Martínez-Téllez Elisabeth, Trujillo-Reyes Juan Carlos, Guarino Mauro, Rami-Porta Ramón, Belda-Sanchis Josep
Department of Thoracic Surgery, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
Network of Centres for Biomedical Research on Respiratory Diseases (CIBERES) Lung Cancer Group, Terrassa, Barcelona, Spain.
J Thorac Dis. 2018 Aug;10(Suppl 22):S2643-S2648. doi: 10.21037/jtd.2018.03.99.
Surgical procedures of pleural cavity are crucial to complete the diagnoses or planning treatment of pleural effusions with an unknown aetiology. Traditionally, the transthoracic approach has been the most used procedure to study the pleural cavity. The subxiphoid video-thoracoscopy is becoming an alternative to the transthoracic approach. Subxiphoid video-thoracoscopy is a minimally invasive technique that allows us to study both pleural cavities with a single subxiphoid incision. In the supine decubitus, through a small subxiphoid incision, a rigid video-mediastinoscope is introduced. Once all the tissues are dissected, mediastinal pleura can be identified and incised. A 30° thoracoscopy is then inserted into the pleural cavity through the video-mediastinoscope to obtain samples of pleural fluid and biopsies of the parietal pleura and lung nodules if present. Subxiphoid approach has some advantages compared with the traditional transthoracic approach. On the one hand, contrary to traditional thoracoscopy, in subxiphoid video-thoracoscopy it is not necessary to do a transthoracic approach even for the insertion of a chest tube. Avoidance of intercostal ports probably decreases the risk of post-operative pain and the patients can be discharged 24 hours after surgery with no increase in surgical risk. On the other hand, we can explore both pleural cavities at the same time through a single incision, in case of bilateral pleural effusion. If malignancy is confirmed by frozen-section or by macroscopic evidence of intrapleural tumour infiltration or implants, a pleurodesis to avoid recurrence can be performed prior to tube insertion and closure.
胸腔手术对于完成病因不明的胸腔积液的诊断或制定治疗方案至关重要。传统上，经胸入路一直是研究胸腔最常用的手术方法。剑突下电视胸腔镜检查正成为经胸入路的一种替代方法。剑突下电视胸腔镜检查是一种微创技术，通过单一的剑突下切口就能对双侧胸腔进行检查。在仰卧位时，通过一个小的剑突下切口插入硬式电视纵隔镜。在分离所有组织后，可识别并切开纵隔胸膜。然后通过电视纵隔镜将30°胸腔镜插入胸腔，以获取胸水样本，并在有壁层胸膜和肺结节时进行活检。与传统的经胸入路相比，剑突下入路有一些优点。一方面，与传统胸腔镜检查不同，在剑突下电视胸腔镜检查中，即使插入胸管也无需采用经胸入路。避免肋间切口可能会降低术后疼痛的风险，患者术后24小时即可出院，且手术风险不会增加。另一方面，如果是双侧胸腔积液，我们可以通过单一切口同时探查双侧胸腔。如果通过冰冻切片或胸膜内肿瘤浸润或种植的宏观证据证实为恶性肿瘤，则可在插入胸管和关闭切口之前进行胸膜固定术以避免复发。
