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Thoracoscopy Service
Anantham Devanand
Respiratory and Critical Care Medicine
Singapore General Hospital
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Getting started
• Training
• Equipment
• Nursing personnel
• Patient selection
• Thoracoscopy
• Post procedure care
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Training
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Anatomy
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Blood supply to Parietal Pleura
• Costal Pleura
– Intercostal arteries
– Branches from internal mammary artery
• Mediastinal Pleura
– Bronchial arteries
– Internal mammary artery
• Apex
– Subclavian arteries
• Venous drainage via perbronchial veins and directly into venae cavae
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Innervation of the pleura
• Visceral pleura is devoid of somatic
innervation
• Parietal pleura is innvervated by somatic
fibres
– Apex, mediastinum and diaphragm by phrenic
nerve
– Lateral chest wall by intercostal nerves
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Equipment and Personnel
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Equipment
• Scope Trolley
– LTF Semi-rigid Thoracoscope
– Suction tubings X 2
• 1 attached to scope
• 1 attached to suction catheter
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Equipment
• Procedure Trolley– Chest tube insertion set
– Sterile dressing set
– Sterile drapes, surgical gowns, towel clips
– Biopsy forceps 55CR
– Spray catheter for lignocaine
– Straight blade
– Sutures 2/0 Prolene; 2/0 Mersilk
– Trochar 8 mm
– Nelathon catheter #16
– 20 cc syringe and needle for lignocaine
– 60cc Bulb syringe
– Talc powder 3-6g
– Biopsy strips
– 20F chest tube
– Pleurovac chest drain
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Patient selection
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Indications
• Diagnostic: pleural effusions of unknown origin– Yield > 90% for malignancy and TB
• Therapeutic: Pleurodesis– Malignant effusions
– Pneumothorax recurrence prevention
• Therapeutic: empyemas– Adhesiolysis, drainage and optimal chest tube
placement
• Really cool but be very careful– Resection of blebs and bullae
– Lung biopsy for the diagnosis of ILD
– Sympathectomy
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Contraindications (Absolute)
• Lack of a pleural space
• Type 2 respiratory failure not attributable
to effusion
• Positive pressure ventilation
• Uncorrectable coagulopathy
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Contraindications (Relative)
• Fever/ongoing sepsis (besides empyema)
• Uncontrolled cough
• Unstable hemodynamics
• Unable to lie in the lateral decubitus
position for at least 1 hour
• Pulmonary arterial hypertension, SVCO
• Morbid obesity
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Consent
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Thoracoscopy
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Positioning and selecting insertion
site
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Ultrasound
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Trochar insertion and drainage
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Inspection of pleural space
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Biopsies
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Ahesiolysis
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Talc poudrage
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Talc poudrage
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Intra-operative complications
• Vagal syncope at the time of pleural entry
• Pain at trochar insertion
• Cough when pleural fluid suctioned out
• Hypoxia/hypotension when sedation given
• Bleeding post biopsy
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Post procedure care
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Early complications• Wound site pain/discomfort
• Wound infections
• Air-leaks/subcutaneous emphysema
• Fever
• Increased oxygen requirements post pleurodesis
• Sub-optimal chest tube placement
• Bleeding
• Pneumonia
• Pulmonary embolism
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Late complications
• Failed pleurodesis
• Empyema
• Pleurocutaneous fistula
• Tumour seeding at thoracoscopic port and
chest tube site