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The Method of
Medical Thoracoscopy
2nd Edition

Ralf HEINE
Jan Hendrik Bartels
Christian WEISS
®

THE METHOD OF
MEDICAL THORACOSCOPY
2nd Edition
Ralf HEINE, MD
Jan Hendrik BARTELS, MD
Christian WEISS

Medical Clinic III – Pneumonology,


Hematology-Oncology and Palliative Medicine
Hospital of St. Elisabeth and St. Barbara
Halle (Saale), Germany
4 The Method of Medical Thoracoscopy

Cover image: The Method of Medical Thoracoscopy


Andreas Heine 2nd Edition
Ralf Heine, MD
Jan Hendrik Bartels, MD
Christian Weiss
Medical Clinic III – Pneumonology, Hematology-Oncology
and Palliative Medicine, Hospital of St. Elisabeth and
St. Barbara, Halle (Saale), Germany

Correspondence address of the author:


Dr. med. Ralf Heine
Facharzt für Innere Medizin, Pneumologie
Important notes: und Notfallmedizin
Medical knowledge is ever changing. As new research and clinical Chefarzt der Medizinischen Klinik III – Pneumologie,
experience broaden our knowledge, changes in treatment and therapy Hämatologie-Onkologie und Palliativmedizin
may be required. The authors and editors of the material herein
have consulted sources believed to be reliable in their efforts
Krankenhaus St. Elisabeth und St. Barbara, Halle/Saale
to provide information that is complete and in accord with the Mauerstr. 5
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The Method of Medical Thoracoscopy 5

Table of Contents

1 Historical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Indications and Contraindications for Thoracoscopy . . . . . . . . . . . 6
2
2.1 Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.2 Contraindications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Preparations for Thoracoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4
4.1 Imaging Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4.2 Diagnostic Pneumothorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4.3 Premedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
4.3.1 The Evening Before the Procedure . . . . . . . . . . . . . . . . . . . . . . . 10
4.3.2 The Day of the Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Technique of Thoracoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
5
5.1 Procedure Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
5.2 Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
5.3 Positioning the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
5.4 Monitoring and Other Measures during the Procedure . . . . . . 12
5.5 Patient Preparation after Positioning . . . . . . . . . . . . . . . . . . . . . 12
5.6 Selection of the Entry Site. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
5.7 Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
5.8 Conscious Sedation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
5.9 Trocar Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
5.10 Inspection of the Thoracic Cavity . . . . . . . . . . . . . . . . . . . . . . . . 14
5.11 Thoracoscopic Biopsy and Lysis of Adhesions . . . . . . . . . . . . 16
5.12 Talc Pleurodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
5.13 Concluding the Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

6 Management after Thoracoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

7 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

8 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Instrument Set for Medical Thoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . 22


6 The Method of Medical Thoracoscopy

1 Historical Background

The idea of using optical instruments to enter and during that time; as a result, the diagnostic capabilities of
examine body cavities that cannot be accessed through thoracoscopy were largely forgotten.18
a natural orifice dates back to the Dresden physician The fascination of being able to look into the chest led
G. Kelling (1866 – 945). As early as 1902, he published a R. Korbsch to state in 1927 that ‘in vivo pathology’ could
report detailing how he was able to perform ‘coelioscopy’ be accomplished if gross visual findings could be supple-
in a dog after first insufflating air into the abdominal cavity. mented by the histologic evaluation of biopsy specimens.
His optical system consisted of a cystoscope like the one
previously developed by M. Nitze (1848 –1906).11 The Viennese physician A. Sattler rediscovered the
diagnostic value of thoracoscopy in the early 1960s. He
Diagnostic thoracoscopy was first performed in human performed thoracoscopies in several thousand patients,
patients in 1910 by the Swedish internist H. C. Jacobaeus and we must credit him with making pleural biopsy practical
(1879 –1937).10 The creation of a pneumothorax did not pose for clinical use.18 He also performed thoracoscopy for
a new challenge for Jacobaeus, as C. Forlanini (1847–1918) therapeutic purposes and described life-saving emergency
had already developed the procedure in the late 1800s endoscopies for the treatment of hemothorax.23
for the collapse therapy to treat tuberculosis.6 Jacobaeus With the advent of video-assisted thoracoscopy in the
advanced the capabilities of diagnostic thoracoscopy by 1980s, it also became possible to use thoracoscopy
the introduction of thoracocautery. This technique, which for surgical indications. Since then, video-assisted
became important in the treatment of tuberculosis, used thoracic surgery (VATS) has become an established part
electrocautery for the lysis of pleural adhesions.9 By the end of the thoracic surgical repertoire. At the same time,
of the 1950s, thoracoscopy with thoracocautery was widely video-assisted thoracoscopy continues to be a mainstay in
practiced in the collapse therapy of tuberculosis. Only a few the medical diagnosis of diseases of the pleura, lung, and
clinicians utilized the diagnostic potential of thoracoscopy mediastinum.

2 Indications and Contraindications for Thoracoscopy

2.1 Indications Diagnostic Indications for Thoracoscopy:


The range of indications for medical thoracoscopy has
changed significantly in recent decades. The standard  Pleural effusions of unknown origin.
indications for medical thoracoscopy in the 1980s were  Pleural effusions with negative cytology in lung cancer
unexplained pleural effusion, peripheral lung lesions, lesions to exclude M1a disease (pleural carcinomatosis).
near the chest wall, and mediastinal disease.7, 17
 Staging and histologic confirmation of pleural
Today, tumors of the pleura, mediastinum and peripheral lung mesothelioma.
are diagnosed by CT- or ultrasound-guided biopsy. Generally
 Pneumothorax (prior to chest tube placement if
these cases are not investigated by thoracoscopy. Interstitial
indicated).
lung diseases and peripheral lung tumors that cannot be
diagnosed by bronchoscopic tissue sampling are a domain  Thoracoscopy in surgical cavities for a suspected
of thoracoscopic surgery. VATS can provide access for tumor recurrence or specific infection.
wedge resections that yield adequate material for histologic
analysis. It is also used for the complete removal of solid In most cases thoracoscopy is performed during the
peripheral lung lesions and isolated pleural tumors. investigation of pleural exudates that are not explained by
cytologic examination. Interstitial lung diseases may be an
indication for medical thoracoscopy in exceptional cases. In
this application tissue is sampled from the periphery of the
lung with a biopsy forceps. Generally speaking, however, a
thoracoscopic wedge excision would be preferred for this
indication.
The Method of Medical Thoracoscopy 7

In patients with a pneumothorax, thoracoscopy can supply 2.2 Contraindications


vital information that is helpful in directing further manage-
Thoracoscopy is generally well tolerated. We believe that
ment. It can be used to inspect the pleural cavity before the
it is contraindicated by conditions in which the creation
placement of a chest tube.16
of a diagnostic pneumothorax would exacerbate existing
functional disorders.8, 19 In patients with large pleural
Therapeutic Indications for Thoracoscopy: effusions that may cause respiratory insufficiency, however,
functional status can be improved by aspirating the effusion
 Talc pleurodesis for rapidly recurring malignant effusions
during the procedure.
and for transudates unresponsive to medical therapy.
In selected cases, the procedure may also be used in
the treatment of chylothorax and refractory exudative
Contraindications to Thoracoscopy:
inflammatory pleural effusions.15,29
 Frank cardiac insufficiency.
 Talc pleurodesis for recurrent pneumothorax.3, 20
 Frank pulmonary insufficiency.
 Pleural empyema and complicated parapneumonic
 Coagulation disorder (Quick value < 60%,
effusions, where thoracoscopy can be used to evacuate
platelets < 80,000 Gpt/L).
the collection, lyse adhesions, and place a chest tube
under vision.5, 12, 22, 25, 30  Dual antiplatelet therapy with aspirin and clopidogrel.
A daily aspirin dose of 100 mg is not a contraindication
Persistent recurrence of pneumothorax with a chest tube in in itself. Clopidogrel should be stopped approximately
place is a definite indication for video-assisted thoracic 1 week before the procedure.
surgery (VATS), which will also establish access for repairing  Treatment with dabigatran (Pradaxa®), apixaban (Ellquis®),
the existing air leak. or rivaroxaban (Xarelto®). Cessation of these drugs
should follow current recommendations.
Pleural empyema is a potential indication for medical
 Anemia (Hb < 6 mmol/L).
thoracoscopy only if it is in an exudative or fibropurulent
stage. Stage III disease is an indication for thoracic surgical  Severe kyphoscoliosis.
intervention.  Myocardial infarction during the previous 6 weeks.
Thoracoscopy for pneumothorax as well as pleural
empyema requires close interdisciplinary cooperation
between pneumonology and thoracic surgery in developing
a treatment strategy.

3 Anesthesia

Medical thoracoscopy is usually performed under local General anesthesia with muscle relaxation and intubation
anesthesia, which should be combined with adequate with a double-lumen endotracheal tube are rarely necessary
conscious sedation. It is recommended that conscious for medical thoracoscopy and are generally reserved for
sedation and patient monitoring during the procedure children and uncooperative patients.
be conducted by an anesthesiologist or a physician
experienced in conscious sedation who can quickly
recognize and manage any threatening situations that may
arise.
8 The Method of Medical Thoracoscopy

4 Preparations for Thoracoscopy

4.1 Imaging Studies


Preprocedure studies for thoracoscopy should always It is good practice to determine the optimal entry site with
include PA and lateral chest radiographs. Thoracic the patient in the lateral decubitus position. In patients
computed tomography may yield important additional with larger effusions, the potential entry site can also be
information, depending on the clinical question. determined and marked with bedside ultrasound.

Thoracic ultrasonography is the method of choice for


locating the optimal entry site. When pleural effusion is
4.2 Diagnostic Pneumothorax
present, ultrasound can accurately determine whether
there is sufficient space between the lung and chest wall Basically there is no need to create a diagnostic pneumo-
to allow safe insertion of the trocar (Fig. 1). Ultrasound can thorax in patients with a large pleural effusion. When
also confirm the absence of chest-wall tumor at the trocar thoracoscopy is used in the investigation of smaller pleural
insertion site (Fig. 2). This ensures that the trocar will not effusions (Fig. 4) or lesions close to the chest wall, it is
penetrate metastases in the chest wall. Thoracic ultrasound advisable to create a diagnostic pneumothorax. Once the
also supplies information on the internal structure of the pneumothorax has been established, it is easily determined
pleural effusion, including the presence of adhesions and the whether there is sufficient space between the chest wall
detection of loculations (Fig. 3). Especially in patients with and lung surface to allow for safe intrathoracic access. If a
small encapsulated pleural effusions, thoracic ultrasound diagnostic pneumothorax is not created, there is a risk of
can provide information on the size of the presumptive accidentally inserting the trocar into the lung if adhesions
space available for thoracoscopy. are present between the lung and chest wall.

1 Ultrasound localization of the thoracoscopy site in a patient with a 2 Metastasis in the parietal pleura (1). It must be confirmed that the
large pleural effusion (1). Sufficient space is available for safe trocar metastasis is located outside the proposed entry site.
insertion. The liver (3), diaphragm (4) and chest wall (2) are also seen.

3 Loculated pleural effusion. It is reasonable to expect that thoraco- 4 Small pleural effusion (1). Ultrasound cannot identify a safe site for
scopy in this patient will be a time-consuming procedure. It must entering the chest. Spleen (2), lung (3).
include the comprehensive lysis of adhesions to improve visualization.
The Method of Medical Thoracoscopy 9

The pneumothorax should be established immediately incision (Fig. 7). It is connected to a CO2 insufflation pump
prior to thoracoscopy. The patient is positioned on the (KARL STORZ Electronic Endoflator, Figs. 8, 9), which
examination table with the healthy side down. After sterile provides for microprocessor-controlled measurement and
skin preparation and draping of the affected side, local regulation of insufflation pressure and flow rate. A maximum
anesthesia with 10 mL of 1% lidocaine is performed in the intrapleural pressure limit of 2 mmHg should be set on the
fifth intercostal space in the midclavicular line or at another insufflation pump. The flow rate for CO2 insufflation should
puncture site previously identified by ultrasound. When be in the range of 0.5 to 1 L/min. The Electronic Endoflator
local anesthesia is completed, it should be determined also gives a numerical readout of the insufflated CO2
whether the lung is broadly adherent to the chest wall. volume.
This is done by filling the needle hub with local anesthetic When the Veress needle has penetrated the chest wall,
solution and then carefully advancing the needle through the insufflator will give a negative pressure reading of -4 to
the chest wall. When the needle tip penetrates the parietal -6 mmHg. If the needle tip is in the lung, the reading will
pleura and enters the pleural space, the fluid in the hub fluctuate around zero. If this does not occur, it means that
will be sucked into the chest by the negative intrathoracic the needle is in the chest wall or that the pleural layers
pressure. Generally we leave the anesthesia needle in place are obliterated. In this case we recommend moving to a
for a short time so that atmospheric air can enter the pleural different entry site because the pleural adhesion may be a
space through the needle (Figs. 5, 6). local process confined to the initial port.
With the local anesthesia needle removed, a stab incision
is made and a Veress needle is introduced through the

5 Fluid in the needle hub just before insertion through the parietal 6 When the needle penetrates the parietal pleura, the fluid in the hub
pleura. is aspirated into the pleural space by the negative intrathoracic
pressure.

7 Veress needle with a spring-loaded blunt inner cannula and Luer 8 Endoflator with initial settings (2 mmHg = upper limit of intrapleural
Lock adapter, length 10 cm. pressure, 1.0 L/min = insufflation flow rate, 00.0 = insufflated gas
volume) and display during CO2 insufflation (inset, Fig. 9: -1 mmHg =
current intrapleural pressure, 0.5 L/min = current flow rate, 00.3 L = gas
volume already insufflated).
10 The Method of Medical Thoracoscopy

When a negative pressure reading is obtained, 100 mL Occasionally, fresh pleural adhesions can be lysed by
of CO2 is insufflated initially into the pleural space. If applying a slight overpressure (2 mmHg). A total of 600 to
the pressure remains negative, the insufflation may be 800 mL of CO2 should be insufflated into the chest cavity.
continued. During this time the Endoflator will give an We recommend using a C-arm fluoroscope to monitor
intermittent reading of the current intrapleural pressure. If the insufflation process. This allows the operator to track
the pressure exceeds the maximum preset pressure level, the progression of the diagnostic pneumothorax and see
CO2 insufflation will stop automatically. whether enough space has been established between the
chest wall and visceral pleura to permit safe trocar insertion
for thoracoscopy (Fig. 10). Alternatively, the insufflation can
be monitored by chest radiography in the lateral position if
a C-arm fluoroscope is not available (Figs. 11, 12).
Carbon dioxide insufflation is recommended for creating
the pneumothorax because if a gas embolism should occur
as a result of visceral pleural injury, the CO2 will be quickly
reabsorbed. This minimizes the risk to the patient. In cases
where the pneumothorax is created the day before the
examination, CO2 should not be used because generally it
will be completely absorbed by the scheduled procedure
time on the following day.

4.3 Premedication
4.3.1 The Evening Before the Procedure
Generally there is no need to premedicate patients on the
evening before the procedure. Very anxious patients may
take 5 mg of midazolam (Dormicum®) orally at night.

4.3.2 The Day of the Procedure


Approximately 1 hour before the start of the procedure, the
patient should be given an oral sedative such as midazolam
(Dormicum®, 2.5 – 5 mg). If an anesthesiologist will be
10 CO2 insufflation under fluoroscopic guidance. The patient lies on present during the procedure, he or she should determine
his side under the fluoroscope. The tip of the Veress needle (1) is the premedication.
intrathoracic. At the time the image was taken, 800 mL of gas had
already been insufflated. The size of the pneumothorax (2) allows for
safe trocar insertion. The lung (3) is almost fully collapsed. Sufficient
space is available between the chest wall and lung surface. The
diaphragm (4) is clearly visible in the caudal part of the field.

Safe entry site

11 Chest radiograph of a diagnostic pneumothorax. 12 Chest radiograph in right lateral decubitus shows a left seropneu-
mothorax and identifies a safe entry site for thoracoscopy.
The Method of Medical Thoracoscopy 11

5 Technique of Thoracoscopy

5.1 Procedure Room 5.3 Positioning the Patient


Thoracoscopy should be performed in an operating room A rotating, tiltable operating table is essential for the
under aspetic conditions (as recommended by the German optimum performance of thoracoscopy. The table should
Robert Koch Institute).1 be fluoroscopy-compatible.
The patient is positioned in lateral decubitus with the
5.2 Instruments healthy side down and padding beneath that side. An
The following instrument set is required for thoracoscopy: alternative option to padding the healthy side is to tilt the
operating table at the thoracic level. The goal is to spread
 Rigid thoracoscope (4-mm diameter, 30° HOPKINS® the ribs on the affected side as widely as possible by
endoscope) optimum positioning.
 Biopsy forceps*. The patient’s arms are secured on arm rests to allow free
 Suction tube*. access to the operative site. Anterior and posterior pelvic
rests help to stabilize the position. During positioning, an
 Powder dispenser *. electrode should be taped to the patient’s thigh to allow
 Dissecting electrode*. for the use of electrocautery devices, should they become
 Palpation probe. necessary. The operator should make sure that the patient
 Scalpel.
is lying in a comfortable position (Figs. 14, 15).
 2 flexible 6-mm trocars.
 Tissue forceps.
 Anatomical forceps.
 Blunt scissors.
 Suture material.
 Needle holder.
 2 x 10-mL syringes with 1% lidocaine and hypodermic
needle.
*) compatible for use with the rigid thoracoscope

Fig. 13 shows the instrument stand ready for use.

13 Instrument set for thoracoscopy.


(photo: Andreas Heine).

Anterior pelvic rest

Posterior pelvic rest

14 Patient positioning. The position is stabilized with pelvic and arm 15


rests. A pelvic strap has been added for this patient. The entry site
for thoracoscopy was previously identified sonographically and marked
on the skin. ECG leads, a pulse oximeter sensor, and blood-pressure
cuff have been placed.
12 The Method of Medical Thoracoscopy

5.4 Monitoring and Other Measures an analogous technique is used to locate the site that offers
during the Procedure sufficient clearance between the lung and chest wall. In
patients with little or no pleural effusion or if a pneumo-
Oxygen saturation is continuously monitored by pulse thorax is present, the midaxillary line at the level of the fifth
oximetry throughout the procedure. An ECG trace should intercostal space is particularly favorable for obtaining a
be recorded to monitor cardiac rhythm, and blood-pressure comprehensive view of the pleural cavity. The preliminary
readings should be taken at 5-minute intervals. Oxygen creation of a pneumothorax will enhance safety and
is administered by oronasal mask at a rate of 3 – 4 L/min. facilitate the procedure.
Asecure IV line (20-gauge indwelling venous cannula) is
placed for administering medications during the procedure. 5.7 Local Anesthesia
Local anesthesia is administered in layers by the intra- and
5.5 Patient Preparation after Positioning subcutaneous injection of 1% lidocaine over an area of
When the patient has been positioned, a sterile skin prepa- 2 – 3 cm within the intercostal space. Then the cranial
ration is carried out around the proposed thoracoscopy and caudal rib margins are located, and depots of local
site. Then the patient is completely covered with sterile anesthetic are placed along the rib margins bordering
drapes, leaving an approximately 30 x 30-cm field exposed the intercostal space. Repeated aspirations are done
for trocar insertion (Fig. 16). to ensure that the needle does not enter a vessel. Next,
local anesthetic depots are injected into the muscles
and at the subpleural level. Air will be aspirated when the
5.6 Selection of the Entry Site needle has pierced the costal pleura. At that point the
The selected entry site should give optimum access needle is withdrawn with continuous aspiration until air is
to the pleural lesion requiring biopsy. In patients with a no longer obtained. This indicates that the needle tip is at
large pleural effusion, the best entry site is determined by the immediate subpleural level, and an additional depot of
ultrasonography (Section 4.1). The effusion volume at 3 – 4 mL lidocaine is placed in that region.
the proposed site should be sufficient to allow safe trocar Optimal local anesthesia is essential for a painless
insertion. In patients with an encapsulated pleural effusion, examination!

16 The patient is covered with sterile sheets. A 30 x 30 cm area


around the entry site is draped free.
The Method of Medical Thoracoscopy 13

5.8 Conscious Sedation 5.9 Trocar Insertion


Conscious sedation should be administered by a physician An approximately 8-mm skin incision is made along
with comprehensive experience in that area. At our center, the intercostal space, and the chest is entered by blunt
this responsibility is assumed by an anesthesiologist. The dissection with a scissors (Fig. 17). When the chest wall
operator performing the thoracoscopy should not also be has been perforated, a flexible 6-mm trocar is inserted into
responsible for conscious sedation, so that he or she can the thoracic cavity with a corkscrew motion (Fig. 18). A
devote full attention to the procedure. We recommend a whistling sound will generally be heard when the stylet is
titrated dose of midazolam and piritramide for conscious removed, confirming correct intrathoracic placement of the
sedation, starting with an initial i.v. dose of 2 – 3 mg trocar. It is unnecessary to use trocars with a multifunction
midazolam and 5 mg piritramide. An alternative analgesic is valve.
ketamine. Also, propofol (depending on response) may be
given in combination with an analgesic.28

17 Blunt dissection with a scissors.

18 Flexible 6-mm trocar with a blunt metal stylet.


14 The Method of Medical Thoracoscopy

5.10 Inspection of the Thoracic Cavity


A 4-mm HOPKINS® endoscope (thoracoscope) with a endoscope allows the operator to inspect all portions of the
30° viewing angle is introduced into the chest through the chest cavity. It is particularly effective for evaluating lesions
flexible trocar. The endoscope should be warmed before- of the chest wall.
hand to prevent fogging. The examination begins with a If a pleural effusion is present, it should definitely be
systematic survey of the thoracic cavity. Once the survey aspirated from the pleural space prior to thoracoscopy to
is completed, a more detailed look is taken at suspicious ensure good visualization. This can be done with an optical
areas or lesions. It may be necessary to tilt the operating suction tube or a separate suction catheter.
table longitudinally or transversely to aid visualization of The thoracoscopic images below illustrate a range of
the posterior, anterior, apical and basal lung regions. A 30° anatomic details, normal findings, and pathologic changes.

Intrathoracic Views

Inspection of the
Left Hemithorax

19 View into the posterior part of the left 20 View into the left pleural dome. The lung
hemithorax demonstrates the left upper shows mild anthracosis (1). Notable
lobe (1), lower lobe (2), and oblique interlobar structures in the pleural dome (2) are the left
fissure (3). The intercostal arteries and veins (4) subclavian artery (3) and the internal thoracic
and the ribs (5) are clearly visualized. The lung artery and accompanying veins on the anterior
shows mild signs of anthracosis. The pleura chest wall (4).
has a smooth, glistening appearance (normal).

21 Anteriorly directed view displays the 22 View of the bulging left diaphragm (1). 23 View of the posterior chest wall displays
lingula (1), pericardial fat (2), the phrenic The posterolateral chest wall (2) is visible the ribs (1), intercostal spaces (2) and
nerve and accompanying vessels (3), and the on the left side of the field. vessels (3), and the upper (4) and lower lobe
lower lobe of the left lung (4). Anterior chest (5).
wall (5).
The Method of Medical Thoracoscopy 15

24 Close-up view of the left subclavian artery 25 View of the anterior chest wall displays the 26 Close-up view of the costal pleura, which
(1) and vein (2) along with the internal internal thoracic artery and veins (1). The appears normal. The yellowish areas are
thoracic artery and left internal thoracic veins surface of the left upper lobe (2) is visible on the subpleural fat (1).
(3). Left upper lobe (4), anterior chest wall (5). right side of the field. The costal pleura appears
smooth and shiny and shows normal vascularity.

27 Close-up view of the left pleural dome 28 Pleural carcinomatosis involving the left 29 Pleural empyema.
displays the aortic arch (1), left subclavian parietal pleura. The velvety red appear-
artery (2), and the collapsed upper lobe (3) ance of the pleura is consistent with chronic
and lower lobe (4). pleuritis.

Inspection of the
Right Hemithorax

30 View into the right hemithorax shows the 31 View of the right cardiophrenic angle with
‘border triangle’ formed by the junction of the right atrium (1), diaphragm (2) and
the middle lobe (1), lower lobe (2) and upper middle lobe (3).
lobe (3). The visceral and parietal pleura
appear thickened and fibrotic due to chronic
fibrosing pleuritis.
16 The Method of Medical Thoracoscopy

5.11 Thoracoscopic Biopsy and Lysis of Adhesions


All lesions visible at thoracoscopy should be biopsied. When adhesions are present, they can be cleared by side-
This can be done with an optical biopsy forceps (Fig. 32). to-side movements of the thoracoscope itself if they are
With diffuse pleural diseases, multiple pleural biopsies very soft. Firmer adhesions can be divided with the hook
should be taken to obtain ample material from various electrode. As a note of caution, dense adhesions may
sites. If the desired biopsy sites are not accessible through transmit vessels of significant size that can bleed profusely
the initial portal, a second trocar can be inserted under if severed. If this complication arises, it may be necessary
local anesthesia and thoracoscopic guidance so that to create a second portal for hemostasis with a cautery
the necessary biopsies can be taken from that position. probe or clip. Complicated parapneumonic effusions and
It is rarely necessary to add a second portal, however. pleural empyema may also require a second portal, through
Heavy bleeding from biopsy sites can be controlled by which adhesions can be lysed under vision with a probe.
electrocautery with an optically guided hook electrode As a general rule, however, it is rarely necessary to create a
(Figs. 33, 34). second portal.
Biopsies can be taken from the parietal and visceral pleura
as required. When tissue is sampled from the costal pleura,
the area about the caudal rib margins should be avoided
to prevent injury to intercostal vessels. If the visceral pleura
is biopsied and an air leak occurs, it will generally close
spontaneously within 7 days.

32 Biopsy with an optical forceps. 33 Electrocautery with an optically guided 34 Result of hemostasis by electrocautery.
hook electrode.
The Method of Medical Thoracoscopy 17

5.12 Talc Pleurodesis


The indications for talc pleurodesis are described in Sect. The talc should be applied in fractionated doses. Talc
2.1. It must be possible for the lung to expand fully and insufflation raises the intrathoracic pressure, and a
occupy all of the chest cavity. The expansibility of the potentially dangerous intrathoracic pressure rise is avoided
lung is tested by introducing the thoracoscope and optical by intermittently pausing the insufflation and removing the
suction tube into the chest. The air is then suctioned dispenser. Air escaping from the chest cavity makes an
from the chest while lung expansion is observed with the audible whistling sound.
thoracoscope. Once the lung has expanded completely, it Talc pleurodesis is a very effective procedure with a
is ready for talc pleurodesis. Talcum powder is blown into reported success rate of 83 – 93%.2, 13, 31 Even long-term
the pleural space with an optical powder dispenser (Figs. studies have documented success rates higher than 80%.
35 – 37). For effective pleurodesis, approximately 4 gr of talc In recent years there have been efforts to replace talc
is blown into the pleural cavity under thoracoscopic vision. pleurodesis with other procedures. Studies in relatively
The operator should make sure that all effusion has been small case numbers have shown that the instillation of silver
aspirated from the chest prior to talc pleurodesis and that nitrate solution into the pleura can also induce pleurodesis.21
the entire lung and chest wall are coated with a thin film of To date, there are no comprehensive studies showing that
talcum powder. this technique is superior to talc pleurodesis.

35 Optical powder dispenser. 36 Talc pleurodesis with a powder dispenser 37 Intrathoracic view after talc application.
under vision. The talc dust has been uniformly
distributed over the lung surface.
18 The Method of Medical Thoracoscopy

5.13 Concluding the Procedure


At the end of the procedure, the entire pleural cavity should paravertebral path under direct visual control (Figs. 38 – 40).
be carefully reinspected so that any bleeding from a biopsy Next the thoracoscope is withdrawn, removing it completely
or adhesiolysis can be detected and controlled. from the drain. At this point the thoracoscope and drainage
A 24-Charr. drain is then introduced into the pleura under tube are in the original trocar port, so the thoracoscope can
vision. We recommend the preplacement of vertical again be used to check the drain position and adjust it as
mattress sutures after trocar removal. Then a 24-Charr. needed. After the thoracoscope is removed, the drain can
drain is passed through the trocar port into the chest cavity. be secured with the preplaced suture. It is advisable to tie
During this time the drain should be stabilized with a probe one knot, then wind the suture several times around the
passed into its lumen through a side hole in the drain. The drain and tie a final knot. Next the chest wall is cleaned and
probe is removed, and the 4-mm HOPKINS® endoscope an adhesive dressing is placed around the drain.
is inserted into the drain lumen through a side hole and The drain is connected to a suction pump. We prefer an
advanced until the interior of the chest cavity can be electronic pump that also indicates airflow (Fig. 41).
seen. Now the drain can be advanced posteriorly along a

38 The thoracoscope is inserted into the 39 40 Placement of the drain under vision.
drain lumen, and the drain is carefully
advanced under vision.

41 The drainage tube is connected to the suction pump. In the case


shown, the suction was set to 20 cm H2O. The flow rate is still
420 mL/min but should fall to zero within minutes if there is no air leak.
The Method of Medical Thoracoscopy 19

6 Management after Thoracoscopy

Patients are monitored in the recovery room for 1– 2 hours response necessary for pleurodesis. Vital signs (pulse and
after thoracoscopy. A chest radiograph is obtained when blood pressure) should be taken hourly for the first 6
the patient is returned to the floor. This is necessary to hours after the procedure. Nursing staff should make
check for lung reexpansion and drain position. sure that the chest tube remains patent. Drain output and
Adequate pain management is important after thoraco- fluid appearance should be recorded and documented.
scopy. For this purpose, 50 mg pethidine may be given When the output falls below 100 mL/24 hours, the drain
subcutaneously or 0.2 – 0.4 mg buprenorphine sublingually may be removed. It is important to ambulate the patient
as needed. Following talc pleurodesis, care should be immediately after thoracoscopy. Prophylactic antibiotics
taken that the patient does not receive corticosteroids are unnecessary.
or NSAIDs as they would suppress the inflammatory

7 Complications

The complication rate after thoracoscopy is low. Our own This appears relatively high and is not consistent with our
studies indicate a rate of 2.34%. A total of 214 cases were experience. The longer the drain remains in place, however,
reviewed.7 More recent studies also document the safety of the higher the risk of infection. No thoracoscopy-related
thoracoscopy. Brims et al. (2012)4 report an infection rate of deaths have been reported.
10.5% in 57 cases (4 cases of pneumonia, 2 empyemas).

8 Summary

Medical thoracoscopy is an economical, highly effective In recent years medical thoracoscopy has been increasingly
interventional procedure that can be learned quickly, has applied for therapeutic purposes. It has a major role in the
few complications, and permits the rapid and safe diagnosis treatment of complicated parapneumonic pleural effusions
of pleural diseases. This opinion is shared by many other and pleural empyema. At present, thoracoscopic talc
authors.16, 24 If necessary, thoracoscopy can also be used to pleurodesis is the most effective and economical method
investigate lesions in the peripheral lung and mediastinum. that we have for inducing pleurodesis.
‘Minithoracoscopy,’ which employs thoracoscopes 2 – 5 mm
in diameter, is also described by other authors as a highly
effective, minimally invasive diagnostic procedure.27
20 The Method of Medical Thoracoscopy

References
1. Anforderungen der Hygiene bei Operationen und 16. LODDENKEMPER R: Thoracoscopy – state of the art.
anderen invasiven Eingriffen Mitteilung der Kommission Eur Respir J. 1998;11(1):213–21.
für Krankenhaushygiene und Infektionsprävention
17. MATZEL W: Diagnostische Thorakoskopie bei
am Robert-Koch-Institut. Bundesgesundheitsblatt
intrathorakalen Rundherden. Z Tbk. 1963;120:1–13.
– Gesundheitsforschung – Gesundheitsschutz.
2000;43(8):644-8. 18. MATZEL W: Thorakoskopie. Z Tbk. 1964;122:252–3.
2. ARAPIS K, CALIANDRO R, STERN JB, et al.: Thoraco- 19. MATZEL W: Thorakoskopie. In: Emmrich R, Hrsg.
scopic palliative treatment of malignant pleural effusions: Arbeitsmethoden der inneren Medizin und ihr verwandter
results in 273 patients. Surg Endosc. 2006;20(6):919–23. Gebiete. 3. Ausg. Jena: Gustav Fischer; 1966. p. 177–92.
3. BRIDEVAUX PO, TSCHOPP JM, CARDILLO G, et al.: 20. MORENO-MERINO S, CONGREGADO M, GALLARDO G,
Short-term safety of thoracoscopic talc pleurodesis et al.: Comparative study of talc poudrage versus pleural
for recurrent primary spontaneous pneumothorax: a abrasion for the treatment of primary spontaneous
prospective European multicentre study. Eur Respir J. pneumothorax. Interact Cardiovasc Thorac Surg.
2011;38(4):770–3. 2012;15(1):81–5.
4. BRIMS FJ, ARIF M, CHAUHAN AJ: Outcomes and
21. PASCHOALINI MDA S, VARGAS FS, MARCHI E, et al.:
complications following medical thoracoscopy.
Prospective randomized trial of silver nitrate vs talc
Clin Respir J. 2012;6(3):144–9.
slurry in pleurodesis for symptomatic malignant pleural
5. BRUTSCHE MH, TASSI GF, GYORIK S, et al.: effusions. Chest. 2005;128(2):684–9.
Treatment of sonographically stratified multiloculated
thoracic empyema by medical thoracoscopy. Chest. 22. RAVAGLIA C, GURIOLI C, TOMASSETTI S, et al.:
2005;128(5):3303–9. Is medical thoracoscopy efficient in the management
of multiloculated and organized thoracic empyema?
6. FORLANINI C: Zur Behandlung der Lungenschwind- Respiration. 2012;84(3):219–24.
sucht durch künstlich erzeugten Pneumothorax.
Deutsche med Wochenschr. 1906;32:1401–5. 23. SATTLER A: 3. Tagung der wissenschaftlichen
Gesellschaft für Tuberkulose und Lungenkrankheiten.
7. HEINE R: Methode und Ergebnisse der Pleuroskopie.
Z Tbk. 1964;122:257.
Diplomarbeit, Martin-Luther-Universität Halle-
Wittenberg. 1985. 24. SIMPSON G: Medical thoracoscopy in an Australian
8. HIEN P: Diagnostische Thorakoskopie. Praktische regional hospital. Intern Med J. 2007;37(4):267–9.
Pneumologie. Springer Berlin Heidelberg; 2012. p. 71–3. 25. SOLER M, WYSER C, BOLLIGER CT, et al.: Treatment
9. JACOBAEUS HC: Endopleurale Operation unter Leitung of early parapneumonic empyema by "medical"
des Thorakoskopes. Beitr Klin Tuberk. 1916;35:1–35. thoracoscopy. Schweiz Med Wochenschr. 1997;127(42):
10. JACOBAEUS HC: Kurze Übersicht über meine 1748–53.
Erfahrungen mit der Laparo-Thorakoskopie. 26. STANZEL F: Instrumentarium für die internistische
Münchener med Wochenschr. 1911;58:2017–9. Thorakoskopie – „Pleuroskopie“. EndoGramm,
11. KELLING G: Über Ösophagoskopie, Gastroskopie KARL STORZ GmbH & Co KG. 2005:1–8.
und Kölioskopie. Münchener med Wochenschr. 27. TASSI GF, MARCHETTI GP, PINELLI V:
1902;49:21–4. Minithoracoscopy: a complementary technique for
12. KERN L, ROBERT J, BRUTSCHE M: Management medical thoracoscopy. Respiration. 2011;82(2):204–6.
of parapneumonic effusion and empyema: medical
28. TSCHOPP JM, PUREK L, FREY JG, et al.: Titrated
thoracoscopy and surgical approach. Respiration.
sedation with propofol for medical thoracoscopy: a
2011;82(2):193–6.
feasibility and safety study. Respiration. 2011;82(5):
13. KOLSCHMANN S, BALLIN A, GILLISSEN A: Clinical 451–7.
efficacy and safety of thoracoscopic talc pleurodesis in
malignant pleural effusions. Chest. 2005;128(3):1431–5. 29. TSCHOPP JM, RAMI-PORTA R, NOPPEN M, et al.:
Management of spontaneous pneumothorax: state of
14. KORBSCH R: Lehrbuch und Atlas der Laparo- und the art. Eur Respir J. 2006;28(3):637–50.
Thorakoskopie. München: J.F. Lehmann; 1927
(Zit. nach Matzel W, 1966). 30. VAZIRI M, ABED O: Management of thoracic empyema:
15. LEE WJ, KIM HJ, PARK JH, et al.: Chemical pleurodesis review of 112 cases. Acta Med Iran. 2012;50(3):203–7.
for the management of refractory hepatic hydrothorax 31. WALKER-RENARD PB, VAUGHAN LM, SAHN SA:
in patients with decompensated liver cirrhosis. Korean J Chemical pleurodesis for malignant pleural effusions.
Hepatol. 2011;17(4):292–8. Ann Intern Med. 1994;120(1):56–64.
The Method of Medical Thoracoscopy 21

Instrument Set for Medical Thoracoscopy


Excerpts from the following catalogs:

THORAX and
TELEPRESENCE, IMAGING SYSTEMS,
DOCUMENTATION AND ILLUMINATION
22 The Method of Medical Thoracoscopy

HEINE Instrument Set 6 mm

26072 BA

26072 BA HOPKINS® Forward-Oblique Telescope 30°,


enlarged view, diameter 4 mm, length 30 cm, autoclavable,
fiber optic light transmission incorporated,
color code: red

26072 A

26072 A Optical Biopsy Forceps,


double action jaws,
for use with HOPKINS®
Telescope 26072 BA

26072 SU

26072 SU Optical Suction Tube,


for use with HOPKINS® Telescope 26072 BA

It is recommended to check the suitability of the product for the intended procedure prior to
The Method of Medical Thoracoscopy 23

26072 TK

26072 TK Optical Powder Blower,


for use with HOPKINS® Telescope 26072 BA

26072 UF

26072 UF Optical Dissection Electrode, L-shaped,


with connector pin for unipolar coagulation,
for use with HOPKINS® Telescope 26072 BA

40120 NAL

40120 NAL Trocar, with blunt tip, flexible cannula,


autoclavable, size 6 mm, working length 8.5 cm,
color code: black,
including:
Cannula
Trocar only
30120 X Plastic Cannula, autoclavable,
for flexible trocars, size 6 mm, package of 5

26120 J

26120 J VERESS Pneumoperitoneum Needle,


with spring-loaded blunt inner cannula, LUER-Lock,
autoclavable, diameter 2.1 mm, length 10 cm
24 The Method of Medical Thoracoscopy

Instrument Set 11 mm

26038 AA

26038 AA HOPKINS® Straight Forward Telescope 0°,


with angled eyepiece, diameter 10 mm, length 27 cm,
autoclavable, fiber optic light transmission incorporated,
with 6 mm working channel

26120 J

26120 J VERESS Pneumoperitoneum Needle,


with spring-loaded blunt inner cannula, LUER-Lock,
autoclavable, diameter 2.1 mm, length 10 cm

30103 WX

30103 WX Trocar, size 11 mm,


color code: green-white,
including:
Trocar only, with blunt tip
Cannula without valve, with insufflation stop-cock,
length 8.5 cm,
Multifunctional Valve, size 11 mm

37470 SC 30804

37470 SC Coagulating and Dissecting Electrode,


with suction channel, insulated sheath,
with connector pin for unipolar coagulation,
size 5 mm, length 43 cm

30804 Handle with Trumpet Valve,


for suction or irrigation, autoclavable,
for use with 5 mm coagulating suction tubes
and 5 mm suction and irrigation tubes
The Method of Medical Thoracoscopy 25

34421 MB

34421 MB CLICKLINE MANHES Biopsy Forceps,


rotating, dismantling, insulated,
with connector pin for unipolar coagulation,
with LUER-Lock irrigation connection
for cleaning, single action jaws,
large jaws, size 5 mm, length 43 cm,
including:
Plastic Handle, without ratchet
Metal Outer Sheath
Forceps Insert

26778 UF

26778 UF Coagulation and Dissection Electrode,


L-shaped, with connector pin for unipolar coagulation,
size 5 mm, length 43 cm

40492 TK

40492 TK Powder Blower,


with rubber bulb, straight sheath,
size 5 mm, length 42 cm,
including:
Sheath
Rubber Bulb
Tube
Bottle
26 The Method of Medical Thoracoscopy

Instruments for the Biportal Technique

26046 BA

26046 BA HOPKINS® Forward-Oblique Telescope 30°,


diameter 5 mm, length 29 cm, autoclavable,
fiber optic light transmission incorporated,
color code: red

40120 NAL

40120 NAL Trocar, with blunt tip, flexible cannula,


autoclavable, size 6 mm, working length 8.5 cm,
color code: black,
including:
Cannula
Trocar only

30120 X Plastic Cannula, autoclavable, for flexible trocars,


size 6 mm, package of 5

40170 LB 30804

40170 LB Coagulation Suction Tube,


with connector pin for unipolar coagulation,
distally angled sheath,
size 5 mm, length 28 cm,
for use with Handle 30804

30804 Handle with Trumpet Valve,


for suction or irrigation, autoclavable,
for use with 5 mm coagulating suction tubes
and 5 mm suction and irrigation tubes
The Method of Medical Thoracoscopy 27

43249 DUP

43249 DUP CLICKLINE Biopsy Forceps, dismantling,


insulated, with connector pin for unipolar coagulation,
distally angled outer sheath, single action jaws,
jaws open vertically to angulation,
size 5 mm, length 28 cm,
including:
Plastic Handle, axial, without ratchet,
with 4 locking positions
Outer Sheath with Forceps Insert

40775 LF

40775 LF Dissecting Electrode, L-shaped, insulated,


with connector pin for unipolar coagulation,
distally angled sheath,
size 5 mm, length 28 cm

40491 TKU

40491 TKU Powder Blower, with rubber bulb,


distally angled sheath,
size 5 mm, length 30 cm,
including:
Sheath
Rubber Bulb
Tube
Bottle
28 The Method of Medical Thoracoscopy

IMAGE1 S Camera System n


Economical and future-proof
## Modular concept for flexible, rigid and ## Sustainable investment
3D endoscopy as well as new technologies ## Compatible with all light sources
## Forward and backward compatibility with video
endoscopes and FULL HD camera heads

Innovative Design
## Dashboard: Complete overview with intuitive ## Automatic light source control
menu guidance ## Side-by-side view: Parallel display of standard
## Live menu: User-friendly and customizable ­image and the Visualization mode
## Intelligent icons: Graphic representation changes ## Multiple source control: IMAGE1 S a ­ llows
when settings of connected devices or the entire the simultaneous display, processing and
system are adjusted ­documentation of image information from
two c ­ onnected image sources, e.g., for hybrid
operations

Dashboard Live menu

Intelligent icons Side-by-side view: Parallel display of standard image and


Visualization mode
The Method of Medical Thoracoscopy 29

IMAGE1 S Camera System n


Brillant Imaging
## Clear and razor-sharp endoscopic images in ## Reflection is minimized
FULL HD ## Multiple IMAGE1 S technologies for homogeneous
## Natural color rendition illumination, ­contrast enhancement and color
­shifting

FULL HD image CLARA

FULL HD image CHROMA

FULL HD image SPECTRA A *

FULL HD image SPECTRA B **

* SPECTRA  A : Not for sale in the U.S.


** SPECTRA  B : Not for sale in the U.S.
30 The Method of Medical Thoracoscopy

IMAGE1 S Camera System n

TC 200EN

IMAGE1 S CONNECT, connect module, for use with up to


TC 200EN*
3 link modules, resolution 1920 x 1080 pixels, with integrated
KARL STORZ-SCB and digital Image Processing Module,
power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz
including:
Mains Cord, length 300 cm
DVI-D Connecting Cable, length 300 cm
SCB Connecting Cable, length 100 cm
USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US
* Available in the following languages: DE, ES, FR, IT, PT, RU

Specifications:
HD video outputs - 2x DVI-D Power supply 100 – 120 VAC/200 – 240 VAC
- 1x 3G-SDI Power frequency 50/60 Hz
Format signal outputs 1920 x 1080p, 50/60 Hz Protection class I, CF-Defib
LINK video inputs 3x Dimensions w x h x d 305 x 54 x 320 mm
USB interface 4x USB, (2x front, 2x rear) Weight 2.1 kg
SCB interface 2x 6-pin mini-DIN

For use with IMAGE1 S


IMAGE1 S CONNECT Module TC 200EN

TC 300

TC 300 IMAGE1 S H3-LINK, link module, for use with


IMAGE1 FULL HD three-chip camera heads,
power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz,
for use with IMAGE1 S CONNECT TC 200EN
including:
Mains Cord, length 300 cm
Link Cable, length 20 cm

Specifications:
Camera System TC 300 (H3-Link)
Supported camera heads/video endoscopes TH 100, TH 101, TH 102, TH 103, TH 104, TH 106
(fully compatible with IMAGE1 S)
22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3,
22 2200 54-3, 22 2200 85-3
(compatible without IMAGE1 S ­technologies CLARA, CHROMA, SPECTRA*)
LINK video outputs 1x
Power supply 100 – 120 VAC/200 – 240 VAC
Power frequency 50/60 Hz
Protection class I, CF-Defib
Dimensions w x h x d 305 x 54 x 320 mm
Weight 1.86 kg

* SPECTRA  A : Not for sale in the U.S.


** SPECTRA  B : Not for sale in the U.S.
The Method of Medical Thoracoscopy 31

IMAGE1 S Camera Heads n


For use with IMAGE1 S Camera System
IMAGE1 S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300
and with all IMAGE 1 HUB™ HD Camera Control Units

TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head,


50/60 Hz, IMAGE1 S compatible, progressive scan,
soakable, gas- and plasma-sterilizable, with integrated
Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x),
2 freely programmable camera head buttons,
TH 100 for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-Z
Product no. TH 100
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 114 mm
Weight 270 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm

TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head,


50/60 Hz, IMAGE1 S compatible, autoclavable,
progressive scan, soakable, gas- and plasma-sterilizable,
with integrated Parfocal Zoom Lens, focal length
f = 15 – 31 mm (2x), 2 freely programmable camera head
TH 104 buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-ZA
Product no. TH 104
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 100 mm
Weight 299 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm
32 The Method of Medical Thoracoscopy

Monitors
9619 NB 19" HD Monitor,
color systems PAL/NTSC, max. screen
resolution 1280 x 1024, image format 4:3,
power supply 100 – 240 VAC, 50/60 Hz,
wall-mounted with VESA 100 adaption,
including:
External 24 VDC Power Supply
Mains Cord
9619 NB

9826 NB 26" FULL HD Monitor,


wall-mounted with VESA 100 adaption,
color systems PAL/NTSC,
max. screen resolution 1920 x 1080,
image fomat 16:9,
power supply 100 – 240 VAC, 50/60 Hz
including:
External 24 VDC Power Supply
Mains Cord

9826 NB
The Method of Medical Thoracoscopy 33

Monitors

KARL STORZ HD and FULL HD Monitors 19" 26"


Wall-mounted with VESA 100 adaption 9619 NB 9826 NB
Inputs:
DVI-D l l
Fibre Optic – –
3G-SDI – l
RGBS (VGA) l l
S-Video l l
Composite/FBAS l l
Outputs:
DVI-D l l
S-Video l –
Composite/FBAS l l
RGBS (VGA) l –
3G-SDI – l
Signal Format Display:
4:3 l l
5:4 l l
16:9 l l
Picture-in-Picture l l
PAL/NTSC compatible l l

Optional accessories:
9826 SF Pedestal, for monitor 9826 NB
9626 SF Pedestal, for monitor 9619 NB

Specifications:
KARL STORZ HD and FULL HD Monitors 19" 26"
Desktop with pedestal optional optional
Product no. 9619 NB 9826 NB
Brightness 200 cd/m2 (typ) 500 cd/m2 (typ)
Max. viewing angle 178° vertical 178° vertical
Pixel distance 0.29 mm 0.3 mm
Reaction time 5 ms 8 ms
Contrast ratio 700:1 1400:1
Mount 100 mm VESA 100 mm VESA
Weight 7.6 kg 7.7 kg
Rated power 28 W 72 W
Operating conditions 0 – 40°C 5 – 35°C
Storage -20 – 60°C -20 – 60°C
Rel. humidity max. 85% max. 85%
Dimensions w x h x d 469.5 x 416 x 75.5 mm 643 x 396 x 87 mm
Power supply 100 – 240 VAC 100 – 240 VAC
Certified to EN 60601-1, EN 60601-1, UL 60601-1,
protection class IPX0 MDD93/42/EEC,
protection class IPX2
34 The Method of Medical Thoracoscopy

Data Management and Documentation


KARL STORZ AIDA® – Exceptional documentation

The name AIDA stands for the comprehensive implementation


of all documentation requirements arising in surgical procedures:
A tailored solution that flexibly adapts to the needs of every
specialty and thereby allows for the greatest degree of
customization.
This customization is achieved in accordance with existing
clinical standards to guarantee a reliable and safe solution.
Proven functionalities merge with the latest trends and
developments in medicine to create a fully new documentation
experience – AIDA.
AIDA seamlessly integrates into existing infrastructures and
exchanges data with other systems using common standard
interfaces.

WD 200-XX* AIDA Documentation System,


for recording still images and videos,
dual channel up to FULL HD, 2D/3D,
power supply 100 – 240 VAC, 50/60 Hz
including:
USB Silicone Keyboard, with touchpad
ACC Connecting Cable
DVI Connecting Cable, length 200 cm
HDMI-DVI Cable, length 200 cm
Mains Cord, length 300 cm

WD 250-XX* AIDA Documentation System,


for recording still images and videos,
dual channel up to FULL HD, 2D/3D,
including SMARTSCREEN® (touch screen),
power supply 100 – 240 VAC, 50/60 Hz
including:
USB Silicone Keyboard, with touchpad
ACC Connecting Cable
DVI Connecting Cable, length 200 cm
HDMI-DVI Cable, length 200 cm
Mains Cord, length 300 cm

*XX Please indicate the relevant country code


(DE, EN, ES, FR, IT, PT, RU) when placing your order.
The Method of Medical Thoracoscopy 35

Workflow-oriented use

Patient
Entering patient data has never been this easy. AIDA seamlessly
integrates into the existing infrastructure such as HIS and PACS.
Data can be entered manually or via a DICOM worklist.
ll important patient information is just a click away.

Checklist
Central administration and documentation of time-out. The checklist
simplifies the documentation of all critical steps in accordance with
clinical standards. All checklists can be adapted to individual needs
for sustainably increasing patient safety.

Record
High-quality documentation, with still images and videos being
recorded in FULL HD and 3D. The Dual Capture function allows for
the parallel (synchronous or independent) recording of two sources.
All recorded media can be marked for further processing with just
one click.

Edit
With the Edit module, simple adjustments to recorded still images
and videos can be very rapidly completed. Recordings can be quickly
optimized and then directly placed in the report.
In addition, freeze frames can be cut out of videos and edited and
saved. Existing markings from the Record module can be used for
quick selection.

Complete
Completing a procedure has never been easier. AIDA offers a large
selection of storage locations. The data exported to each storage
location can be defined. The Intelligent Export Manager (IEM) then
carries out the export in the background. To prevent data loss,
the system keeps the data until they have been successfully exported.

Reference
All important patient information is always available and easy to access.
Completed procedures including all information, still images, videos,
and the checklist report can be easily retrieved from the Reference module.
36 The Method of Medical Thoracoscopy

Cold Light Fountain Power LED 175 SCB

20 1614 20-1 Cold Light Fountain Power LED 175 SCB,


with integrated SCB, high-performance LED
and one KARL STORZ light outlet,
power supply 110 – 240 VAC, 50/60 Hz
including:
Mains Cord

ENDOFLATOR® 40 with KARL STORZ SCB


with High Flow Insufflation (40 l/min.)

UI400S1
ENDOFLATOR® 40 SCB,
Set, with integrated SCB module,
power supply 100 – 240 VAC, 50/60 Hz
including:
ENDOFLATOR® 40
Mains Cord, length 300 cm
SCB Connecting Cable, length 100 cm
Universal Wrench
Insufflation Tubing Set, with gas filter, sterile,
for single use, package of 5 *

Subject to the customer’s application-specific


requirements additional accessories must be
ordered separately.
* This product is marketed by mtp.
For additional information, please apply to:
*mtp medical technical promotion gmbh,
Take-Off GewerbePark 46,
78579 Neuhausen ob Eck, Germany

DUOMAT®
Suction and Irrigation Pump
20 3210 08
DUOMAT®
Suction and Irrigation Pump,
including:
DUOMAT®,
power supply 100 – 120,
230 – 240 VAC, 50/60 Hz
Mains Cord
VACUsafe Promotion
Pack Suction, 2 l *
(not illustrated)

Subject to the customer’s application-specific


 This product is marketed by mtp. requirements additional accessories must be
For additional information, please apply to: ordered separately.
*mtp medical technical promotion gmbh,
Take-Off GewerbePark 46,
78579 Neuhausen ob Eck, Germany
The Method of Medical Thoracoscopy 37

Equipment Cart

UG 220 Equipment Cart


wide, high, rides on 4 antistatic dual wheels
equipped with locking brakes 3 shelves,
mains switch on top cover,
central beam with integrated electrical subdistributors
with 12 sockets, holder for power supplies,
potential earth connectors and cable winding
on the outside,
Dimensions:
Equipment cart: 830 x 1474 x 730 mm (w x h x d),
shelf: 630 x 510 mm (w x d),
caster diameter: 150 mm
inluding:
Base module equipment cart, wide
Cover equipment, equipment cart wide
Beam package equipment, equipment cart high
3x Shelf, wide
Drawer unit with lock, wide
2x Equipment rail, long
Camera holder
UG 220

UG 540 Monitor Swivel Arm,


height and side adjustable,
can be turned to the left or the right side,
swivel range 180°, overhang 780 mm,
overhang from centre 1170 mm,
load capacity max. 15 kg,
with monitor fixation VESA 5/100,
for usage with equipment carts UG xxx

UG 540
38 The Method of Medical Thoracoscopy

Recommended Accessories for Equipment Cart

UG 310 Isolation Transformer,


200 V – 240 V; 2000 VA with 3 special mains socket,
expulsion fuses, 3 grounding plugs,
dimensions: 330 x 90 x 495 mm (w x h x d),
for usage with equipment carts UG xxx

UG 310

UG 410 Earth Leakage Monitor,


200 V – 240 V, for mounting at equipment cart,
control panel dimensions: 44 x 80 x 29 mm (w x h x d),
for usage with isolation transformer UG 310

UG 410

UG 510 Monitor Holding Arm,


height adjustable, inclinable,
mountable on left or rigth,
turning radius approx. 320°, overhang 530 mm,
load capacity max. 15 kg,
monitor fixation VESA 75/100,
for usage with equipment carts UG xxx

UG 510
with the compliments of
KARL STORZ — ENDOSKOPE

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