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INDICATIONS

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This type of approach is ideal for a wide variety of elective and urgent procedures. Through this approach, the lung, mediastinum, pericardium, diaphragm, esophagus, sympathetic chain and chest wall are well visualized. Over the last decade, minimally invasive surgical techniques have gained widespread acceptance as technological improvements in imaging systems and instrumentation have occurred. Thoracoscopy has become the procedure of choice for the management of early-stage non–small-cell lung cancer, posterior and mediastinal masses biopsy or excision, primary spontaneous pneumothorax, fibropurulent empyema, evacuation of hemothorax, management of effusive pericardial disease, sympathetic chain ablation for hyperhidrosis, pleural biopsy, and recurrent pleural effusions. Depending on the indication, thoracoscopy can therefore be used both as a diagnostic and/or therapeutic intervention. For successful thoracoscopy, a sound understanding of surgical anatomy is essential due to limitation of viewing angles and reduction of tactile sense.

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PREOPERATIVE PREPARATION

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Thoracoscopy is performed for the most part in elective, non-emergency situations. This allows for the pulmonary function to be optimized with preoperative incentive spirometry and smoking cessation. For thoracoscopy to be performed, the patient must be able to tolerate contralateral single lung ventilation which must be trialed prior to positioning the patient. Similarly, if the patient is on maximal ventilator support prior to the operation, it is unlikely that thoracoscopy will be well tolerated by the patient. A history of previous chest surgery including pleurodesis or empyema must be ascertained.

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ANESTHESIA

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Prior to undergoing thoracoscopy, the patient should have bronchoscopy performed through a single-lumen tube. This will eliminate secretions, ensure normal anatomy, rule out endobronchial pathology, and ultimately facilitate the insertion of the double-lumen endotracheal tube by the anesthesiologist. Although thoracoscopic procedures are reported to be less painful, a thoracic epidural should be offered to the patient prior to the procedure and arterial blood pressure monitoring should be placed prior to induction. A double-lumen endotracheal tube is ideal for securing single lung ventilation, although an endobronchial blocker through a single-lumen endotracheal tube is a possible alternative. Prior to positioning the patient for thoracoscopy, the anesthesiologist should verify the position of the double-lumen tube or the endobronchial blocker and secure it well so it does not migrate during positioning. A trial of contralateral single lung ventilation should be attempted prior to positioning the patient. Relative contraindications to thoracoscopy include the presence of dense pleural adhesions or pleural symphysis as well as large intrathoracic tumors and hilar granulomatous disease that would preclude adequate visualization of the hilar vascular structures.

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POSITION

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The patient is placed in a lateral decubitus position, facilitated by a bean bag on the operating room bed, with the hips secured to the table. The table is flexed so to expand the intercostal spaces. The lower leg is flexed at the knee and a pillow is placed between it and the upper leg which is extended. An axillary roll is placed ...

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