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Rigid endoscopy: thoracoscopy

image of Rigid endoscopy: thoracoscopy
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Abstract

Thoracoscopy allows for exploratory and interventional procedures within the chest to be performed through multiple 5 mm or 10 mm thoracic portals. Significant spreading of the ribs or sternum is avoided, decreasing the perioperative morbidity associated with intrathoracic procedures. Use of a rigid endoscope allows for significant visual magnification of normal structures while allowing access to the organs and areas normally approached by standard intercostal thoracotomy or median sternotomy. Complete evaluation of the parietal pleura, mediastinum, lungs, lymph nodes, diaphragm and pericardium can be accompanied by biopsy of any of the listed structures. Samples may also be obtained for aerobic, anaerobic and fungal culture. This chapter considers Indications; Instrumentation; Patient preparation and positioning; Preoperative diagnostic work-up; Anaesthetic considerations; Procedure; Normal findings; Pathological conditions; Pericardiocentesis; Mediastinal debridement; Pericardectomy; Partial and complete pneumolobectomy; Division of the ligamentum arteriosum; Occlusion of a patent ductus arteriosus; Thoracic duct occlusion; Postoperative care; and Complications.

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Figures

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12.1 Excellent illumination and magnification during thoracoscopy provide detail beyond that normally seen with open thoracotomy.
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12.2 Flexible endoscopic ports and the blunt obterator used for placement. Ports have been cut to different lengths for different sized patients.
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12.3 The normal mediastinum seen upon entry via a paraxiphoid cannula must be opened to explore the contralateral hemithorax.
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12.4 Intercostal vessels (arrowed) seen coursing along the caudal border of the ribs should be avoided during cannula insertion and pleural biopsy.
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12.5 A view of the caudodorsal thorax at the dorsal pleural reflection demonstrates the detail visible during thoracoscopy.
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12.6 Endoscopic appearance of normal lung.
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12.7 Telescopic view of the middle chest toward the thoracic inlet (arrowed) in a dog with chronic pleural effusion.
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12.8 Caudal mediastinal mass in a patient with chronic pleural effusion. The diagnosis was lymphosarcoma.
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12.9 Port sites for pericardectomy. Sites may be adjusted to match the anatomy of each patient. The paraxiphoid port (PX) can be used for the telescope with the operative ports placed either bilaterally at the 6th intercostal space, or at the 6th and 10th intercostal spaces on the right of the patient. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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12.10 Identification of the phrenic nerves (arrowed) is paramount to subtotal pericardectomy.
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12.11 Lateral view of the oesophagus of a dog with a persistent right aortic arch prior to dissection.
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12.12 The ligamentum arteriosum (arrowed) is visible after dissection of the mediastinum.
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12.13 Appearance of the oesophagus (arrowed) following transection of all fibrous bands.
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12.14 Port sites for thoracic duct ligation. Ports may be moved caudally in patients with a deep-chested conformation. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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12.15 The sympathetic trunk (long arrow) and an intercostal vessel (short arrow) are visible prior to dissection of the thoracic duct, which is seen as a grey linear structure crossing the intercostal vessel.
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12.16 Appearance of the heart through the pericardial window with longitudinal pericardial fenestration.
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12.17 Video-assisted thoracostomy tube placement.

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