy and VATS
Complications of thoracoscopy and VATS are similar to those of thoracentesis and include
Postprocedural fever
Pleural tears causing air leak and/or subcutaneous emphysema
Serious but rare complications include
Hemorrhage
Lung perforation
Gas embolism
Patients are also at risk of the complications of general anesthesia.
References
1. Diacon AH, Van de Wal BW, Wyser C, et al. Diagnostic tools in tuberculous pleurisy: a direct comparative study. Eur Respir J 2003;22(4):589-591. doi:10.1183/09031936.03.00017103a
2. Durgeshwar G, Mohapatra PR, Bal SK, et al. Comparison of Diagnostic Yield and Complications in Ultrasound-Guided Closed Pleural Biopsy Versus Thoracoscopic Pleural Biopsy in Undiagnosed Exudative Pleural Effusion. Cureus 2022;14(4):e23809. doi:10.7759/cureus.23809
