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Pleuroscopy, also referred to as medical thoracos-copy, generally describes the evaluation of thepleural space in a nonintubated patient underconscious sedation (1).

A visual inspection of the pleural space, drainageof a pleural effusion, performance of pleural biop-sies, and pleurodesis are commonly performedprocedures during pleuroscopy. This type of en-doscopy is usually performed by a pulmonologistwith special training. This is in contrast to videoas-sisted thoracic surgery, performed by a thoracic-surgeon in the operating room.

In experienced hands, medical thoracoscopy isvery well-tolerated. The patient does not have toundergo general anesthesia and endotracheal in-tubation (2).

Since there is no need for an operating room andanesthesia time, there may be significant cost ad-

vantages compared to conventional thoracos-copy. Despite these well-known facts, pleuros-copy is not frequently performed by pulmonolo-gists in the United States. There are few practitio-ners with expertise in the procedure (3). In thepast, it has required the use of specialized rigidendoscopic instruments with appropriate cameraequipment, as well as a dedicated processor andlight source. Besides the expense of this additio-nal equipment, the rigid thoracoscope is an unfa-miliar tool for most pulmonologists.

The semirigid pleuroscope (LTF-160, OlympusMedical Systems, Tokyo, Japan) is a novel endos-cope that is similar in design to a commonly usedbronchoscope. This pleuroscope interfaces withexisting processors and light sources that are ro-utinely employed for flexible bronchoscopy and,therefore, are available in most endoscopy units(Figure 1).

Semirigid Pleuroscopy

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Pneumology and Critical Care MedicineThoraxklinik, University of Heidelberg

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The Instrument

The instrument consists of a handle similar to astandard flexible bronchoscope. The outer diame-ter of the shaft is 7.0 mm. The length of the inser-tion portion is 27 cm, which consists of a proxi-mal rigid portion (22 cm) and a bendable distalend (5 cm). The tip is movable in one plane withthe help of a lever on the handle, which is similarto a conventional flexible bronchoscope. A 2.8-mm single working channel accommodates thebiopsy forceps and other instruments. Angulationis 100° and 130°. The instrument connects to astandard video processor and light source (mo-dels CLV-U40 and CV-240, respectively;Olympus), and images are viewed on a screen.

Pleuroscopy Technique

The procedure is performed using a single-punc-ture technique (4). Patients will be placed in thelateral decubitus position, with the affected sideup. Most patients received IV conscious sedationusing midazolam and fentanyl, with appropriatemonitoring. After local anesthesia is placed, asmall incision is made in the mid-axillary line andan 11-mm trocar is introduced. A somewhat lar-ger sized trocar than is necessary for the instru-ment is chosen as to allow for the use of rigidequipment if necessary. After all fluid is suctioned,the pleuroscope is introduced into the pleural ca-vity, and the lung, diaphragm, and pleural surfa-ces will be inspected.

Parietal pleural biopsy specimens are obtainedwhen indicated (Figure 2), in case of malignanteffusion the procedure is followed by talc poudra-ge (with 5 g sterilized talc) when indicated. Rigidinstruments (Karl Storz Endoscopy-America; Cul-ver City, CA) are always available, if the examina-tion with the semirigid pleuroscope is deemedunsatisfactory. The procedure is followed by theplacement of a 24F standard chest tube throughthe trocar. A chest radiograph is obtained post-procedure.

Summary

Although pleuroscopy is generally safe, it is an in-vasive procedure. To minimize procedure-relatedcomplications, pulmonologists intent on perfor-ming pleuroscopy should not only receive spesifictraining in the techniques and instrumentation butbe cognisant of appropriate patient selection, theindications and contraindications of pleuroscopy.

Moreover, a consultative collaboration betweenthe pleuroscopist, primary care physician, chestradiologist and thoracic surgeon assures that pati-ents undergoing these procedures are fully andadequately assessed.

The arrival of the semirigid pleuroscope will revo-lutionize the practice of pulmonary medicine inthe same way that the flexible bronchoscope did

Semirigid pleuroscopy

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Figure 1: The semirigid thoracoscope.

Figure 2: A biopsy of the pleura using the semirigid

pleuroscope.

four decades ago. Current debate should not fo-cus on the time-honoured controversy of whereto perform and who should perform pleuroscopybut rather when to use conventional rigid and se-mirigid instruments for different clinical scenarios.

The semirigid instrument may offer a way for-ward. It appears to have some advantages overthe rigid thoracoscope. With its similarity in de-sign to the flexible bronchoscope, it is hoped thatchest physicians will be able to adapt to its usewithout too much difficulty, although formal trai-ning is essential. It is easy to manoeuvre withinthe pleural cavity. It is compatible with standardbiopsy forceps and can be used with the proces-sors and light sources found in most endoscopyrooms. Undoubtedly, the biopsy size from the ri-gid thoracoscope is larger than with the semirigidinstrument. This has been quoted as a reason forthe former’s superiority. However, smaller biopsysize does not necessarily translate to inferior diag-nostic yield; indeed, the present authors’ results,as well as those of other operators, have been ex-cellent (5). The fact that the instrument used canbe autoclaved is a huge bonus and it opens theway for its wider use abroad.

Overall, there is immense potential for the use ofthe autoclavable semirigid thoracoscope in thespeedy and accurate diagnosis and effective ma-nagement of pleural disease.

The semirigid pleuroscope is a significant inventi-on in the history of minimally invasive pleural pro-cedures. As pleuroscopic technology and techni-ques continue to evolve, it will certainly pave newinroads into stimulating and directing novel rese-arch and education in the future.

REFERENCES

1. Loddenkemper R. Thoracoscopy: State of the art. EurRespir J 1998; 11: 213-21.

2. Menzies R, Charbonneau M. Thoracoscopy for the di-agnosis of pleural disease. Ann Intern Med 1991;114: 271-6.

3. Tape TG, Blank LL, Wigton RS. Procedural skills ofpracticing pulmonologists: A national survey of 1,000members of the American College of Physicians. Am JRespir Crit Care Med 1995; 151: 282-7.

4. Ernst A, Hersh CP, Herth F, Thurer R, LoCicero J 3rd,Beamis J, Mathur PA novel instrument for the evalu-ation of the pleural space: An experience in 34 pati-ents. Chest 2002; 122: 1530-4.

5. Munavvar M, Khan MA, Edwards J, Waqaruddin Z,Mills J. The autoclavable semirigid thoracoscope: Theway forward in pleural disease? Eur Respir J 2007; 29:571-4.

Felix JF Herth, MD, FCCP

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