THORACOSCOPIC EXAMINATION AND CAUTERIZATION OF ADHESIONS
(Intrapleural Pneumolysis) By P. V.BENJAMIN, m.b., b.s. (Madras), t.dj>. (Wales) Assistant Medical Superintendent, Union Mission Tuberculosis
Sanatorium, Arogyavaram,
near
Madanapalle,
South India Adhesions preventing sufficient collapse of the lungs are the most frequent causes of partial or complete failure in the treatment of pulmonary tuberculosis by artificial pneumothorax. It is estimated that at least 40 per cent of failures in artificial pneumothorax treatment Unfortunately can be attributed to this cause. adhesions are very often distributed over the more diseased of the lung which is in
part
greatest need of collapse. In the earlier years of artificial treatment adhesions
pneumothorax
attempts were made to by thoracotomy (by
sever
these
the
open
method). This was attended with many com, plications and the procedure is not now considered justifiable. In 1910 Jacobeus introduced the present method of intrapleural pneumolysis
and invented the instruments for the intrapleural division of adhesions by the closed method by galvano-cautery under the guidance of vision through a thoracoscope. The thoracoscope Is an instrument built on the principles of the cystoscope* In Jacobeus' thoracoscope the lenses are arranged in such a way that the adhesions are seen indirectly by reflection. Others have improved on this and Kremer's we have now several modifications. thoracoscope is a direct-vision one where the
CAUTERIZATION
April, 1037] adhesions
OF
ADHESIONS: BENJAMIN
directly without any dis or tion. In Jacobeus' instrument, as the lens is Placed on the side, a complete examination 01 the pleural cavity on all sides can be ma e easily, but, although the general view is not always so complete with Kremer's thoracoscope, this instrument gives a better orientation of e their direction and position, and is adhesions, a are seen
much easier
In
our
one
to work with.
first thoracoscopic work
Jacobeus' thoracoscope, general use
but
we
Kremer's.
we
used lor
prefer
In Jacobeus' method galvano-cautery is used tor the severance of adhesions. This is to be less efficient in controlling bleeding than the current. Hence recent modifications use the diathermy current for the c?agulation and for cutting. There is still some
diathermy
controversy
as to
cautery should
whether diathermy
or
galvano-
be used. We have used both methods in our work and we are of opinion that a outfit should have both available. There are certain adhesions, especially the thin string-like adhesions, where the galvanocautery is the better. On the other hand, some ?r?ad adhesions containing blood vessels require hrst
thoracoscope
coagulation by diathermy.
..For both
the galvano-cautery and the it is useful to have different types cautery electrodes. Kremer's outt operating is usually equipped with straight and curved electrodes. We have found flexible and jointed operating electrodes a very useful addition to e equipment for reaching adhesions difficult to each
diathermy
?
Salvano-cautery ^fatson's diathermy
by inflexible instruments.
Types of adhesions.?The types
of adhesions
the collapse of the lung vary ^eventing eal. Xn some
patients the whole
a
great
the major a lobe vii may be adherent to the chest adhesions being very extensive, and in nfk ers the I space between the wall and the ?Un8 may be so narrow thatchest no cauterization Possible. Some adhesions are broad and or
J? nembranous; some are cone-shaped, containing Projection of lung tissue; some are purely I r?us and band-
i
string-like; and some are the outer part consisting of tissue with or without blood vessels, and Par^ consisting mainly of lung
c?Ur~glass shaped, ro^s
tV>
or
tissuDaec^
Limitations
^oseopic ?f of
of x-ray.?A good
adhesions, p*cture. In tin6 ions we tr
z-ray film
or
examination may show some or ? the adhesions present. But it must be +?stood that though the z-ray gives an idea
yet it aoes not always give a actual thoracoscopic examinaare likely to see more adhesions than the a>ray, and the nature of the adu S^en may be quite different. Flat posterotin ?ri0r films may not show adhesions that go and anteriorly, and some adhesions lch look like strings turn out to be really .
lesions
posteriorly
213^
broad membranous adhesions. A thoracoscopic examination alone can reveal the nature and the number of adhesions.
Indications for
thoracoscopy
and cauterizatreated by artificial pneumothorax in which radiological examination after the first six or eight weeks shows the lung is collapsing imperfectly is a potential case for thoracoscopy and cauterization of adhesions.
tion.?Every
case
Some of the adhesions which look incauterizable at the beginning may stretch and become cauterizable in course of time. Hence it may be advantageous in some cases to wait even three or four months before cauterization is attempted. But, on the other hand, it is dangerin some cases to wait too long. The ous adhesions may give way under pressure tearing open the lung underneath, causing spontaneous pneumothorax and attendant complications. In others effusion may take place and the cauterization may be more difficult. The presence of adhesions per se is not always indication for operation. Some adhesions do not prevent a satisfactory collapse. Whether a collapse is satisfactory or not can be judged by the effect of the pneumothorax on the clinical symptoms such as temperature, cough, the quantity of sputum and the presence of bacilli and also by the blood findings. an
hand, in some cases, although the under pneumothorax treatment improves patient in spite of the presence of adhesions, cauterization may have to be done eventually, if the adhesion shows a tendency to pull out the lung too early. The adhesions must also be reasonably suitable for cauterization. To judge this requires considerable experience, as it is specially important to be able to recognize what is seen through the thoracoscope and to be able to say whether particular adhesions contained blood On the other
vessels
or
lung tissue.
Finally, there must be sufficient pneumothorax space for the manipulation of the instrument. Contra-indications.?There are few contraindications for the division of adhesions. If effusion is present, it has to be aspirated before cauterization. But a recent acute onset of effusion is a definite contra-indication and thoracoscopic examination should be postponed till the acute stage is over, as interference inside the pleura at this stage is likely to cause severe reactions. Technique.?For the technique the reader is referred to one of the various books on the surgery of the thorax as it would take too much space to give it in detail here. during operation.?Serious place during the cauterization of the adhesions. In our experience adhesions that go towards the anterior part, i.e.,
Complications
bleeding
may take
214
THE INDIAN MEDICAL GAZETTE
towards the sternum, are more likely to bleed than those going laterally or posteriorly. In our series we have had three cases of severe bleeding, but none of them were fatal. Two of these bleedings occurred when we used galvanocautery before we had the diathermy outfit. In one of these it was possible to stop the bleeding by coagulation with galvano-cautery at dull-red heat. In the other, this procedure did not materially lessen the bleeding which stopped by natural coagulation after some time; about 300 c.cm. of blood were aspirated from the pleural cavity 48 hours after the operation. The patient made an uneventful recovery and ' was discharged much improved', free from bacilli. The third case of severe bleeding occurred while using the diathermy outfit, but the bleeding was controlled immediately by touching the parietal end of the adhesion with the coagulating electrode. There have been 15 instances of mild oozing which was controlled easily by coagulation either by galvano-cautery In our experience diathermy or by diathermy. is more certain of stopping the bleeding than
galvano-cautery. Another complication that may occur during the operation is too deep coagulation, and if this extends into the lung tissue it may later cause necrosis and pleuro-pulmonary fistula. Due care in coagulation can obviate this, and in our series no such complication occurred. If cauterization is attempted close to the mediastinum, sudden death may be caused by touching the vagus nerve; or injury by heat or by electric current may be done to the medias-
tinal vessels. In one of our cases the mere touching of an adhesion near the mediastinum, even without switching on the current, caused severe shock and the attempt had to be given
up.
Cauterization
pleura
may
too
cause
close to the dome of the to the sub-clavian
injury
vessels. Another complication is that bleeding may take place from the site of the trocar puncture in the chest wall. Complications after the operation.?Secondary bleeding may in some cases take place either from the ends of cauterized adhesions which showed no tendency to bleed at the time of cauterization or from the puncture wounds in the chest wall where the instruments were introduced. We had a secondary bleeding in one of our cases. On the third day after the operation the patient was found to be very ansemic and slightly breathless?internal bleeding was suspected and a diagnostic puncture revealed the presence of blood in the pleural cavity and 600 c.cm. of bloody fluid were aspirated. The patient got better without any other complication and we are not sure whether the bleeding came from the adhesion or from the puncture wound. The
adhesion that a
simple
for any
[April, cauterized in this
was
and
thorough bleeding points after one
a
1937
case was
search was made the cauterization,
we do as a routine in every case, and there was no sign of bleeding whatever from the cut ends of the adhesions. The bleeding probably took place from one of the punctures in the chest wall.
which
The most common complication after subfascial operation is subcutaneous or emphysema. The air escapes from the pleural cavity along the track of the trocar and canula, and if the patient coughs after the operation
it may spread more and more under the skin during the first 24 hours. The emphysema may extend up to the face, sometimes causing pressure on the neck and difficulty in swallowing; it may extend down to the legs. This complication has never been fatal, but it causes slight discomfort for the first 24 or 36 hours after the operation. The administration of morphia after operation to reduce excessive cough may prevent it. Effusion may occur after thoracoscopy, but it is difficult to judge how far this is due to the operation as effusion is a very common complication in ordinary pneumothorax treatment. Of 40 cases later reviewed, three had an effusion the before the thoracoscopy; in remaining 37 effusion appeared in 19 within three months, the effusion in a number being only very small in amount. This gives a percentage of 51.2, almost the same as the general percentage for effusion in pneumothorax treated
patients. Usually
the after effusion appearing is serous, but it is possible for infection to be introduced by unsterile technique and by injury to the lung during operation. However in our series of cases there was no instance of infection.
thoracoscopy
Results in patients operated on in U. M. T. Sanatorium.?S'mce May 1932 thoracoscope
examinations and cauterization
were
attempted
in 52 patients. In a few the cauterization was done in more than one stage. In all, 64 thoracoscopic examinations were made. The number of adhesions seen in the 52 patients was 178, but not all of them were cauterizable. In four of the patients no cauterization could be done; in eight patients the period after operation is less than a month and they are therefore omitted; and so 40 patients are left for consideration in the following statistics:?
Among these 40, only in 10 could all the adhesions be cauterized. Collapse of the lung was increased in all these 10 after the ' operation; 1five of them were much improved' and two improved'. Tubercle bacilli were present in the sputum in all the 10 at the time of the operation, and disappeared after operation in six.
Plate VIII
?1
E Zh
IT1" F'cr 'a- 1. ?Mr. IVIr. S. S. P. P. Before Before cauterization. cauterization. adhesions. held held open by adhesions. open by
^'8. ig. 3.?Air. 3.?Mr
X.
S.
preventing
cavity Big Big cavity
cauterization?adhesion collapse of upper lobe. Before
Fig. 2.?Mr. S. P. Same patient as figure 1, after cauterization?cavity collapsed.
Fig. 4.?Same
as
figure 3, after cauterization?collapse of lung good.
Plate IX
Iff5'-'
?,:W
A. Before cauterization. cauterization. Fig. 5.?Mr. A.
Fig. 7.?Mr. K. Before cauterization. Several adhesions keeping cavities nncollapsed. uncollapsed.
Fig. 6.?Same Fig. 6.?Same
Fig. 8.?Same
as
as as
after cauterization. cauterization. figure figure 5,5, after
figure 7, after cauterization?good
collapse.
April, 1937]
PHRENIC EVULSION IN TUBERCULOSIS: UKIL&OTHEftS
In the remaining 30 patients, all adhesions that were seen could not be cauterized, but one or more adhesions were cauterized in every case. As a result of the operation, the collapse of the lung was increased in all 30. Twelve Patients were 1 much improved' and nine
improved',
making
cent
a
total of 21
70 per
or
positive results. Tubercle bacilli were Present in all the 30 patients in this group at the time of the operation, and they disappeared from the sputum in 14 or 46.7 per cent after the operation. Table I
Results of treatment
Number
of
Much i Stationary Worse improved Improved
Patients
All adhesions cauterized 10 or
more
f vesions
Prized not
cau-
(but all)
Positive
results 28 out of 40.
Table II
Disappearance of Number All
+ T
of patients
adhesions
cauterized
10
tubercle bacilli T ? aft.er cauterization
>
I
10
I One or more adhesions cauterized (but not all) |1
Total
!
B.bef?re
cauterization
30
d 30
40
40
I 14
|
20
Judged from the point of view improvement and from the point
of general of view oi lsappearance of tubercle bacilli from the sPutum, these results are encouraging and give an Jdea of the scope of thoracoscopy and cauterization in improving the results of pneumothorax treatment in pulmonaiy .
fr^ificial .
^~^rculosis. The
j11
results of the cauterization of adhesions are shown in figures IX.
four individual cases 8 in plates VIII and
1 t0
215