ANATOMY OF THE PLEURA

The pleura develops in the embryo from the coelomic cavity (fetal body cavity).
The coelomic cavity is where the vital organs (heart, bowels, and lungs) will develop.
This cavity will then be divided into the peritoneal cavity and the pleural space by the
septum transversum and the pleuroperitoneal membranes. The pleural space will later be
separated into two distinct cavities by the pericardium. The lungs then develop from the
premordial buds (central mass of mesenchyme) and as they grow laterally, they
invaginate each pleural space, thus taking its pleural covering. The pleura covers the
entire thoracic cavity (parietal pleura) and the lungs (visceral pleura). The pleural layers
are reflected back-to-back in the interlobar fissures, and at the pulmonary ligament which
extends from the hilum down to the diaphragm.
The pleural space is a potential space that contains minute amounts of pleural fluid
essential for lubricating expansion and movement of the lungs. The lung fills the pleural
space during deep inspiration, while during expiration, the lung retracts and the costal
parietal pleura and the diaphragmatic pleura may come in apposition and for the pleural
recesses.
The pleura is composed of five layers: () a single layer of mesothelial cells, (!) a
thin submesothelial connective tissue layer, (") a thin superficial elastic layer, (#) a loose
connective tissue layer, and ($) a deep fibroelastic layer. The surface of the mesothelial
cells contains microvilli. These microvilli were thought to function in the absorption of
fluid, but recently, it has been shown to enmesh glycoproteins to lubricate the gliding of
both pleural layers.
The parietal pleura receives its blood supply from systemic capillaries. %mall
branches of the intercostal arteries supply the costal pleura, whereas the mediastinal
pleura is principally by the pericardiophrenic artery. The diaphragmatic pleura is supplied
by the superior phrenic and musculophrenic arteries. The blood supply of the visceral
pleura in humans and animals with thick pleura originates from the systemic circulation
via the bronchial arteries. &nvestigators have demonstrated that in sheep -an animal with
thick pleura- the visceral pleura is supplied completely and exclusively by the bronchial
artery. %ince humans have thick pleura, it is possible that the visceral pleura is suppplied
similarly, although there is still controversy concerning this.
The venous drainage of the parietal pleura is through the intercostal veins
(systemic veins) while the visceral pleura drains to pulmonary veins.
The lymphatics of the parietal pleura drain the pleural fluid and any noxious
particles that reach the pleura. The lymphatic system starts with small stomas that
communicate to lymphatic foci that will drain through lymphatic vessels to nodes along
the internal thoracic artery and to the internal intercostal nodes (along the heads of the
ribs posteriorly). The parietal pleural lymphatics can remove about !' times the fluid
formed under normal conditions (up to '.! m( per kg per hour). The visceral pleura
drains through two systems: a) a superficial system that floats over the surface of the lung
towards the hilum, and b) a deep system that penetrates the lung parenchyma to reach the
hilar nodes.
%ensory nerves endings are present in the costal and diaphragmatic parietal pleura.
The intercostal nerves supply the costal pleura and the peripheral part of the
diaphragmatic pleura. )hen either of these areas is stimulated, pain is referred to the
ad*acent chest wall. &n contrast, the central portion of the diaphragmatic pleura is
innervated by the phrenic nerve, and stimulation of this part of the pleura causes pain that
is referred to the ipsilateral shoulder. The visceral pleura contains no pain fibers

Physiology of The Pleural Space
) +leural pressure:
The pleural pressure is subatmospheric due to the tendency of the lung to collapse
versus the tendency of the chest wall to expand. This negative pleural pressure keeps the
inflated. There exists a pressure gradient between the superior and the inferior portions of
the pleura, with the superior portions being lowest (more negative). The magnitude of the
pressure gradient appears to be approximately '.$ cm ,!- per cm vertical distance.
.onsidering the si/e of the lung to be !$ cm in height in normal persons, the difference in
pleural pressure between the apex and the base may be around ! cm ,!-.
!) +leural 0luid 0ormation:
+leural fluid is normally formed from parietal pleural capillaries. The forces
governing this process are the pleural capillaries hydrostatic pressure and the oncotic
pressure of the pleural capillaries and the oncotic pressure of fluid in the pleura space.
This can be summari/ed in the following schematic illustration.
PARIETAL P L E U R A L VISCERAL
PLEURA S P A C E PLEURA
Hydrostatic pressure
30 - 5 +24
35 29
6 0
29 29
34 5 34
Oncotic pressure
This illustration shows that the pleural fluid is normally formed from filtration from
the parietal pleural capillaries with a gradient of 12 cm ,!-. &t is noteworthy to
remember that the fluid is also removed from the pleural space through the parietal
pleural lymphatics through the lymphatic stomas. 3ormally, '.' m( per 4g per hour is
formed through pleural fluid lymphatics.
!) -ther -rigins of +leural 0luid:
a) &nterstitial origin: in conditions where the interstitial tissues of the lung are
overloaded with transudate (e.g., high pressure or high permeability pulmonary edema),
fluid may escape in the pleural space. The fluid is then removed through parietal pleural
lymphatics which have the ability to remove considerable amounts of fluid.
b) +eritoneal cavity: ascetic fluid can pass to the pleural space through minute
openings in the diaphragm. This can be seen in cases of hepatic hydrothorax, 5eig6s
syndrome, and peritoneal dialysis.
c) Thoracic duct or blood vessel disruption: lymphatic vessel disruption (as in cases
of trauma, or lymphoma) will lead to chylothorax. 7lood vessel disruption will result in
hemothorax.
Pathogenesis of Pleural Flui For!ation
The pathogenesis of pleural fluid accumulation can be summari/ed in the following table:
Pathogenesis of Pleural Effusions
A"#ncrease pleural flui for!ation$
#ncrease interstitial flui in the lung$
(eft ventricular failure, parapneumonic effusion, pulmonary embolus,
89:%, +ost lung transplantation.
#ncrease intra%ascular pressure in the pleura:
9ight or (eft ventricular failure, %uperior vena caval syndrome (%;.), and
pericardial effusion.
#ncrease pleural flui protein le%el: parapneumonic effusion
&ecrease pleural pressure 'e()%aco effusion"*
(ung atelectasis or increased elastic recoil of the lung.
#ncrease flui in peritoneal ca%ity$
8scites, peritoneal dialysis, and 5eig6s syndrome.
&isruption of the thoracic uct$ trauma, tumors (lymphoma)
+"&ecrease pleural flui rea,sorption:
O,struction of the ly!phatics raining the parietal pleura:
+leural malignancies
Ele%ation of the syste!ic %ascular pressures$
%;. syndrome or right ventricular failure.
-&isruption of the a.uaporins syste!$ a group of proteins that help
transport water across the pleura ( still under investigation)
/eneral 0auses of Pleural Effusions
Table : causes of pleural effusions
&ifferentiation +et1een Pleural E(uates an Transuates
The most crucial aspect in reaching a diagnosis for pleural effusions is the
differentiation between pleural exudates and transudates. Transudates are usually the
result of systemic factors that influence the formation and absorption of pleural fluid.
They are usually caused by conditions other than the lung and pleura (table ).
-n the other hand, exudates are the result of pleural or pulmonary processes that
lead to pleural fluid accumulation. &n other words, they are the result of local disease.
There are many laboratory tests that could help separate exudates from
transudates. The most accepted and valid criteria for the diagnosis of pleural exudates are
called (ight6s criteria. The application of (ight6s criteria re<uires the simultaneous
analysis of pleural fluid and serum for protein content and (:,. 8ny pleural fluid that
meets one of the following criteria is considered an exudate:
i- +leural fluid=serum protein >'.$
ii- +leural fluid (:,=serum (:, >'.2
iii- +leural fluid (:, >!=" upper normal serum level
8ny pleural fluid that doesn6t meet the above criteria is considered a transudate.
&f the pleural fluid is a transudate, search cardiac, renal, or hepatic causes that may cause
the effusion.
The hard task remains for the pulmonologists to differentiate between the
different causes of exudates. 0or this reason, several tests are re<uired before reaching the
exact cause of the effusion.
- 8ppearance of the pleural fluid:
8 bloody exudate can be seen in cases of malignancies, pulmonary embolism, or
may be due to traumatic thoracentesis. &f the pleural fluid is deeply hemorrhagic,
obtain a pleural fluid hematocrit. &f the hematocrit is >$'? of the peripheral
blood, consider inserting an intercostal tube for a possible hemothorax.
8 turbid pleural effusion should be centrifuged and the supernatant fluid
examined. &f the supernatant appears clear, the pleural fluid is an empyema, while
if it remains turbidly white, the fluid is a chylothorax.
!- +leural fluid differential cell count:
&f neutrophils predominate the differential cell count, the process is an acute
process, as in cases of parapneumonic effusions, pulmonary embolism, viral
infections, malignancy, or early stage tuberculous effusion. &f the effusion shows a
predominance of mononuclear cells, the effusion is a chronic process as in cases
of malignancy, pulmonary embolisation, tuberculous pleural effusion, or
following .87@.
"- +leural fluid glucose level:
8 pleural effusion with a low (A2' mg?) glucose level limits the diagnosis to four
main diagnoses: parapneumonic effusion, malignancy, T7, or rheumatoid pleural
effusion. -ther rare causes include: paragonimiasis, .hurg-%trauss syndrome,
Brinothorax, and occasionally %(C.
#- +leural fluid (:,:
+leural fluid (:, should be obtained every time a thoracentesis is performed for
an undiagnosed pleural effusion. (:, is an indicator for pleural inflammation. &f,
with repeated thoracenteses, pleural fluid (:, level increases, the process is
progressing and one should be more aggressive in pursuing a diagnosis. -n the
other hand, if (:, level decreases, the process is regressing and one can
conserve and follow up.
$- +leural fluid cytology:
.ytological examination is a useful test in detecting malignancies in #'-D'? of
cases. 8lmost all adenocarcinomas of the lung may be diagnosed by cytology,
while s<uamous cell carcinoma, lymphomas, and sarcomas are less commonly
detected on cytological examination. The yield depends on the skill of the
cytologist and on the tumor burden in the pleural space.
2- +leural fluid marker for Tuberculosis:
8- +leural fluid 8:8 level:
8denosine :eaminase (8:8) is an en/yme produced by active
lymohocytes. 8 pleural fluid level above D'B per ( with a lymphocyte
predominant effusion in a patient who doesn6t have empyema of
9heumatoid arthritis is essentially diagnostic of T7 pleural effusion.
(evels above #' B=( are suggestive of T7, while patients with 8:8 levels
below #' B=( are unlikely to have T7 pleural effusion.
7- +leural fluid interferon @amma levels:
&nterferon @amma increases in patients with T7 pleural effusion. Bsing a
cutoff level of ".D B per ml is almost always diagnostic of T7 effusion.
Fig* 2$
Fig* 3$
Options 4hen No &iagnosis Has +een O,taine After #nitial
Thoracentesis
The first thing to order for a patient whose pleural effusion remains undiagnosed after the
initial thoracentesis is a spiral .T scan of the chest to exclude or prove pulmonary
embolism. %piral .T will help identify a pulmonary embolus in a ma*or vessel, as well as
more clearly identify mediastinal lymphadenopathy, or pulmonary infiltrates. &f still the
diagnosis cannot be reached after .T, then there are five options for the pulmonologists:
- -bservation:
This is a possible option if the patient is improving and there are no parenchymal
infiltrates. &f the condition doesn6t improve, one should be more aggressive in
reaching a diagnosis.
!- 7ronchoscopy:
This is a useful investigation if one or more of the following is present: (a) a
pulmonary infiltrate is present, (b) hemoptysis is present (hemoptysis in a case of
pleural effusion is very suggestive of an endobronchial lesion), (c) the pleural
effusion is massive (occupying more than three fourths of the hemithorax), or (d)
the mediastinum is shifted towards the side of the effusion (possibly an
endobronchial lesion is present).
"- Thoracoscopy:
This is the most accurate method of diagnosis if the necessary e<uipment and
expertise are present. The procedure is minimally invasive, highly specific, and
can be performed in patients with poor general condition who are not fit for
general anesthesia and open biopsy.
#- 3eedle biopsy of the pleura:
3eedle biopsy of the pleura can reach a diagnosis in processes that affect the
pleural space uniformly (T7 or mesothelioma), while in metastatic cases where
the pleural metastasis are in the form of nodules separated by areas of normal
pleura the yield of this procedure is very low. %pecial expertise are needed to
obtain ade<uate samples of the pleura as well as skilled pathologists.
$- -pen pleural biopsy
This is the most accurate diagnostic method, although it is the most aggressive. &n
the presence of medical thoracoscopy, open pleural biopsy is becoming less
preferred. 8lthough it has the highest yield, there is an incidence of failure of
thoracotomy to reach a diagnosis. .onsiderable mortality and morbidity are
associated with the procedure.
Meical Thoracoscopy
Thoracoscopy was used first used as a diagnostic tool by ,. Eacobaeus in F', but it
soon also was used as a therapeutic techni<ue for lysis of pleuropulmonary adhesions. 7y
means of thoracocautery, Eacobaeus divided the adhesions holding the lung to the chest
wall to facilitate pneumothorax treatment of tuberculosis (Eacobaeus6 operation). (ater,
the addition of the term G5edicalH was necessary to distinguish the procedure from the
more invasive intervention re<uiring general anesthesia, double lumen endotracheal tube,
and multiple points of entry G%urgical ThoracoscopyH or ;ideo 8ssisted Thoracoscopic
%urgery (;8T%). 5edical thoracoscopy can be performed with or without video
assistance, under local anesthesia and conscious sedation, in an endoscopy suite, using
non-disposable instruments. &t is therefore considerably less invasive, with less morbidity,
and less expensive.
5edical thoracoscopy is now mainly a diagnostic tool but has some therapeutic
capabilities. +leural effusions are the leading indication for medical thoracoscopy, both
for diagnosis (mainly in exudates of unknown etiology and for staging of malignant
mesothelioma or lung cancer) and for treatment by talc insufflation for pleurodesis in
malignant or other recurrent pleural effusions, or in cases of empyema. %pontaneous
+neumothorax is an excellent indication for both diagnostic as well as for therapeutic
medical thoracoscopy. 0or those who are more familiar with the techni<ue, other
indications for thoracoscopy are biopsies from the diaphragm, the lung, the mediastinum,
and the pericardium, as well as thoracoscopic sympathectomy, and local management of
spontaneous pneumothorax. &n this section, the pleural applications will be discussed.
Historical +ac5groun$
,ans-.hristian Eacobaeus, an internist working in %tockholm, %weden, in F'
introduced thoracoscopy at the same time as laparoscopy in a paper entitled I.oncerning
the possibility of using cystoscopy in the examination of serous cavities6. ,e reported
two cases of exudative pleural effusions in which, after aspirating the pleural fluid and
replacing it with filtrated air, he performed thoracoscopy under local anesthesia. ,e
found that Gexamination of the pleural cavities was of particular interest, not in the least
because they were only to a limited degree suitable for a surgical approachH. &n addition
to the diagnostic aspects, Eacobaeus hoped to gain prognostic information from the
procedure. :uring the ensuing years, thoracoscopy was used for diagnostic purposes by
some other pulmonologists mainly in %candinavia, @ermany, &taly, and other Curopean
counties. &n F!$, Eacobaeus published his vast experience in thoracoscopy, describing in
detail his studies of the etiology and staging of tuberculous pleurisy, of malignant pleural
effusion, rheumatoid pleurisy, parapneumonic effusion, as well as idiopathic
pneumothorax.
#nications of &iagnostic Thoracoscopy
Pleural effusions
+leural effusions of unknown etiology are the main indication for diagnostic
thoracoscopy. 8 large study comprising ''' consecutive patients with pleural effusions
showed that after extensive workout of pleural fluid analysis and closed pleural biopsies
(needle biopsy), !$ cases remained undiagnosed (!.$?). 8fter thoracoscopy, the
number of left undiagnosed effusions was #' (#?).
Malignant pleural effusions:
5alignant pleural effusions (5+Cs) are today the commonest indications for both
diagnostic and therapeutic thoracoscopy. Thoracoscopy is a very sensitive tool for
diagnosing 5+Cs which may defy diagnosis using cytological examination and closed
pleural biopsies for months. 5any investigators who were conservative regarding the use
of thoracoscopy for diagnosing a suspected 5+C and claiming that at some point of time
the diagnosis will become evident, are now reconsidering because waiting is detrimental
to the patient, and because the delay in diagnosing reduces the likelihood that a
therapeutic pleurodesis may be effective. 8s time passes, the tumor load increases and the
invasion of the visceral pleural results in a condition termed Gtrapped lungH that causes an
irreversible functional deficit. &t has also been proven that gamma interferon, one of the
few agents to show action in malignant mesothelioma, is only effective if administered
early in the disease process.
Thoracoscopy can reveal the features suggestive of malignancy morphologically
by their appearance: nodules -$ mm in diameter, larger polypoid masses, locali/ed
tumor massesJ rough, pale, thickened pleural surfacesJ and hard, poorly vasculari/ed
pachypleuritis. The diagnostic sensitivity of thoracoscopy is similar in all types of pleural
malignancies, whether of lung origin, extrathoracic malignancies, and in diffuse
malignant mesothelioma.
5edical thoracoscopy in metastatic lesions of the pleura has the advantage of
obtaining samples under direct vision from the diaphragmatic and the visceral pleurae,
and obtaining larger samples which help in easier identification of the primary tumor and
determination of hormone receptors in breast cancer cases. The extent of intrapleural
spread can be described using a scoring system which has shown close correlation with
survival.
The main advantage of using thoracoscopy for diagnosis of metastatic
malignancies to the pleura is the possibility of performing thoracoscopic talc insufflation
(TT&) during the procedure to produce an effective pleurodesis. The is the most
acceptable conservative option for pleurodesis nowadays because of its high success rate
(>F'?), even in cases of lymphomatous chylothorax where all other measures may fail.
0or details of the procedure, please see later.
Tuberculous pleural effusion
8lthough the diagnostic yield of pleural fluid cultures for T7 and closed needle
biopsy combined is <uite high, there may be indications for medical thoracoscopy in
otherwise uncertain pleural effusions. The diagnostic accuracy of thoracoscopy
approaches ''? because the pathologist and the lab are provided with multiple, selected
biopsies resulting in a more fre<uent pathological and mycobacteriologic proof.
The early diagnosis that medical thoracoscopy provides has resulted in the
diminution of cases that developed fibrothorax due to longstanding T7 pleurisy in the
centers that routinely use medical thoracoscopy in undiagnosed pleural effusions, as
opposed to observation. The procedure helps in more complete drainage of the fluid, and
division of loculations which hamper the total expansion of the lung.
Other pleural effusions
&n cases of pleural effusions that are neither malignant nor tuberculous,
thoracoscopy may give macroscopic clues to the etiology (e.g., in rheumatoid effusions,
effusions following pancreatitis, liver cirrhosis, extension from the abdominal cavity, or
trauma). 8lthough in thee entities history, pleural fluid analysis, physical and other
examinations are usually diagnostic, thoracoscopy may be indicated in those cases where
a definite diagnosis could not be reached. )hen the effusion is secondary to underlying
lung pathology such as a pulmonary infarct or pneumonia, the diagnosis can be obtained
macroscopically and confirmed microscopically from lung biopsies. 8s already
mentioned, thoracoscopy is well suited for diagnosing 78+C, which, by definition, is a
diagnosis of exclusion.
&n other conditions where the diagnosis is unknown, the main advantage of
thoracoscopy is to exclude the possibility of malignancy and tuberculosis. 7y means of
thoracoscopy, the proportion of the so-called idiopathic pleural effusions usually falls
markedly below '?, whereas studies that did not use thoracoscopy report a !'?
incidence of idiopathic pleural effusions.
&n rare occasions, the performance of thoracoscopy can be impossible due to the
presence of dense pleuropulmonary adhesions. These dense adhesions are the result of K
most probably- repeated diagnostically fruitless aspirations of large volumes of pleural
fluid. 0or these cases, the reader is referred to the section on extended thoracoscopy when
discussing the techni<ue of thoracoscopy.
Empyema
:uring the exudative phase of empyema, effusions are characteristically thin and
adhesions have not been formed. &n this stage, the fluid can be drained with a chest tube.
7eyond this stage, however, fluid is thick and multiple adhesions are formed, resulting in
loculations. Thoracoscopic visuali/ation may allow debridement of fibrinoid adhesions
and permit evacuation of loculated fluid. Thoracoscopy can allow complete evacuation of
purulent empyema. 8fter removal of pus from the pleural cavity, adhesions are dissected
to form one large cavity. +lacement of a large caliber chest drain in a clean adhesion-free
cavity ensures the best chances for lug re-expansion, with the aid of negative pressure
applied through the chest tube. Therefore, to benefit most from the procedure, it should
be performed as early as possible before the adhesions are too fibrous and adherent.
&rrigation of the pleural space during the procedure has been tried. The procedure
has been found beneficial especially when the irrigation is continued daily through two
chest drains until the aspirated fluid is culture negative. This method has shortened
hospital stay and avoided thoracotomy.
&n conclusion, if chest tube insertion is indicated in cases of complicated
parapneumonic effusion, and if the facilities are available, medical thoracoscopy should
be performed at the time of chest tube insertion to gain benefit from the procedure.
Spontaneous pneumothorax
&n spontaneous pneumothorax, medical thoracoscopy can be applied easily for
diagnostic as well as therapeutic purposes, if the facilities and the expertise are available.
8t the time of insertion of the chest tube, introduction of a thoracoscope will help stage
the disease visually according to the classification of ;anderschueren: stage &:
endoscopically normal lungJ stage &&: pleuropulmonary adhesionsJ stage &&&: small bullae
and blebs (A!cm diameter)J and stage &;: numerous large bullae (>!cm diameter).
5edical thoracoscopy for spontaneous pneumothorax offers the possibility of
combining chest drainage with coagulation of blebs or bullae as well as pleurodesis using
talc poudrage. &n cases staged visually as stage &; (numerous large bullae), the patients
should be transferred to surgical department directly after insertion of the chest tube.
-nly if the conditions are unfavorable for surgical intervention (e.g., respiratory
insufficiency, secondary to severe airway obstruction or other advanced pulmonary
diseases), stage &; bullae are coagulated or talc poudrage is performed.
@enerally, medical thoracoscopy is *ustified in all patients with spontaneous
pneumothorax where tube drainage is indicated, since several advantages are offered:
precise assessment of underlying lesions under direct visual control, choice of best
treatment strategies (conservative or surgical), direct treatment by coagulation of blebs
and bullae, and by severing adhesions if necessary, as well as selection of the best site to
place the chest tube.
&iagnostic Thoracoscopy$ E.uip!ent an Techni.ue*
The use of thoracoscopy has been resumed as a result of considerable progress in
modern techni<ues, particularly in the following areas: () Cndoscopic telescopes have
been greatly improved, and now have an extremely high optical <uality despite their
small diameter, (!) 8de<uate instruments, including video camera, forceps, endoscopic
scalpels, staplers, and laser, and (") +rogress in anesthesia allowing for a broad choice of
agents that range from local anesthetics in outpatients to general anesthesia.
0linical prere.uisites$
)ith the rare exceptions of tension pneumothorax and massive pleural effusion, in
which emergency therapeutic pleural drainage can be performed at the same time as
diagnostic thoracoscopy, this procedure should be considered only after careful
evaluation aimed at answering specific <uestions.
The history reveals information about the acute or chronic nature of the disease,
effort intolerance and possible underlying extrapulmonary disease such as tumor, deep
venous thrombosis, congestive heart failure, myocardial infarction, renal insufficiency,
pancreatitis, liver cirrhosis, etc. it is well known that the lung and the pleura may be
involved in many diseases.
&t is of particular importance to in<uire about previous treatment with cytotoxic
agents, radiotherapy, or previous antibiotic therapy. Thoracoscopy is contraindicated in
patients with severe coagulation defects or those on anticoagulant therapy.
9adiological evaluation routinely involves a postero-anterior and lateral chest x-
ray, fre<uently supplemented by .T scan. &n cases of suspected pulmonary embolism,
ventilation-perfusion scintigraphy and high resolution .T scan may be advised. &n
patients with diffuse lung disease, radiological examinations will assist in deciding the
hemithorax on which thoracoscopy should be performed. +ractically, radiological
examination determines the optimum point of insertion of the thoracoscope.
Cvaluation of the respiratory status re<uires, as a minimum, arterial blood gases
(87@s) analysis. 8n electrocardiogram should be done to exclude recent myocardial
infarction or significant arrhythmia.
The clinical chemistry laboratory should provide the physician with
thromboplastin time, serum electrolytes, blood glucose levels, blood group typing,
platelet count, liver function, rheumatoid factor anti-nuclear antibody, or serum amylase.
The results of pleural fluid should be available and include: chemical analysis
((:,, sugar, protein content, and 8:8), cytological examination, and microbial
cultures.
&f the physician has convinced himself that thoracoscopy is indicated, he should
have little difficulty explaining the need for the procedure to the patient obtaining an
informed consent. +atients may be provided by a hand-out followed by a verbal
explanation of the procedure including methodology, management of post-operative pain
and other so-called typical complications as well as the expected diagnostic and
therapeutic results.
E.uip!ent for thoracoscopy$
2)Telescopes$
8- 9igid telescopes: the rigid thoracoscope with cold light source id the instrument
that is most widely used. &ts design must satisfy two re<uirements: () to make high
<uality visual exploration and faultless photographic or video documentation, and (!)
to facilitate multiple, large biopsies of sufficient si/e to ensure definitive
histopathologic diagnosis, while accommodating electrocautery and=or L8@ laser
cautery when necessary.
7- 0lexible fiberoptic thoracoscopes: flexible thoracoscopes have been used with
controversies regarding its effectiveness. %ome operators have used these
instruments because the rigid instruments were not available and others have
found it extremely useful. The si/e of the biopsies obtained by the flexible
endoscopes is small and may make the diagnosis of such cases as mesothelioma
very hard.
.- %emiflexible thoracoscopes: these are the innovation in the endoscope technology
that is now getting more and more popularity. These scopes have a rigid shaft and a
flexible tip that allows for a more complete examination of the pleural cavity. %ome
models have a working channel and these are easiest to work with, while some other
models have no working channel and necessitate a second port of entry for the biopsy
forceps.
3)Trocars$
Trocars consist of an obturator and a cannula. To make the examination easier,
Trocars should not be too large. Trocars of the ! mm and even the ' mm diameter
are somewhat difficult to manipulate in all directions especially when the intercostal
spaces are narrow. The examination may be limited due to pain caused by the trocar
pushing against the ribs. The optimum si/e of the trocar therefore should be Dmm in
diameter and about ''mm in length. 8 second trocar $x''mm that is electrically
insulated to avoid burns to the chest wall should be used when applying
electrocautery.
6)Forceps$
The Dmm optical forceps for biopsy under direct vision using a single point of entry is
ideal for sampling the parietal pleura. 8 $mm coagulating forceps is used for
obtaining biopsies via a second point of entry through a $mm trocar. &t is essentially
useful for collecting samples from the diaphragmatic pleuraJ thick, hard, or fibrous
pleural lesions including asbestotic pleural pla<uesJ and the visceral pleural and lung.
7)Au(illiary instru!ents an accessories$
%heets, clamps, sterile gowns for the practitioner and his assistant.
3eedles, syringes, and cupula for the local anesthetic agent.
%calpels, compresses, sutures, and anionic surfactant to prevent the formation of
mist in the lens surfaces (Ganti-fog solutionH).
+lastic aspiration tubes, #mm and 2mm in diameter.
%wab
Talc atomi/er.
+leural drainage tubes (chest tubes) between !'0 and "!0.
@uide for the chest tube or a self-contained chest tube set.
(ight sources, cold light cables.
;ideo camera, videotapes.
5anometer to measure pleural pressure.
The enoscopy roo!$
Thoracoscopy can be performed either in an operating theater or in an endoscopy
suite. The suite must ideally contain the following:
8 thoracoscopy table: this may e a simple operating table or, ideally, may have a
height ad*ustment and a back that can be raised for operating in the semi-sitting position.
%ome tables can be ad*usted laterally along the longitudinal axis that allows the patient to
be repositioned easily. %uch sophisticated tables are very helpful not really essential.
8spiration e<uipment for the pleural fluid, with !-liter or more collecting bottles
connected to negative pressure.
8nesthetic e<uipment, with air feed and oxygen supply.
8n overhead light with ad*ustable brightness.
8 5ayo stand placed sideways across the table to hold the instruments.
8 $'-)att high fre<uency (,0) scalpel for electrocautery, or a 3eodymium:
Lttrium @arnet (3d:L8@ laser) laser.
%eparate mobile carts for endoscopic light sources, photographic e<uipment, films,
and videos.
8 stool.
8 cupboard or drawers for instruments.
The endoscopic area should be, like other operating areas, bacteriologically clean
ventilated with filtered air. 0loors and walls should be seamless and washable.
.leanliness re<uirements are greater than endoscopy via natural body orifices, for
example bronchoscopy, but less than in cardiac catheteri/ation. Thus, thoracoscopy is
best performed in rooms used for lapaoscopy or operating rooms. 8 premedication area, a
washroom for personnel and an area for cleaning and sterili/ing instruments should be
provided.
Personnel$
The personnel re<uired to re<uired to perform thoracoscopy include an endoscopy
nurse or an endoscopy assistant for the instrumentation, an additional circulating assistant
who is not sterile, the physician who performs the procedure and, if possible, an
additional physician assistant. &n an emergency, thoracoscoy can be performed with only
a physician and a nurse but this is less efficient and prolongs the duration of the
procedure.
Thoracoscopy techni.ue$
#nuction an !onitoring of pneu!othora($
The indication of inducing pneumothorax varies according to the
prethoracoscopic condition e.g., pleural effusion, previous pneumothorax, pr a normal
pleural space.
&n the presence of a pleural effusion, an open needle puncture should be
performed at the level of greatest opacification or dullness. )hen the syringe is removed
from the needle, the pleural fluid will come out (due to increased intrathoracic pressure)
or air will be heard being sucked through the needle if the intrapleural pressure is
negative. 8ir can be in*ected from a syringe, or even better, .-! under slight positive
pressure from a pneumothorax apparatus. The pneumothorax can be fluoroscopically
monitored, and ideally, it should measure ' cm in diameter on antero-posterior and
lateral views. 8lternatively, in the presence of massive effusion, the thoracoscope can be
directly introduced without induction of pneumothorax although this carries a greater risk
of lung in*ury.
&n the presence of a preexisting pneumothorax, fluoroscopy should be performed
in the lateral position in order to find the best point of entry for the trocar and to establish
the position of the diaphragm. -ccasionally, addition gaseous medium may be added.
&f neither effusion nor pneumothorax is present, an artificial pneumothorax must
be induced using the techni<ue of 0orlanini. 0or this purpose, many types of
pneumothorax needles have been developed including the oldest blunt %augmann cannula
with mandarin, stopcock and side hole. -ther needles like the blunt %alomon cannula
with side hole, or the cannula developed for laparoscopy that has an inner blunt cannula
that springs forward as soon as the peritoneum or pleural space have been penetrated can
be used, but less effectively. The most commonly used needles are the pneumothorax
needles developed by :enecke (it has a slit like hole *ust proximal to its tip and can be
introduced even without local anesthesia) or the 7outin needle (which has a soft,
atraumatic tip that will enter the pleural cavity with the least risk of in*ury). 8ny of these
needles can be connected to a pneumothorax apparatus for in*ecting .-! gas or to a
syringe for in*ecting air. The pneumothorax apparatus operates according to the principle
of communicating tubes and utili/es a water manometer. &t is very simple and even more
sensitive and user-friendly than the electronic instruments auch as those used for
pneumoperitoneum.
The best site for induction of pneumothorax is the mid-axillary region between
the "
rd
and the $
th
intercostal spaces as here, the intercostal vessels are protected by the rib
margins.
&nduction of a pneumothorax can take place on table at the time of thoracoscopyJ
but some physicians prefer to induce pneumothorax on the day before the procedure by
in*ecting "''-$'' ml of gas intrapleurally. This allows time to review the radiographs to
chose the most appropriate site of entry for the thoracoscope. &n any case, the intrapleural
pressure must remain negative. 8 positive pressure may cause 5ediastinal shift,
compromise cardiovascular performance, and be painful to the patient.
Position of the patient$
The patient must be comfortably installed in lateral position with the healthy side
down. 8 rolled-up sheet is placed under the patient6s thorax to spread apart all the
intercostal spaces on the exposed side of the chest. The head is lowered and the arm
attached at right angle to the head of the head with gau/e or a sling to a bar. The patient
should be grounded by placing a metal plate between the table and one buttock if
electrocautery is to be used. The physician usually faces the patient while the assistant is
across the table behind the patient6s back.
Anesthesia$
(ocal anesthesia is the preferred method as long as the thoracoscopy procedure is
to be brief in a patient whose pleural cavity is free of adhesions. (ocal anesthesia is also
preferable in high risk patients exhibiting poor general condition, compromised
respiratory function, or cardiac insufficiency.
@eneral anesthesia may be re<uired in some cases and it is the techni<ue of choice
for procedures re<uiring double-lumen intubation and lung immobili/ation. This method
gives is favorable for both the physician and the patient because it allows time for
multiple biopsy collection, section of extensive adhesions, and electrocautery as well as
high <uality photography and video filming.
The Gconscious sedationH techni<ue or light anesthesia is simple and has
practically no contraindications. The techni<ue consists of local anesthesia and
neuroleptanalgesia with modern drugs that combine properties of sedation, analgesia, and
amnesia. %uitable neuroleptanalgesics include mida/olam (the most commonly used),
propofol, pethidine, dia/epam, and fentanyl.
Perfor!ance of thoracoscopy
8 First point of entry$
8n axillary point of entry is selected in most cases. The axillary triangle has no
large muscles that could obstruct the passage of the instruments. The axillary triangle is
bounded anteriorly by the lower edge of the pectoralis ma*or muscle, posteriorly by the
edge of the latissimus dorsi muscle, and inferiorly at the level of t diaphragmatic
insertions. &ts apex reaches the second intercostal space. The point of entry is generally
near the mid-axillary line, within this triangle and is selected as follows:
&n the third or fourth intercostal space in patients with spontaneous pneumothorax
because the leak is usually in the upper lobe.
&n the $
th
, 2
th
, or D
th
intercostal space for pleural effusions. The last two spaces are
preferred when metastatic tumor and mesothelioma are suspected, to reach the most
common sites for those malignancies. This entry provides an excellent view of both the
diaphragm and the costovertebral gutter.
&n the #
th
or $
th
intercostal space for pulmonary biopsies so that all lobes can be reached
<uickly and easily.
-ne must be aware that a pleural lesion that is too close to the point of entry
cannot be biopsied with a rigid thoracoscope, but can be dealt with using a flexible
instrument. These lesions would be easier to approach through an incision '-! cm
further. Cvery effort should be made to precisely identify the level of the lesion on the
roentgenograms so the appropriate intercostal space could be used for the point of entry.
MThe secon point of entry$
The second point of entry is established <uickly and easily. &ts position is
determined by viewing through the $'N scope while depressing the possible entry site
with the index finger. The resulting depression can be easily viewed from inside the
thorax. %ometimes it is helpful to actually insert a needle through that site while viewing
the precise location through the scope.
8fter administering the local anesthetic, a $-mm incision is made and the $-mm
trocar is inserted directly. This trocar and the forceps used should be insulated so as to
allow the use of electrocautery or laser.
8 Points of entry for specific locali9e regions$
&n unusual situations, other points of entry are used, depending on the clinical
setting or the roentgenograms. 8 pleural lesion that is too close to the point of entry
cannot be reached and biopsied with a rigid scope. Thee lesions are better approached
from the opposite side. Therefore, for posterior lesions one would ideally place the trocar
in the anterior axillary line, while for anterior lesions the posterior axillary line best
chosen. (esions on the lateral aspect of the costal pleura would best be reached through
ports placed in the midclavicular line.
&t is needless to mention that the flexible and semiflexible instruments are superior in
dealing with such lesions.
M #ntrouction of the trocar$
)ith a scalpel, a vertical incision is made through the skin and subcutaneous
tissue, appropriate to the si/e of the trocar to be used. The handle of the trocar is held
firmly in the palm of the hand while the extended index finger limits, for safety6s sake,
the depth of the depth of insertion. The approximate distance from the kin to the pleural
space can be estimated by the local anesthetic needle, while applying the local anesthetic.
Bnder difficult circumstances, the needle should be left in the chest wall and the trocar
can be inserted parallel to it. )hile fixing the intercostal pace with two fingers, the trocar
is advanced with a fairly forceful corkscrew motion until the detectable resistance of the
internal thoracic fascia has been overcome. The tip of the trocar should lie '.$ cm inside
the pleural cavity.
+leural effusions should be completely removed prior to inserting the scope. This
can be done without risk because, as the fluid is removed, it is substituted rapidly with
ambient air that provides pressure e<uilibration.
M Enoscopic %isuali9ation an anato!y$
8fter completely removing the effusion, orientation is simple although
visuali/ation of the pleural space may be made difficult, if not impossible, by
inflammatory, 0ibrinous pleural thickeningJ adhesions and fibrous bandsJ inflammatory
exudates with empyemaJ or extensive tumor overgrowth obscuring the lungs, chest wall,
diaphragm and mediastinum.
8natomical relationships and intrathoracic structures are usually very well
identified during thoracoscopy. .ases of pneumothorax re<uiring thoracoscopy are ideal
for examining intrathoracic structures and to observe the normal parietal pleura, pleural
vessels, and the underlying intercostal muscles and ribs.
To prevent the lens from becoming fogged up, the tip of the thoracoscope can be
immersed in deminerali/ed sterile water at D'-O'Nc. The optics and light source should be
dried with a sterile cotton ball and wiped dry.
&nside the right pleural cavity, orientation can be achieved by locating the point at
which the three lobes meet: the *unction of the obli<ue and the hori/ontal fissures. -n the
left side, the obli<ue fissure can be used for orientation. The diaphragm can be
recogni/ed because of its respiration-related movements. 9ibs, intercostal muscles, fat,
blood vessels, and nerves are usually readily distinguishable. The position of the large
vessels such as, on the lest side, the aorta and the subclavian artery and on the right, the
vena cava and the innominate vein as well as the subclavian artery are readily
recogni/able. The heart and great vessels are identified because of their pulsations, which
are occasionally transmitted to ad*acent parts of the lungs.
&f fibrous bands or adhesions are present, these should be avoided. Torn and
bleeding adhesions can be cauteri/ed by means of diathermy and served if desired.
:elicate spider-web adhesions that are not vasculari/ed can be separated or removed with
the forceps.
Enoscopic %isuali9ation of the parietal pleura$
;isual exploration of the pleura is carried out in few minutes. &t is done by
rotating the scope to explore the whole pleural cavity after dissecting adhesions. There
are always two levels of observation using the scope: from a distance of $-'cm to
obtain a wide-angle view with weak magnificationJ and then a close magnified view at a
distance of -!cm to insect the pleural cavity very carefully and to select the best biopsy
site.
&n its normal state, the pleura is transparent allowing visuali/ation of many
structures through it, including the ribs, the parietal vascular pattern, the diaphragmatic
insertions and central tendon, the pericardium with its attendant fat, the fibrous or fatty
tissues of the pleural dome, the sympathetic trunk, the intercostal vessels, etc. ;ariable
amounts of anthracotic pigment can be present within the parietal pleura, especially
posteriorly and in the costovertebral gutter. These are often linear canalicular, or
corresponding to the underlying lymphatics, or they may be punctiform like the
lymphatic formation that was described by 4ampmeier and named after him
(4ampmeier6 foci).
0atty collections are often abundant in the pleura, especially in obese people.
These may take the form of long yellowish brownish pla<ues located long the ribs, in the
apex, in the anterior mediastinum around the pericardium and on the diaphragm.
P A,nor!al pleura$
-ne of the hardest tasks of the endoscopist is to distinguish between innocuous
and malignant or tuberculous GinflammationH. &n fact, it is often impossible to tell the
difference *ust by looking, since invasive cancers may sometimes look like a simple
inflammation.
%imple inflammation is usually redder with a smoother, more regular surface and
is more edematous than malignant pachypleuritis. )hen biopsies are taken, the forceps
will cut a clear section of malignant tissue, whereas it easily pulls away much larger
sections of inflamed pleura. ,owever this difference is only a matter of degree, and many
biopsies (up to $-!') should be taken to be certain that the pathologist as representative
samples of the lesions that had been observed.
P Non)specific pleural infla!!ation$ can be found in different stages:
i- 5ild: a simple increase in normal pleural vasculari/ature, giving the pleura a pinkish
hueJ it is still thin and transparent.
ii- &ntense: the pleura is bright red with engorged blood vessels and subpleural edema.
The serosa become opa<ue and the outline of the ribs and intercostal vessels can no
longer be seen distinguished. The pleura can be up to "-$mm thick. These changes are
often more prominent in the costovertebral gutter and on the diaphragml as the pleura is
viewed upwards, fre<uently the pleura thins out, has progressively less reddish
discoloration, and finally may look completely normal at the apex.
iii- chronic: in long-established pleurisies, the pleura maintains it thickness, but has a
white or grayish tingeJ it is opa<ue as a result of invasion by fibro-elastic and collagenous
tissue.
P Specific pleural lesions$
The following three patterns can be distinguished as opposed to non-specific
inflammation:
i- (ymphangitis appears as fine reticular pattern covering all or part of the pleura
ii- Tuberculous or sarcoid granulomata -"mm in diameter. &n sarcoidosis, they are
much common on the parietal pleura.
iii- 5alignant nodules, which are variable in si/e and shape, usually predominate
inferiorly. 8lso, asbestotic pla<ues, which are thick, pearly white, fibrohyaline or
calcified pleural lesions that are often found in asbestotic effusions. &n these cases,
thoracoscopic pulmonary biopsy may reveal high concentrations of asbestos fibers.
Positioning of the chest tu,e for pleural rainage
8t the end of thoracoscopy, a chest tube is inserted through the point of entry. The
tube is mounted over a $'cm rigid blunt guide and inserted through the point of entry.
The tube is inserted perpendicular at first, and then directed in the desired direction until
it meets the chest wall. 3o special force is re<uired.
&deally, the tube should be directed posteriorly and then as close to the apex of the
pleural cavity as possible. )hen thoracoscopy is performed for pneumothorax or for
pulmonary biopsies, the tube can be removed shortly after radiological confirmation of
lung re-expansion. &n cases of pleural effusions, the tube is left in place for several days
until the drainage provides less than '' ml of fluid per day. The performance of
thoracoscopic talc insufflation during the procedure reduces the postoperative hospital
stay.
%ecuring of the chest tube with silk sutures to the skin should be done to prevent
the tube from slipping. 8n additional pure string suture is placed and left open until the
time of removal of the tube, when it is tightened to be removed D-'days later.
Thoracoscopy$ 0o!plications an 0ontrainications
Thoracoscopy is one of the safest in the interventional pulmonology procedures.
The mortality was found to be '.'F? in a cohort of #"'' thoracoscopies.
A) Potential co!plications$
- 8ny perioperative incidents (trocar in*ury, intercostal in*ury) that may re<uire
immediate thoracotomy.
!- 8ir leak of more than one week after intervention,
"- 8ir leak re<uiring re-intervention or thoracotomy,
#- 7leeding greater than $' ml or re<uiring blood transfusion,
$- 9espiratory failure more than !# hours after intervention,
2- +neumonia,
D- +ost-procedure effusion with suspected infection prompting drainage
or
hospitali/ation,
O- -nset of newly developed pneumothorax resulting in symptoms or
re<uiring
insertion of a chest tube,
F- +ulmonary embolism or deep venous thrombosis,
'- -nset of new chest pain, arrhythmias, or myocardial infarction,
- &mproperly placed chest tube re<uiring repositioning,
!- 8telectasis prompting bronchoscopy.
+)Potential !inor a%erse e%ents$
- Temperature greater than '.$Nc above baseline for at least #O hours after
thoracoscopy,
!- .linically significant subcutaneous emphysema,
"- )ound infection,
#- 3ew clinically significant pneumothorax,
$- +araesthesia or lateral chest wall discomfort lasting "' days or more.
The five unacceptable disasters of thoracoscopy can be summarized below:
- )rong side: a patient, who was operated on the wrong side, con*ured
up immediate visions of massive negligence.
!- 4ebab lung: this occurs when an ill-directed trocar is inserted in the
lung.
"- .lotted hemothorax: a patient Kvictim of a road traffic accident- was
referred for thoracotomy after unsuccessful intercostal drainage. -n opening the chest, a
green structure presented that was mistaken for a gangrenous lung. That was the gall
bladder. The trocars had been transfixing the misplaced liver in a traumatic diaphragmatic
hernia.
#- 8rtificial lunchothorax: this occurs when a distended stomach in a
para-esophageal hernia is mistaken for a hydropneumothorax.
$- 8orto-pleuro-cutaneous fistula: this is the most dramatic of the
disasters. 8 registrar had forgotten the 5ediastinal shift while trying to drain an infected
post-pneumonectomy space. This resulted in disastrous bleeding.
0ontrainications to thoracoscopy$
A" A,solute contrainications$
There are only a few absolute contraindications, the principal one is insufficient space in
the pleural cavity. The minimum space re<uired for the insertion of the thoracoscope is
'cm in diameter. 8lso, absolute contraindications include: honey comb lung, pulmonary
arteriovenous malformation, suspected hydatid disease, and highly vasculari/ed
pulmonary lesions.
+" Relati%e contrainications$
These are related to the general health of the patient, and a careful risk=benefit analysis at
the time of thoracoscopy is considered. 0ever, cough, hypoxemia, hypocoagulable state,
unstable cardiovascular status, etc may all prevent the procedure temporarily.