THERAPEUTIC THORACOSCOPY - 09/09/11

The history of therapeutic thoracoscopy parallels that of diagnostic interventions. Indeed, our ability to treat patients with pleural and pulmonary diseases through small incisions using a rigid telescope attached to a video camera is only limited by our imaginations, access to newer technology, and the need to justify the use of new techniques after comparing their safety and efficacy with time-proven therapies.

Today, therapeutic thoracoscopy encompasses procedures performed by medical and surgical thoracoscopists alike. Many procedures are direct extensions from those used during open chest surgical procedures and readily fall under the umbrella of video-assisted thoracic surgery (VATS). Improved instrumentation, however, has also allowed the experienced and expert nonsurgeon thoracoscopist to expand the spectrum of therapeutic alternatives already available. In this article, turf issues or medical/surgical boundaries are ignored in an attempt to present simply, from the thoracoscopist's perspective, a basic description of the instrumentation, techniques, indications, and complications of therapeutic thoracoscopy as it is performed in the operating room today.

The first therapeutic thoracoscopy was actually performed by Jacobaeus,²³ who, in 1921 described a technique of cauterization of pleural pulmonary adhesions during collapse therapy for tuberculosis. Thoracoscopic pleurodesis was performed between 1920 and 1950 in Europe and the United States for recurrent malignant pleural effusions and pneumothorax.⁶⁰ In the 1940s thoracoscopy was used to evacuate traumatic hemothoraces and detect bleeding. Parietal pleural and intercostal blood vessels could be repaired through small incisions rather than subjecting patients to open thoracotomy.⁴ Between 1965 and 1990, however, thoracoscopy was virtually ignored in the United States. Additional advances of therapeutic thoracoscopic techniques were made only in Europe, where thoracoscopy continued to be performed by a small number of pleural disease specialists.

Since 1990, thoracoscopy has exploded worldwide. Thoracoscopists were encouraged by the results of therapeutic laparoscopy, advanced videotechnology, and improved endoscopic instrumentation. Initially, instruments designed for laparoscopy were used for chest procedures, but quickly, specially designed instruments and new thoracoscopic strategies were developed. In 1991, the councils of the American Association for Thoracic Surgery and the Society of Thoracic Surgeons appointed a joint committee to develop standards and guidelines pertaining to therapeutic thoracoscopy.⁵³ A few months later, thoracoscopic interventions were a major topic at the First International Congress of Thoracic Endoscopy held in Paris, France.