At the source of diagnostic thoracoscopy is the Swedish pulmonologist Hans Jacobus, who in 1910 used a cytoscope for diagnostic examination of the pleural cavity of his patients suffering from tuberculosis. A little later, he designed an optical device, called a thoracoscope, through which 89 thoracoscopy procedures were performed for three years.
After the improvement of the device and the attachment of the galvanocautery( instrument for cauterization of tissues), Jacobus began to use the thoracoscope also to burn the pleural adhesions, and in 1925 he performed the first sight biopsy of the pleural tissue in a patient with mesothelioma.
Modern torakoscopes are equipped with color video cameras, working on microcircuits, having high resolution and allowing to transfer the received picture to the screen of the monitor.
This expanded the capabilities of thoracoscopy, allowing it to be used not only for diagnostic examination, but also for performing full-fledged surgical interventions: after all, what happens on the monitor can be seen not only by the surgeon, but also by the assisting specialists.
The concept of diagnosis
Thoracoscopy( synonymous names - pleuroskopia or videotorakoskopiya) refers to the technique of endoscopic examination, designed to examine the pleural cavity of a sick person by introducing a special device - a thoracoscope - through a puncture made in the wall of the chest.
Thanks to the clear color image displayed on the screen, the specialist who conducts the procedure has the opportunity to assess the condition of organs located in the pleural cavity: lungs, mediastinum and external connective tissue membrane of the heart - the pericardium.
Modern surgeons often use it instead of traditional thoracotomy - a surgical operation consisting of a chest dissection.
This is associated with a number of advantages that are characteristic of thoracoscopy, because it:
- enables you to repeatedly enlarge the image of individual structures on the monitor screen due to the use of modern optical technology;
- is less traumatic;
- is not so painful;
- requires less narcotic analgesic drugs during the postoperative period( sometimes the need for their prescription may be completely absent);
- is performed in a shorter period of time;
- gives fewer postoperative complications( usually pneumonia and cardiac arrhythmias);
- significantly shortens the period of hospitalization of the patient;
- eliminates the need for the patient to be placed in the intensive care unit;
- does not require a long period of rehabilitation: after it, patients quickly recover;
- does not leave large scars on the patient's body.
The procedure for thoracoscopy is designed for:
- Precise diagnosis of pleural diseases - serosa, lining the chest from the inside and protecting the surface of the lungs, diaphragm, and mediastinum.
- Obtaining samples of the examined tissues( biopsy) for the purpose of their further laboratory study.
- Removal of subpleural cysts( cavities filled with fluid) and bulls( air bubbles) from the lungs.
- Evacuation of excess fluid from the pleural cavity.
- Performs an atypical marginal resection of the lung.
Indications for the appointment of thoracoscopy
The basis for the appointment of thoracoscopy is the presence of:
- Exudative pleurisy of unclear etiology. Because pleurisy can develop due to various causes( for example, under the influence of malignant mesothelioma, tuberculosis or the spread of a cancerous tumor on the pleura), thoracoscopy is necessary to obtain informative biopsy material, the study of which will make it possible to establish an accurate diagnosis.
- Penetrating chest wounds. Thoracoscopy will detect or exclude damage to the pericardium or mediastinal organs.
- Peripheral lung cancer. If a cancer is suspected, carrying out a diagnostic test( with mandatory hilar biopsy sampling) will give an idea of the prevalence of the oncological process and will determine its stage.
- Benign neoplasm of mediastinum.
- Mediastinal lymphadenopathy is a condition accompanied by a significant increase in lymph nodes localized in the mediastinum region. Thoracoscopy will determine the type of lesion( it can be a consequence of tuberculosis, lymphogranulomatosis, sarcoidosis or malignant lymphoma).Only an analysis( immunohistochemical or histological) of the tissues of the affected lymph nodes can clarify the preliminary diagnosis.
- Lymphoma accompanied by involvement of mediastinal lymph nodes. Thoracoscopy is the only diagnostic method that makes it possible to select morphological specimens to perform immunohistochemical studies, the results of which will establish the type of lymphoproliferative process occurring in each specific case.
Contraindications
The procedure for thoracoscopy is contraindicated in the presence of:
- Pronounced coagulopathy( violation of the process of blood coagulability).
- Acute pulmonary insufficiency accompanying bilateral pneumonia.
- Disorders of the functioning of the cardiovascular system, accompanied by acute coronary insufficiency and arrhythmia.
- Hemopericarda - hemorrhages in the pericardial cavity caused by trauma, swelling, rupture of the blood vessels of the heart.
- Hemorrhagic diathesis.
- Only one healthy lung. In this regard, the implementation of single-pulmonary ventilation becomes impossible.
- Acute disorders of cerebral circulation.
- Intra pleural adhesions, as pleural adhesions prevent the imposition of artificial pneumothorax.
- The general severe condition of the patient due to diseases of the internal organs.
- Pustular lesions of the skin in the chest.
- Peritonitis and intraperitoneal bleeding accompanying combined injuries of the abdominal and thoracic cavity.
Patient preparation
Given the large number of contraindications to thoracoscopy, the patient is referred to:
- chest x-ray;
- electrocardiogram;
- coagulogram( a study showing how well the blood coagulation system works);
- spirometry( a study aimed at studying the function of external respiration).
A set of studies will allow the attending physician to verify the presence or absence of the above contraindications.
Before performing thoracoscopy, the attending physician must:
- Explain to the patient the essence of the procedure, consisting of examination of the chest wall, mediastinal organs, pericardium and pleural cavity.
- Warn patient that in some cases the procedure may require general anesthesia and thoracotomy.
- Inform the patient that after a thoracoscopy, he for some time passes with a system designed to remove excess fluid( drainage) from the pleural cavity.
- Calm the patient with information about the extreme rarity of complications arising after thoracoscopy. Here it should be mentioned that very effective and quick pain relievers can be used to remove the possible pain syndrome after the procedure, therefore, one should not be afraid of severe pains.
- Notify the patient that twelve hours before the thoracoscopy, he must completely stop eating.
Technique of
To perform the thoracoscopy procedure at the highest level, the thoracoscopic cabinet should be equipped with: video cameras, monitors, rigid endoscopes with a whole set of laparoscopic instruments( different types of trocar, scissors, clamps, forceps, electrocoagulators) and endoscopic devices( insufflators, lighting devices, endovideo systems, aspirators and at least a minimal set of instruments for laparoscopic surgery).
- To anesthetize the procedure, apply either local infiltration anesthesia with 1% novocaine, lidocaine or trimecaine, or endotracheal( general) anesthesia, which requires the involvement of an anesthesiologist. After the patient is plunged into deep medical sleep, the anesthesiologist inserts into his trachea a special double-lumen tube.
- To perform thoracoscopy the patient is most often laid on the healthy side of the , without forgetting to place a cushion under it, placed approximately in the middle of the chest.
- Having determined the cut point( as a rule, it is located at the level of the fourth or fifth intercostal space), it is surrounded with sterile napkins and performs antiseptic treatment of the skin.
- Having achieved a lung sagging, perform a skin incision with the scalpel ( the width of the incision is not more than a centimeter).For piercing soft tissues of the intercostal space, a thick trocar is used. The used stylet is removed, and a thoracoscope is inserted through the liberated canal of the trocar( through its cannula).To prevent fogging of the optical system, before inserting the device into the pleural cavity, its distal end is placed for some time in a vessel with hot sterile water.
- Gently pushing and turning the thoracoscope, begin to examine the pleural cavity.
- After making two or three additional incisions, they introduce trocars , designed to suck fluid and biological tissue for subsequent histological examination( the biopsy is taken with a special needle, scissors or bronchoscopic forceps inserted through the trocar).This manipulation is carried out under the control of vision.
- The procedure of thoracoscopy can be used to perform medical manipulations: cauterization of pleural bullae( provoking the appearance of spontaneous pneumothorax) and bronchopleural fistulas, burning of pleural adhesions, pleurodesis( artificial pleurisy) with the use of talc in the presence of malignant pleural effusions. Thoracoscopic operations are low-traumatic and provide rapid recovery of patients. Drainage pipes inserted after the operation is removed after complete spreading of the lung( as a rule, it occurs three to four hours later).
- After completing the procedure, a pleural vacuum drain is introduced through one of the incisions, and the other incisions are sealed with an adhesive plaster and covered with an additional aseptic bandage( most often - a sticker).
- The patient who has undergone thoracoscopy is left in the hospital and closely watches the basic physiological parameters. Within the first hour after the procedure, they are determined at least four times. For the next two hours, the control is carried out every half hour. For another two hours, control becomes hourly. After that, the indicators are checked every four hours. As a rule, the main attention is paid by the treating specialist to breathing and the work of the drainage system.
- If a patient complains of pain, he is immediately prescribed narcotic analgesics and controls their effects.
Study time
The duration of thoracoscopy is determined by a number of different factors, primarily by the need to take a biopsy or perform endoscopic surgery.
Feedback on thoracoscopy of the lungs
Yuri:
In August of last year, doing some simple housework, I suddenly felt a sharp pain in my chest, to which after a while dyspnea joined. This condition worried me greatly, so I immediately went to a surgical clinic. The specialist, the leading reception, directed me to a computer tomography of the chest.
The result of the study showed the presence of spontaneous right-sided pneumothorax( in other words - there was air in the pleural cavity), accompanied by a collapse of the right lung. Specialists suspected me of bullous lung disease with localization of bullae in the upper part of both lungs.
After carrying out thoracoscopy and establishing drainage, air from the pleural cavity was withdrawn, and the sleeping lung was disposed of. For two months, being in a satisfactory condition, I continued to be observed at the doctor, until again there was a sharp deterioration. The procedure of computed tomography showed that the cause of repeated pneumothorax was the rupture of bullae localized in the upper lobe of the right lung.
I was prescribed an emergency operation of thoracoscopic resection, during which I removed a small piece of the tip of the right lung and the same small amount of pleura. The operation was very successful, without causing any complications, so already three days after the operation was performed, I was discharged from the hospital. Now I feel good, there were no other relapses.
Prices
The range of prices for diagnostic thoracoscopy and thoracoscopic surgery in Moscow clinics is very significant. Here are just a few figures:
GKB number 1 named Pirogov:
- Diagnostic thoracoscopy - 3600 rub.
Thoracoscopic resection of the lung - 20 000 rub.
Clinical Center of Moscow State Medical University. Sechenova:
- Diagnostic thoracoscopy - 11 000 rub.
Thoracoscopic resection of the lung - 44 000 rub.
The same amount will cost the patient a thoracoscopic operation to remove a benign tumor and cyst of the mediastinum.
Institute of Surgery. Vishnevsky:
- Diagnostic thoracoscopy - 6500 rub.
Thoracoscopic resection of the lung - 25 000 rub.
Institute of First Aid to them. Sklifosovsky:
- Diagnostic thoracoscopy - 20 300 rub.
Thoracoscopic operations of resection of the lung, pleurectomy, removal of a benign mediastinal tumor are estimated at 57,700 rubles.
Video on thoracoscopic lung resection with pneumothorax: