Pleuroscopy: A Minimally Invasive Approach to Pleural Disease

 

                                 Semi-rigid Medical Thoracoscopy

INTRODUCTION

Pleuroscopy, also known as medical thoracoscopy, is a type of minimally-invasive procedure that makes use of a pleuroscope to provide direct visualization of the pleural space. It is mostly used to diagnose and treat pleural conditions, such as effusions or malignancies. This blog gives an in-depth explanation of pleuroscopy, including indications,procedure steps etc.

WHAT IS PLEUROSCOPY?

Pleuroscopy involves inserting a pleuroscope into the pleural cavity under local anesthesia or conscious sedation. It enables physicians to biopsy pleural tissue, drain fluid, or perform therapeutic interventions like pleurodesis.

Semi-rigid Medical Thoracoscopy/Pleuroscopy

INDICATIONS OF PLEUROSCOPY

Diagnosis of Pleural Effusions:

• Unexplained exudative pleural effusions.

Pleural Tumors:

• Suspected mesothelioma or metastatic pleural disease.

Therapeutic Applications:

• Pleurodesis for recurrent pleural effusions or pneumothorax.
• Adhesion lysis in trapped lung syndrome.

CONTRAINDICATIONS OF PLEUROSCOPY

• Uncontrolled coagulopathy.
• Severe cardiorespiratory instability.
• Extensive pleural adhesions (hindering thoracoscope insertion).

PLEUROSCOPY PROCEDURE

. Preparation

• Patient Evaluation:

  • Comprehensive history, physical examination, and imaging studies (e.g., chest X-ray, CT scan).
  • Blood tests for coagulation profile.

• Informed Consent:

  • Explain risks, benefits, and alternatives.

• Pre-Procedure Setup:

  • Administer sedatives or local anesthetics as needed.
  • Position the patient in the lateral decubitus position, with the affected side up.

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2. Equipment Setup

• Sterile thoracoscope or video-assisted thoracoscope.
• Suction device, biopsy forceps, and instruments for pleurodesis.
• Sterile drapes and antiseptic solution.

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3. Incision and Entry

• Mark the entry site, usually in the midaxillary line at the 5th–7th intercostal space.
• Make a small skin incision (~1–2 cm).
• Insert a trocar and cannula into the pleural space under local anesthesia.
• Introduce the thoracoscope through the cannula.

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4. Inspection of the Pleural Cavity

• Examine the pleural surfaces, lung, and diaphragm.
• Identify abnormalities like nodules, adhesions, or inflammation.

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5. Biopsy

• Use biopsy forceps to obtain pleural tissue samples from abnormal areas.
• Ensure adequate samples for histopathological and microbiological analysis.

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6. Therapeutic Interventions (if needed)

• Pleurodesis: Instill a sclerosing agent (e.g., talc) to prevent recurrent effusions or pneumothorax.
• Fluid Drainage: Suction out excess pleural fluid.

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7. Closing the Procedure

• Remove the thoracoscope and cannula.
• Place a chest tube for post-procedure drainage.
• Close the skin incision with sutures or adhesive strips.

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8. Post-Procedure Care

• Monitor the patient for complications such as bleeding, infection, or air leak.
• Obtain a chest X-ray to confirm lung re-expansion and rule out pneumothorax.

The side of the pleural effusion identified with thoracic ultrasound and marked (A) infiltration of skin, subcutaneous tissue, intercostal muscle, and parietal pleura with local anesthetic; (B) aspiration of pleural fluid with a needle confirming pleural effusion; (C) making the incision with the scalpel through the skin and subcutaneous tissue, appropriate to the size of the trocar to be used; (D) blunt dissection with blunt dissecting forceps through the chest wall and into the pleural cavity; (E) insertion of trocar/introducer port into the pleural space via corkscrew motion; and (F) advancement of thoracoscope into the pleural cavity under direct vision through the trocar.

Thoracoscope advanced into the pleural cavity under direct vision through the trocar.

BEENIFITS & RISKS

Benefits:

• Minimally invasive.
• Accurate diagnosis and effective therapeutic interventions in one procedure.

Risks:

• Minor bleeding or infection.
• Pneumothorax.
• Subcutaneous emphysema.

Pleuroscopic pictures of some pleural abnormalities: (A) Big pleural masses in cases of MPM. (B) Diffuse thickening of the costal pleura mainly in cases of MPM. (C) Different forms of adhesions mainly in cases of empyema. (D) Multiple variable sized pleural nodules mainly in cases of tuberculosis, metastatic adenocarcinoma and MPM.

CONCLUSION

Pleuroscopy is a versatile and valuable tool in diagnosing and treating pleural diseases. With proper technique and adherence to guidelines, it ensures high diagnostic yield and therapeutic success with minimal risks.