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Ann Thorac Surg 2009;88:315-317. doi:10.1016/j.athoracsur.2008.10.089
© 2009 The Society of Thoracic Surgeons
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How To Do It

A Cervical Approach to Investigating Pleural Disease

Lucy Fowkes, BM, Kelvin K.W. Lau, MRCS, DPhil, Nehal Shah, MRCS, Edward Black, FRCS(CTh)*

Department of Thoracic Surgery, Nottingham City Hospital, Nottingham, United Kingdom

Accepted for publication October 21, 2008.

* Address correspondence to Dr Black, Department of Thoracic Surgery, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, United Kingdom (Email: edwardblack{at}mac.com).


   Abstract
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We describe a modern cervical approach to the pleural space using video-mediastinoscopy, which allows both mediastinoscopy and pleuroscopy to be performed simultaneously. Mediastinoscopy is carried out with lymph node sampling, and the pleura are exposed and the pleural cavity is entered under direct vision. A thoracoscope is admitted into the pleural space, where lavage, biopsy, and pleurodesis can be carried out. Fifteen patients underwent mediastino-pleuroscopy to investigate pleural effusion and stage malignancy. One patient underwent bilateral pleuroscopy through a single cervical approach. There were no mortalities and the mean postoperative stay was 2.4 days. Mediastino-pleuroscopy is safe, uses a small incision, is well tolerated, and allows access to both pleura and the mediastinum.


   Introduction
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Technique
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Pleuroscopy and mediastinoscopy have traditionally been considered and performed as separate entities. Pleuroscopy entails internal inspection of the pleural cavity and has both diagnostic and therapeutic applications. Diagnostic pleuroscopy is conventionally performed through a 1-cm intercostal incision; occasionally further ports are required. Mediastinoscopy permits visualization of the mediastinum and is indicated for diagnosis and staging of thoracic diseases.

Pleuroscopy has been described as a safe and reliable diagnostic investigation [1]. For evaluation of the mediastinum, mediastinoscopy serves as the gold standard and is proven to be highly effective for diagnosis and staging [2], in particular for lung cancer [3]. It would seem logical to combine these procedures to maximize successful diagnosis, obtain accurate staging, avoid intercostals nerve injury, and minimize surgical trauma with a single incision.

Use of a cervical approach for both procedures is therefore attractive; however, information regarding its practice is scarce. There has been little advancement since its inception over 30 years ago [4]. Here we report our contemporary experience of cervical pleuroscopy.


   Technique
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Conventional video-mediastinoscopy and lymph node sampling is carried out through a standard 2-cm mediastinoscopy collar incision. The pretracheal plane is developed and intubated with a video-mediastinoscope. Pleurotomy is carried out after lymph node sampling, including subcarinal nodes (Fig 1). On the left side, fat and lymph nodes are excised to aid identification of the recurrent laryngeal nerve and exposure of the pleura. The windows between the innominate and left common carotid artery, or the left common carotid and subclavian arteries are identified digitally, and the pleurotomy is carried out through a video-mediastinoscope, with the lung deflated within the palpated pocket. On the right side, the superior vena cava can be retracted anteriorly or posteriorly to expose the pleura, and the pleural space can be entered anterior or posterior to this. Thoracoscopes at 0° and 30° are passed through the mediastinoscope into the pleural cavity.


Figure 1
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  		Fig 1. On the left side, the pleura is approached between the innominate, left common carotid and left subclavian arteries (a) where the lung can be seen beyond the translucent pleura (b). On the right side, it can be approached anterior or posterior to the superior vena cava (c), also where the lung is most obviously seen through the pleura (d). The accessible area of the hemithorax is limited by the angle of view of the scope (e); however this can be expanded with a 30 scope.

 
The viewable area of the hemithorax is limited posteriorly by dependence of the lung. Although the apex could not be easily visualised with a 0° thoracoscope, this area can easily be examined using a 30° thoracoscope. The diaphragm and pericardium can easily be seen using this approach.

After pleurotomy, standard procedures, such as pleural biopsy, lavage, and pleurodesis can be carried out. At the conclusion of the operation, an intrapleural 19-French Blake drain (Ethicon Inc, Somerville, NJ) is brought out beneath the cervical incision.

Between September 2006 and April 2008, we performed mediastino-pleuroscopy in 15 patients. The indications were diagnosis of pleural effusion as the cause in 7 patients, staging of mesothelioma in 7 patients, and staging of lung cancer, with lymphadenopathy and effusion in 1 patient. Pleuroscopy was carried out on the left in 6 patients, on the right in 8 patients, and bilaterally in 1 patient. Unilateral pleuroscopy was carried out for staging of contralateral and lymph node spread of mesothelioma. Bilateral pleuroscopy was carried out for the investigation of effusion in patients whose history and imaging suggested likely mesothelioma to allow simultaneous diagnosis and staging.

Talc poudrage was carried out in 2 patients, and concurrent laparoscopic staging was performed in 3 patients. In one case, pleuroscopy failed due to dense adhesions in the pleural space, which also prevented video-assisted thoracoscopic surgery, so an open biopsy was performed. The mean duration of unilateral procedures was 64.4 minutes (range, 24 to 142 minutes), whereas the bilateral procedure took 62 minutes.

The procedure was well tolerated and there were no mortalities. One patient developed acute lung injury and renal failure after talc poudrage culminated in a 22-day admission. With the exception of this patient, the mean postoperative stay was 2.4 days. Left recurrent laryngeal nerve palsies developed in 2 of 7 patients who underwent left cervical pleuroscopy. Diagnostic histology was obtained for all patients.


   Comment
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 Technique
 Comment
References
 
Disease processes are not confined to separate compartments within the thoracic cavity; therefore the investigation should reflect this subject. The combination of mediastinoscopy and pleuroscopy (both effective methods of diagnosis and staging) is logical.

Deslauriers and colleagues [4] originally extended cervical mediastinoscopy to pleural exploration in 1969. His work involved 275 patients for 7 years. Notably his operative technique and thus biopsy was limited by his equipment. Consequently, the percentages of histological diagnoses achieved (78% malignant and 91% benign pulmonary disease) were poor. These problems may partially explain the seeming unpopularity of mediastino-pleuroscopy, in addition to its technical challenge. Our experience nevertheless demonstrated that accurate tissue diagnosis can be achieved. Access to the thoracic cavity may be further enhanced by the use of flexible instrumentation [5].

Our patients had a mean postoperative stay of 2.4 days, although the length of stay in hospitals within the United Kingdom is dependent on factors such as social circumstances, transport, and issues beyond the controls of the surgeon(s). Ultimately, coordinated discharge planning may permit the procedure to be performed as a day case; we note that 4 patients were discharged 1 day postoperatively, whereas 3 patients also underwent laparoscopy, and 2 had talc poudrage.

We have also extended this procedure to bilateral pleuroscopies. This was performed in one patient to diagnose and stage mesothelioma. Talc poudrage was also performed on one side. The procedure was uncomplicated and he was discharged after 3 days. Although convenient, the risk of tumor seeding, albeit to one incision, needs further study. No patients have developed tumor seeding during follow-up. Furthermore, local radiotherapy can be delivered to the operative site. Laryngeal nerve palsy in two left-sided cases may reflect anatomical variation or the need for technique refinement.

Although obliteration of the pleural space prevents safe pleurotomy, this is also true of traditional thoracoscopy, as evidenced by our failed pleuroscopy case. Access to the aortic-pulmonary window lymph nodes remains suboptimal, and is safest performed through an anterior mediastinotomy.

The benefits of this approach supersede the risks. Ultimately it is more efficient and safer to perform one operation than two. Significantly for the patient it uses a single, small incision, avoiding intercostal nerve damage and minimizing postoperative pain. Postoperative stay is shorter and the cost is reduced. Importantly, it is a reliable diagnostic tool with a high diagnostic yield.

We conclude that mediastino-pleuroscopy is a valuable technique that is advantageous to both patients and surgeons. We would advocate that it be practiced on a wider level to be further developed.


   References
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 Abstract
 Introduction
 Technique
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  1. Weissberg D, Refaely Y. Pleuroscopy: therapeutic applications Scand J Thor Cardiovasc Surg 1996;30:1-10.[Medline]
  2. Hammoud ZT, Anderson RC, Meyers BF, et al. 1999: The current role of mediastinoscopy in the evaluation of thoracic disease J Thor Cardiovasc Surg 1999;118:894-899.[Abstract/Free Full Text]
  3. Lemaire A, Nikolic I, Petersen T, et al. Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate Ann Thorac Surg 2006;82:1185-1189.[Abstract/Free Full Text]
  4. Deslauriers J, Beaulieu M, Dufour C, et al. Mediastino-pleuroscopy: a new approach to the diagnosis of intrathoracic diseases Ann Thorac Surg 1979;22:265-269.
  5. Munavvar M, Khan MA, Edwards J, et al. The autoclavable semi-rigid thoracoscope: the way forward in pleural disease? Eur Resp J 2007;29:571-574.[Abstract/Free Full Text]



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