Thoracoscopy is a relatively simple invasive procedure that allows interventional pulmonologists to examine the surface of a patient’s lungs and the space surrounding the lungs. The surface of the lungs is also known as the pleura; the space surrounding the lungs is also known as the pleural space. Pleuroscopy is the name for the focused examination of the pleural space. As a whole, thoracoscopy provides images and video that allow visualization of suspected malignant pleural mesothelioma and confirmation via lung biopsy. It also supports therapeutic interventions and surgical treatment.

Thoracoscopy: What to Expect, Step by Step

The first step in a thoracoscopy is a chest x-ray or CT scan to identify signs of malignant pleural mesothelioma. Such signs may include

• Reduced lung volumes
• Excess fluid around the heart or lungs
• Pleural thickening
• Pleural plaques
• Enlargement of lymphatic tissue
• Masses of the chest wall

These imaging scan findings equip the interventional pulmonologist to perform the procedure effectively and efficiently. After the patient has been safely prepared for the procedure and anesthetized, a small incision is made near the point of the scapula. Air is emitted into the lung cavity to partially deflate the affected lung for safe performance of the procedure and to increase camera visualization. Three more incisions are made in the patient’s side or back to allow for insertion of the endoscope and other surgical instruments required to perform the procedure.

During the procedure, the pulmonologist directs a flexible, sterilized tube containing an endoscope, a tiny fiber-optic camera, into the chest cavity to investigate the affected area. The endoscope provides a live feed image of a patient’s pleura and pleural space to the pulmonologist via a video monitor. Images alone are insufficient in confirming a diagnosis of malignant pleural mesothelioma, so the pulmonologist also performs a lung tissue biopsy to ensure an accurate diagnosis is made.

The biopsy is conducted by inserting precise tools through the endoscopic tubing while viewing the pleural space on the video monitor. These tools collect tissue samples from several different sites within the chest cavity. Once the biopsy is completed, the pulmonologist drains excess fluid and air with suction tubing and valves. Drain tubing in the form of a chest tube is placed through one of the incision sites to allow any residual fluid to drain out over the next two to three days. The remaining surgical incisions are then closed with surgical staples or sutures. The entire procedure usually lasts about 45 to 90 minutes long, providing there are no complications or newly identified areas of concern. The biopsied lung tissue samples are analyzed in the lab to evaluate for malignant pleural mesothelioma. If the biopsy confirms a diagnosis of malignant pleural mesothelioma, the thoracoscopy media can later guide the surgical resection of all visible tumors.¹

Recovery from Thoracoscopy

The chest tube is removed within two to three days of the procedure or whenever the lung fully reinflates with no leaks detected. Pain medication is given orally, through a patient’s vein, or through the endoscopic tubing to provide pain relief. Nurses guide the patient in performing daily breathing exercises to help prevent pneumonia and other lung complications. Symptoms concerning for such complications include

• Worsening shortness of breath or difficulty breathing
• Chest pain
• Sucking sounds coming from an incision site
• Fever or temperature exceeding 100.4 degrees Fahrenheit
• Foul-smelling liquid draining from an incision site

Once the patient is discharged from the hospital, he or she will typically follow up in one to two weeks with the pulmonologist who performed the procedure.

Risks and Possible Complications of Thoracoscopy

The risks and complications of thoracoscopy include

• Reactions to anesthesia: these reactions can be allergic or toxic in nature
• Neuropathy: numbness and pain around the incision sites
• Subcutaneous emphysema: trapping of air beneath the skin
• Persistent air leak: failure to reinflate the lung despite chest tube drainage
• Hemorrhage: excessive bleeding
• Wound infection: infection of an incision site
• Pneumonitis: inflammation of the lung
• Pneumonia: infection of the lung
• Tumor seeding: manual deposition of cancerous cells into biopsied tissue
• Metastasis: cancer spread via tumor seeding

The risk of anesthesia-related complications is rare, and the risk of procedure-related complications is low. Tumor seeding is commonly prevented with the completion of radiation therapy before thoracoscopy.²

Thoracoscopy Research

A recent study published in the Annals of Thoracic Medicine in 2016 evaluated the effectiveness of thoracoscopy in diagnosing malignant and benign pleural diseases. Of the 2,752 patients involved in the study, over half of the patients were diagnosed with cancer. The researchers ultimately determined that thoracoscopy improved diagnostic accuracy, including diagnosis of malignant pleural mesothelioma, by about 20%.³