Having a Thoracoscopy

What is a thoracoscopy?

Thoracoscopy is a routine procedure which is undertaken in the Endoscopy Unit at Dorset County Hospital. It is a way of looking inside your chest to examine the chest wall, while you are asleep (sedated, not anaesthetised), with a special camera called a thoracoscope. This allows us to learn more about your illness and the cause of the accumulation of fluid or air in your chest.

The doctor can also take small samples (called biopsies) from the inside of the chest and drain any fluid that has collected there. Sometimes we can do something to stop the re-accumulation of fluid or air in the future.

Why are the samples taken?

Most thoracoscopies are performed to find out why fluid has collected in the chest cavity. The procedure usually involves taking some samples from the pleura (the membrane lining the chest wall) through the thoracoscope. These samples are then looked at in a laboratory to help find out the cause of your problem and the best way of treating it. Some of the fluid in the chest may also be sent to the laboratory for analysis.

What are the benefits of Thoracoscopy?

Your doctor has recommended a Thoracoscopy because he/she feels that this is the best way to find out more about your illness and/or to control your chest symptoms. This decision is taken carefully and with your best interests in mind.
It is of course up to you to decide whether to have the procedure – and we will ask for your written consent before going ahead. If there is anything you are unclear about, or if have any further questions about the procedure, please do not hesitate to contact us (see below).

Will it be painful?

The procedure is carried out under intravenous sedation and local anaesthesia. The sedative drugs used usually prevent patients from being aware during the procedure or from remembering anything from around the time of the procedure. These sedatives are not a general anaesthetic, and although most patients have no memory of the procedure, some people do remember part or all of it. If this does happen it is not unexpected. The principle aim of the sedation is to ensure you remain calm and comfortable throughout the procedure. As well as using sedatives, local anaesthetic is injected into the chest wall, where the small cut will be made to introduce the thoracoscope, so that you do not feel the thoracoscope being inserted. Painkillers are also given to control any pain.

What are the risks of thoracoscopy?

Thoracoscopy is generally a very safe procedure. Any medical procedure carries a very small risk to life, but for thoracoscopy this is very low indeed (less than one in 1,000).

Pain

All patients experience some pain, but this is rarely severe. The local anaesthetic stings briefly and the chest tube positioned at the end of the procedure can be mildly painful. We will give you painkillers to control this.

In some patients, sterile medical talc (a white powder) is put in the chest to help prevent re-accumulation of fluid or air. If this may be needed in your case, your doctor will discuss it with you when you sign the consent form. This talc can cause some chest pain over the twenty-four hours after the procedure. If this happens it can also be treated with painkillers.

After discharge, the chest may remain sore for a while and we will give you painkillers to control this. For a few patients, occasional sharp “’car pains’ can affect the chest for some months afterwards. These are uncommon, usually very brief and not severe, and do not suggest that anything has gone wrong with the procedure.

Infection

About one patient in every 100 who has a thoracoscopy suffers an infection at the site of the chest tube. If this occurs it can usually be treated with antibiotics, but it may require a longer stay in hospital. Very rarely such infections can be serious and require an operation for their resolution. In our unit, however, we usually give an intravenous injection of an antibiotic at the time of the procedure to minimise the risk of infection.

Bleeding

About one or two patients in 1,000 may develop some significant bleeding. This can usually be effectively treated at the time of the procedure, but might (very, very rarely) require an operation for its control.

Before you come to hospital

Eating and drinking
Please remember not to eat or drink anything for at least six hours before the procedure is to take place. This is to prevent any sickness during or after the procedure.

What to bring with you:

• Any medicines that you are taking
• Any belongings you may need for a four to five night stay.

What will happen on the day of the thoracoscopy?

Please come to the reception desk in the Endoscopy Unit at Dorset County Hospital. We will have given you an appointment time. You will be admitted to the ward and the nurse will ask you some questions about the medicines that you are taking, and check your blood pressure, pulse, temperature and breathing. One of the doctors will then put a needle into the back of your hand – which will allow us to give you the intravenous medication you need before and during the procedure.

We will then take you to the thoracoscopy room and ask you to lie down on the bed. To ensure that you have enough oxygen during the procedure, an oxygen mask will be placed over your nose and mouth and a probe attached to your finger to continuously monitor your oxygen levels. We will also monitor your heart with an ECG monitor.

Once the doctor is happy that the sedative medication is taking effect, he/she will inject local anaesthetic into a very small area of the chest wall where the small cut that is necessary to introduce the thoracoscope will be made. This stings a little at first but then numbs the area so you do not feel anything during the rest of the examination.

One, or sometimes two, small cuts are then made in the side of your chest, usually under your arm. The thoracoscope, a slim metal telescope, is then passed through one of these cuts, allowing the doctor to see inside the chest. Images are displayed on a TV monitor. Any fluid inside the chest is drained away and the inside of the chest cavity is thoroughly inspected by rotating the thoracoscope. Biopsy specimens are then taken, if deemed appropriate by the doctor. Finally, the doctor will decide whether or not to spray a fine white powder (talc) into the chest cavity to make the lung stick to the chest wall and prevent fluid from re-accumulating. The procedure usually takes about 30-40 minutes. During the procedure you may sometimes be able to hear what is happening around you. This is normal.

After the procedure

At the end of the procedure a tube (“chest drain”) will be inserted through the cut to allow any residual fluid or air to be drained from the chest. The tube is attached to a bottle, which stands on the floor. You may feel some discomfort from the chest tube, but your nurse will give you the painkillers you need. We will take you back to the ward and, when it is appropriate, the nurse will attach the bottle to some gentle suction to help the drainage. You may feel a little bit more discomfort from this but you can have more painkillers if you need them.

Your nurse will regularly record your temperature, pulse, blood pressure and breathing and also check your oxygen levels. Please tell the nurse if you feel any increased shortness of breath.

You will remain in hospital for approximately one further day, unless talc is given in which case you may need to stay in hospital longer. The chest drainage will usually be continued for between a few hours and about four to five days, depending on your particular circumstances. Your doctors and nurses will be able to estimate how long this will be for you.

Rarely with this procedure blood clots can form in the legs. We will give you heparin injections (under the skin, once daily) to help prevent this. We will do a chest x-ray the day after the thoracoscopy to check that all the fluid and air that may have collected in your chest during the procedure has drained away and, if talc is used, you will have a further chest x-ray at four to five days to help assess the success of the procedure.

Looking after your chest tube

Your doctors and nurses will look after your chest tube. However, there are a few simple rules that you can follow to minimise any problems, particularly the risk of chest tube being accidentally pulled out.

• Be very careful when adjusting your position in bed and moving about.
• While your chest tube is attached to suction you will need to stay close to your bed (as the suction tube will limit your movement).
  Keep the drainage bottle on the floor/below the level at which the chest tube enters your body.
• Do not swing the bottle by the tube
• Take care not to knock the bottle over
• If your chest is painful, or if you become very breathless, please tell your nurse
• If you feel your tube may have moved or may be coming out, please tell your nurse.

Removal of your chest tube

This is a simple procedure. It is usually only very mildly painful, but we will give you painkillers to control any pain as much as possible. The nurse removing the chest tube will encourage you to take a couple of deep breaths. She will then ask you to hold your breath, and while you are doing this, will gently pull the tube out. There will already be a stitch in place and she will be pull this tight to close the wound and put a dry dressing over the wound. A chest x-ray will be taken after the chest drain has been removed.

After discharge you should try to keep your stitch dry for five days. The stitch is usually removed by your GP or a nurse after seven days.

Follow up in Outpatients

You will be given an appointment to come back to the outpatient clinic in about 10 – 14 days, when the results of your biopsies will be known.

Are there any alternatives?

There are alternative ways of getting biopsies from the chest using a biopsy needle or a CT scan guided approach. Prior to recommending thoracoscopy, we will have assessed for your particular case the pros and cons of the various methods. We will only recommend a thoracoscopy if the benefits of diagnosis and treatment outweigh the risks for your situation. The alternative biopsy methods are usually less good at identifying the cause of fluid in the chest than the thoracoscopy but, in some circumstances, can be better. If so, we will recommend the alternative. The biopsy methods have a further disadvantage in that they do not allow us to use sterile talc powder to prevent reaccumulation of fluid or air. We would be pleased to discuss the alternatives with you if you wish.

Contact numbers

If you would like any further information about this procedure, or if any problems arise, please contact the Endoscopy Unit on 01305 255225.

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