Endoscopic Thoracoscopy
Endoscopic thoracoscopy includes both rigid and flexible thoracoscopy, which is mainly done by a respiratory physician in an endoscopy room or operating room. As a modern interventional respiratory disease diagnosis and treatment technique, it is a powerful tool for respiratory physicians to diagnose and treat pleural and pulmonary diseases, and is an easily tolerated, safe, minimally invasive and low-cost interventional treatment method.
Indications: Its main indications can be divided into two categories: diagnostic and therapeutic
1.Diagnostic thoracoscopy
(1) unexplained pleural effusion and encapsulated pleural effusion
(2) pleural masses
(3) Pneumothorax and hemothorax
(4) Examination of bronchopleural fistula
(5) Staging of lung cancer
(6) Diaphragmatic lesions such as inflammation, tumor, injury, etc.
(7) Partial mediastinal masses
(8) Pericardial disease
(9) Biopsy of mediastinal or parasternal intramamammary lymph nodes
(10) Others such as morphological examination of the pleura or determination of certain substances of the pleural tissue, etc.
2.Therapeutic thoracoscopy
(1) Pleural fixation: treatment of malignant pleural effusion, recurrent benign pleural effusion, persistent or recurrent pneumothorax
(2) pleural adhesion release: removal of restricted adhesions in the thoracic cavity, treatment of pneumothorax and pulmonary atelectasis
(3) Treatment of bronchopleural fistula
(4) Treatment of hemothorax such as intrathoracic hemostasis, removal of blood clots and drainage of hemothorax
(5) Removal of foreign bodies in the pleural cavity
Contraindications
(1) Fusion of mural and dirty pleura
(2) Extensive pleural adhesions and loss of pleural cavity
(3) Coagulation disorders
(4) Severe cardiac and pulmonary insufficiency, unable to lie down
(5) Severe cough or extreme failure and cannot tolerate surgery
(6) Severe pulmonary hypertension or intrathoracic vascular malformation
Preoperative preparation
1.General preparation.
(1) Blood count, clotting time, activated partial thromboplastin time
(2) Liver and kidney function, electrocardiogram and lung function
3) Chest frontal and lateral views and/or chest CT
4) Enhanced communication with the patient to prepare the patient mentally and sign an informed consent form
5）Surgical environment such as sterilized endoscopy room or operating room, surgical gown and resuscitation facilities
2.Establishment of artificial pneumothorax: usually done one day before the examination or before the examination.
1）Artificial pneumothorax: apply artificial pneumothorax needle to inject filtered air so that the distance between dirty and wall is at least 250px
2）Artificial pneumothorax for pleural effusion: 400-800ml of pleural fluid is withdrawn at the ultrasound localization point, and then 400-800ml of filtered air is injected, etc.
3.Selecting the entry point: The principle of selecting the entry point is to facilitate observation, biopsy and/or treatment, and to avoid pleural adhesions, hypertrophic muscles and blood vessels. Generally, it is chosen in the 3rd, 4th, 5th, 6th or 7th rib space in the anterior axillary line, mid-axillary line and posterior axillary line. Spontaneous pneumothorax is more likely to be in the 3rd or 4th intercostal space, and pleural effusion is preferred in the 6th or 7th intercostal space. Special or limited lesions can be localized under fluoroscopy or CT depending on the situation.
4.Pre-operative medication: half an hour before the examination, intramuscular injection of Valium 5~10mg or Pethidine (Dulcolax) 50~100mg, Atropine 0.5mg. Local anesthetic medication is usually chosen from 1% lidocaine (or procaine) 10~20ml for subcutaneous, intradermal and intercostal muscle infiltration injection to the wall pleura. To prevent bleeding at the puncture site, 1/100,000 epinephrine can be added to the anesthetic solution.
5.Patient position: Most of them use the position of the healthy side lying on the side and the affected side on the top (standard position), and less use the supine and prone positions.
Examination operation steps
1.After disinfection at the entry point, local anesthetic is infiltrated to the wall pleura, a parallel incision of 1~37.5px is made along the rib space, and hemostatic forceps are bluntly separated to the pleural cavity.
2, Insert the trocar needle vertically at the incision, pull out the needle core, insert the thoracoscope along the trocar, and perform observation.
3.Observation order: it is generally customary to examine the anterior chest wall, anterior mediastinum, pleural apex, posterior chest wall, posterior mediastinum and whole lung, and finally the diaphragm and posterior costophrenic sinus.
4, abnormalities such as neoplasia, pleural thickening, small nodules, congestion and erosion should be biopsied promptly, and biopsies should be performed several times (5~8 times). In case of bleeding, electrocoagulation, clamping or compression is feasible to stop the bleeding.
5.After the examination, a catheter should be left at the incision for closed drainage.
Postoperative complications of thoracoscopy
1, emphysema: subcutaneous emphysema is more common, mediastinal emphysema is rare.
2, fever: some patients have postoperative fever with body temperature around 38℃, which usually recovers on its own within 24~48 hours.
3.Gas leakage: gas continues to enter the pleural cavity due to the rupture of the dirty pleura during the dirty pleural biopsy.
4.Wound and intrathoracic infection: When the patient has an elevated body temperature within 48 hours after surgery or the original elevated body temperature increases instead of decreasing, or is accompanied by more secretions from the wound, the possibility of infection should be considered.
5.Intrapleural hemorrhage: It is mostly caused by separation of adhesion zone, tissue tear or accidental injury to large blood vessels.
6.Tumor implantation: mostly seen in malignant pleural mesothelioma after surgery.
7.Gas embolism: It is a rare but serious complication. It mostly occurs in patients without pleural effusion and artificial pneumothorax is established.
8, abdominal pain: If the drainage tube is left in the pleural cavity for a long time after surgery, and if the drainage tube is slightly stiff, it will stimulate the diaphragm and cause abdominal pain.