How is a medical thoracoscopy (pleuroscopy) performed?

Answer

To prepare for the procedure, the pulmonologist can remove 500 ml of fluid from the pleural space through thoracentesis and induce a pneumothorax before inserting a trochar. Alternatively, the pulmonologist can make an intercostal incision that allows fluid to be aspirated freely once the trocar is inserted.

If malignancy is suspected, a single skin incision is made in approximately the fifth to seventh intercostal space along the lateral chest wall of the involved hemithorax. Pleural fluid is evacuated and pleural biopsies are obtained of the pleura. If the procedure is performed to visualize blebs and bullae in the lung apex, an incision in the fourth intercostal space is preferred.

Medical thoracoscopy is usually performed with a single-puncture technique, but can also use a double-puncture technique. For both, the pulmonologist visualizes the pleural space with a rigid or semirigid pleuroscope. Once the pleural cavity is entered, almost complete visualization of the parietal cavity is possible; only the posterior and mediastinal side of the lung cannot be seen.

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Media Gallery

Biopsy forceps sampling parietal pleura.
Talc pleurodesis on lung and parietal pleura.
Bulky metastasis on parietal pleura.
Examination for evidence of metastasis.
Pleural adhesions on medical thoracoscopy.
Patient positioning for medical thoracoscopy.
Trocar insertion for medical thoracoscopy.
Insertion of semirigid scope through trocar.
Olympus semirigid pleuroscope.
Olympus semirigid pleuroscope.
Olympus semirigid pleuroscope.
Semirigid pleuroscope in extension.
Semirigid pleuroscope in flexion.
Semirigid pleuroscope in neutral position.

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Author

Rajiv Malhotra, DO, MS, FCCP Assistant Professor of Internal Medicine, Division of Pulmonary and Critical Care, Department of Internal Medicine, Virginia Commonwealth University; Medical Director of Cardiac Surgery ICU, Associate Fellowship Director of Interventional Pulmonology, Virginia Commonwealth University Health System

Rajiv Malhotra, DO, MS, FCCP is a member of the following medical societies: American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, International Society for Heart and Lung Transplantation, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Cecilia C Bergh, MD Fellow in Pulmonary and Critical Care Medicine, Virginia Commonwealth University Medical Center

Disclosure: Nothing to disclose.

Hans J Lee, MD Assistant Professor of Medicine, Director of Pleural Disease Services, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine

Hans J Lee, MD is a member of the following medical societies: American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American Thoracic Society, Association of Interventional Pulmonary Fellowship Directors

Disclosure: Nothing to disclose.

Ray W Shepherd, MD Associate Professor of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University School of Medicine; Staff Physician, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Medical Center

Ray W Shepherd, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Christian Medical and Dental Associations, American Association for Bronchology and Interventional Pulmonology

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

How is a medical thoracoscopy (pleuroscopy) performed?

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