Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion

To begin, perform a patient health check, reaffirming his consent and health conditions. Prepare and check any medications such as sedatives. Place the patient in a lateral decubitus position on a pillow, effusion side up, and ensure patient vital signs monitoring is in place.

With ultrasound guidance, mark the expected entry side on the thorax with a blunt indentation marker. Reconfirm with ultrasound after marking. Once the practitioner has scrubbed and donned the appropriate sterile gear, prepare and check the equipment and local anesthetic which will be used in the procedure.

In parallel, the prepared sedative medications can be administered by an assistant. Thoroughly disinfect the insertion site and create a sterile field. Then inject the anesthetic solution into the insertion site.

While the anesthetic is taking effect, prepare and check the camera and other equipment. Next, make a 10-millimeter-long incision on the skin. Widen the incision with a pair of surgical scissors.

After dissecting down a few millimeters, insert a closing suture. With a pair of narrow-tip forceps, carefully dissect the layers between the skin and the pleura until the pleural cavity is entered. For some patients, wider forceps may also need to be used.

If needed, reconfirm the position of the tract using the local anesthetic needle. Now, insert the trocar and the cannula using gentle pressure. Then remove the trocar.

Now insert a suction tube via the cannula to remove the remaining fluid using a suction system. Insert the thoracoscope via the cannula and inspect the pleural cavity, turning the scope gently to obtain a clear view of as wide an area as possible. Note the position, appearances, and movement of the diaphragm, lung, and pleural surfaces.

If biopsies are to be performed using the rigid scope, switch to a zero-degree lens with biopsy forceps attached. Obtain pleural biopsies from suspicious areas by gripping the pleura with the forceps and gently peeling the layers away incrementally. Areas of nodularity may be biopsied using a more traditional pinch approach.

After each biopsy, remove the scope and inspect the sample to ensure adequacy. Once biopsies are complete, inspect the pleural cavity for signs of significant bleeding. To finish, remove the trocar and insert the post-lat chest tube into the pleural space using the port tract.

Secure the chest tube using a skin suture, ensuring that the suture is kept separate from the closing suture. Wrap the closing suture with a cotton gauze pad. Then cover the procedure site with adequate padding and dressing.