Dry Medical Thoracoscopy with Artificial Pneumothorax Induction Using Veress Needle

Abstract

Background: In the absence of significant pleural effusion, conventional medical thoracoscopy (MT) is often not feasible due to the risk of lung injury. Dry MT mitigates these risks by inducing artificial pneumothorax through needle insufflation or blunt dissection. Although the Veress needle is commonly used by surgeons to create pneumoperitoneum before laparoscopic surgeries, its application in dry MT has not been widely reported in recent times.

Methods: We report on a series of 31 patients who underwent dry MT with artificial pneumothorax induction using Veress needle under thoracic ultrasonography (TUS) guidance. A procedure was considered technically successful if it met all the following criteria: successful pneumothorax induction, allowing smooth insertion of the semi-rigid thoracoscope; absence of immediate significant procedural-related complications; and no delayed complications such as persistent air leaks, defined as leakage lasting more than 5 days necessitating extended chest tube placement.

Results: Complete pneumothorax induction was achieved in 25 cases, resulting in an 80.6% technical success rate; however, biopsies were successfully performed in all cases. The most frequent histopathological diagnoses were malignancy (n=9, 29.0%), followed by inflammatory pleuritis (n=8, 25.8%) and tuberculosis (n=8, 25.8%). No procedural complications were reported.

Conclusion: These results indicate that TUS-guided dry MT utilizing a Veress needle is technically feasible and secure when performed by experienced MT practitioners in TUS.

Keywords: Pleural Effusion; Pleural Medicine; Pleuroscopy; Pneumothorax; Thoracoscopy.

Fig. 1.

A Veress needle (Karl Storz) with its components labelled. The sharp tip is used to penetrate through the chest wall layers till it breaches the parietal pleura into the pleural cavity. Upon entering the pleural cavity, due to loaded spring action, the blunt tip will automatically remerge beyond the sharp tip, thereby protecting underlying lung structures from injuries. The stopcock can be used to adjust the amount of air that will go through the needle. The air entry point is pointed with an orange arrow.

Fig. 2.

Thoracic ultrasonography (TUS) image for a patient that is suitable for dry medical thoracoscopy. There is no pleural effusion at the safety triangle but a pleural sliding sign was present.

Fig. 3.

Steps of performing dry medical thoracoscopy with a Veress needle. (A) The Veress needle is inserted perpendicularly to the chest wall under direct ultrasound guidance. (B) Performing the saline drop test to confirm that the tip of the Veress needle is within the pleural cavity. (C) Insufflating air into the pleural cavity to expedite pneumothorax formation. (D) Forceps dilatation of chest wall incision site. (E) Trochar placement to allow entry of medical thoracoscope. (F) Performing medical thoracoscopy using a semi-rigid thoracoscope after successful induction of pneumothorax.