Diagnostic thoracoscopy using a laparoscope

Rexeena Bhargavan; Chandramohan Krishnan Nair; Arun Peter Mathew; Madhu Muralee; Mira Wagh; Preethi Sarah George

doi:10.4103/ksj.ksj_33_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 26 | Issue : 2 | Page : 154-157

Diagnostic thoracoscopy using a laparoscope

Rexeena Bhargavan¹, Chandramohan Krishnan Nair¹, Arun Peter Mathew¹, Madhu Muralee¹, Mira Wagh¹, Preethi Sarah George²
¹ Department of Surgical Oncology, Regional Cancer Centre, Trivandrum, Kerala, India
² Department of Bio-statistics, Regional Cancer Centre, Trivandrum, Kerala, India

Date of Submission	14-Aug-2020
Date of Decision	16-Aug-2020
Date of Acceptance	14-Oct-2020
Date of Web Publication	07-Nov-2020

Correspondence Address:
Dr. Chandramohan Krishnan Nair
Department of Surgical Oncology, Regional Cancer Centre, Trivandrum, Kerala
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ksj.ksj_33_20

Abstract

Introduction: Minimally invasive surgery has revolutionized thoracic oncology. Although there are various nonsurgical methods of biopsy, some patient's require a surgical biopsy. We present an innovative use of laparoscope for thoracoscopic biopsy. Materials and Methods: This is a retrospective analysis of 33 patients who underwent thoracoscopic biopsies for undiagnosed thoracic lesions in our hospital. Diagnostic thoracoscopy was performed with the laparoscopy unit used for abdominal surgeries. Results: Thoracoscopic biopsy yielded a histopathological diagnosis in 32 patients (96.67%). Median surgery duration was 40 min. Conversion rate was 6%. Morbidity rate was 10.7% with no mortality. The sensitivity and specificity of thoracoscopic biopsy was 95.83% and 100% respectively. The positive predictive value was100% and negative predictive value was 90%. Conclusion: Thoracoscopic biopsy using the laparoscopy unit can be done with minimal morbidity and without any additional financial burden in a low resource setting.

Keywords: Diagnostic, introthoracic, thoracoscopy

How to cite this article:
Bhargavan R, Nair CK, Mathew AP, Muralee M, Wagh M, George PS. Diagnostic thoracoscopy using a laparoscope. Kerala Surg J 2020;26:154-7

How to cite this URL:
Bhargavan R, Nair CK, Mathew AP, Muralee M, Wagh M, George PS. Diagnostic thoracoscopy using a laparoscope. Kerala Surg J [serial online] 2020 [cited 2020 Dec 5];26:154-7. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/154/300240

Introduction

Minimally invasive techniques have revolutionized the management in thoracic oncology. In suspected thoracic malignancies, computed tomography (CT) guided or bronchoscopic biopsy are the current gold standards for diagnosis. However a small fraction of patients fail to achieve a diagnosis through these techniques. In the past, these patients used to undergo thoracotomy and biopsy of the lesions with its associated increased morbidity and mortality. Thoracoscopy can be used in these patients for diagnosis and staging with minimal morbidity. We present a retrospective analysis of patients with suspected malignancy who underwent thoracoscopic biopsies in a tertiary care centre. Thoracoscopy was done by an innovative use of laparoscopic system, which is usually used for abdominal procedures.

Materials and Methods

This is a retrospective analysis of 33 patients who underwent thoracoscopic biopsies for various suspected intrathoracic malignancies from November 2011 to January 2014 at our tertiary cancer centre. All patients had undergone contrast-enhanced computed tomography (CECT) Thorax with or without flexible bronchoscopy and had at least one failed attempt of CT guided biopsy of the lesion. Diagnostic thoracoscopy with a laparoscope used for abdominal surgeries (Karl Storz high definition laparoscopic system, Germany) was done under general and epidural anaesthesia. After induction, the patient was positioned in right lateral position with a 45 degree angle with the operating table. The camera port was at 5^th intercostal space mid axillary line and two working ports were at 4^th and 7^th intercostal space at posterior axillary line [Figure 1]. 5 mm zero-degree laparoscope was used. Pneumothorax (8 mm of Hg) was created to collapse lung and facilitate the procedure as double lung ventilation was used. The dissection was done using an ultrasonic scalpel and electrocautery. For biopsy of pulmonary parenchymal lesions, biopsy forceps were used for surface lesions and whenever lesion was deeply situated, 12G biopsy needle was passed under vision. In suspected cases of lymphoma, discrete lymph nodes were excised in toto whenever present. In conglomerate nodes multiple wedge biopsies was done. Pleural lesions were biopsied using biopsy forceps. Any pleural fluid present was aspirated for cytology and other investigations. After biopsy, haemostasis was ensured and adequate expansion of the lung was ensured. An intercostal drain (ICD) was inserted through the port at the 7^th intercostal space. In patients who were converted to open procedure, a mini thoracotomy was done in the fifth intercostal space. Single shot of antibiotic before and after procedure was given. All patients were extubated immediately post operatively. Oral intake was started after 6 h. Postoperative pain was controlled via thoracic epidural analgesia with supplementation of analgesics as required. Pulmonary physiotherapy was given. ICD was removed after x ray of the chest showed adequate expansion of the lung and absence of air leak. Sutures were removed on postoperative day (POD) 10.

Figure 1: Thoracoscopic port positions, the camera port at 5^th intercostal space mid axillary line: two working ports at 4^th and 7^th intercostal space at posterior axillary line

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Results

The study included 11 females and 22 males with the age from 18 years to 73 years. All patients underwent a CECT Thorax. The suspected diagnosis in the CT Thorax is depicted in [Table 1].

Table 1: Contrast enhanced computed tomography scan thorax diagnosis

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All patients had undergone an inconclusive CT guided biopsy. Fifteen patients had a negative bronchoscopy biopsy. The median surgery time was 40 min (25–135 min) with a longer duration for the earlier cases, suggesting learning curve of the surgical team. Two cases were converted to open mini thoracotomy due to difficulty in access. First case was a suspected case of malignant mesothelioma with difficult access due to severe adhesions resulting in frozen thorax and second a suspected case of mediastinal lymphoma with hilar nodes which could not be approached thoracoscopically, due to extensive lung adhesions. Blood loss was minimal. All patients were extubated immediately. No patient required postoperative ventilatory support.

ICD was removed on the first POD in 28 of the thoracoscopy patients. Three patients had prolonged air leak following lung biopsy and ICD was removed after three, four and 6 days each. The morbidity rate was 10.7% and there was no mortality. The ICD of the thoracotomy patients were removed on POD 2. All patients were discharged the next day after ICD removal. After surgical biopsy, histopathological diagnosis was achieved in 32 patients (96.67%). The final histopathology of all patients is shown in [Table 2].

Table 2: Final histopathology after thoracoscopy

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In one patient, the biopsy showed only inflammatory tissue. A repeat thoracoscopy and biopsy was deferred in view of high risk for general anaesthesia. He developed liver metastasis which on ultrasound guided biopsy was diagnosed as carcinoma. Eight patients suspected with mediastinal lymphoma on CT scan had biopsy suggestive of tuberculosis/sarcoidosis. All were was confirmed to be tuberculosis on polymerase chain reaction evaluation of the biopsy specimen. It ruled out malignancy in 27% of the patients. The final diagnosis after CECT guided biopsy and thoracoscopic biopsy are shown in [Figure 2]. The sensitivity and specificity of thoracoscopic biopsy was 95.83% (95% CI 78.81% to 99.30%) and 100% (95% CI 66.21% to 100%) respectively. The positive predictive value (PPV) was100% (95% CI 85.05% to 100%) and negative predictive value (NPV) was 90% (95% CI 55.46% to 98.34%).

Figure 2: Final diagnosis after computed tomography guided biopsy versus thoracoscopic biopsy

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Discussion

Diagnostic thoracoscopy is an important tool in the diagnosis and management of thoracic malignancies. The first clinical application of VATS dates back to 1913, when Dr. H. C. Jacobaeus of Stockholm performed adhesiolysis in a patient with pulmonary tuberculosis via a cystoscope introduced into the pleural cavity. This was known as Jacobaeus' operation.^[1],[2] After Kurt Semm performed first laparoscopic appendicectomy,^[3] laparoscopic procedures outpaced thoracoscopy in the minimal invasive approach. Thoracoscopy witnessed a comeback since the advent of modern video technology.^[4] Compared to conventional thoracotomy, VATS lobectomy has resulted in better preservation of pulmonary function.^[5] In the study by Yang et al. the mortality of VATS lobectomy is 0.3%.^[6] Thoracoscopy minimises chest wall trauma and post-operative pain leading to decreased postoperative hospital stay. Role of thoracoscopy in staging of lung cancer was described by Krasna as early as 1996.^[7]

CT screening have resulted in increased detection of pulmonary and mediastinal lesions at very early stage.^[8] CT guided biopsy and bronchoscopic biopsy are the gold standard for diagnosis of thoracic malignancies. CT guided biopsy has a sensitivity and specificity of 95.7% and 100% respectively.^[9] For pulmonary hilar lymph nodes CT guided percutaneous needle biopsy has a sensitivity of 91.5%^[10] The overall sensitivity of bronchoscopy is 88%.^[11] Other techniques like Endobronchial ultrasound has a high sensitivity of 92% in the detection of isolated mediastinal nodes.^[12] However, when they fail, thoracoscopy is a boon. Thoracoscopy has an identification rate of 100% in a recent study in the diagnosis of mediastinal tumors.^[13]

All our patients were suspected to have cancer on CT scan and required a tissue diagnosis for further management. A CT guided biopsy was inconclusive in all cases. We used our laparoscopy unit for thoracoscopy. Conversion to mini thoracotomy occurred in the earlier cases with a conversion rate of 6%. No patient required postoperative ventilatory support.

In 90% of the patients ICDs were removed on POD1 in the thoracoscopy patients and they were discharged on the next day. The ICD in the thoracotomy patents were removed on POD 2 and they were discharged on third second POD. Thus the duration of hospital stay was reduced by thoracoscopy. The patients who had ICD for longer duration had prolonged air leak from lung parenchyma. They were managed conservatively. ICDs were removed after adequate lung expansion and stopping of air leak.

Thoracoscopy provided the diagnosis in 96.67% of the patients. It ruled out malignancy in 27% of the patients. The sensitivity and specificity of thoracoscopic biopsy was 95.83% and 100% respectively. The PPV was100% and NPV was 90%.

Thoracoscopy however has its limitations due to loss of tactile feedback, difficulty in detecting deep seated and intraparenchymal lesions, difficulty in biopsy of prevascular and retro-tracheal nodes, lack of three-dimensional view and difficult technical manoeuvrability.

The most common technique of diagnostic thoracoscopy is a medical thoracoscopy using a uniport rigid scope.^[14] Our results represent a tertiary care centre's experience with the state of art laparoscopy equipment. The laparoscopy unit was utilised for thoracoscopic biopsy with no added cost. Single lung ventilation was avoided by using a laparoscopic insufflator system. Thus it can be used in any low resource setup which has laparoscopic facilities without any additional financial burden on the system.

Conclusion

In patients suspected with intrathoracic malignancies where CT and other nonsurgical methods fail to procure a diagnosis, thoracoscopy has a major role to play. It can be practised in low resource setup with no additional burden on the resources by using the laparoscopy unit and instruments.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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