Versatility of disposable scopes and their use in flexible, semi-rigid and rigid thoracoscopy

Introduction

Thoracoscopy is a minimally invasive technique that allows the physician to thoroughly explore the pleural cavity through a small window. It was initially described over a century ago and became a mainstay for the treatment of tuberculosis. Despite its waxing and waning popularity, it has successfully stood the test of time—enabling diagnosis, staging and therapeutic opportunities to a wide variety of pathologies. Today, the technique has evolved and is used in a variety of procedures, ranging from pleural biopsies to complex pulmonary resections.

Initially described by an internist, it took two distinct paths to bring forth the separate entities now recognized as medical and surgical thoracoscopy. The former, commonly referred to as pleuroscopy, is performed by respirologists, focusing on a myriad of pleural diseases but generally focusing on the parietal pleura and avoiding interventions on the lung parenchyma. Surgical thoracoscopy, on the other hand, is performed by surgeons, and was established following the description of video-assisted thoracoscopic surgery (VATS) in the early 1990s. It has now become a widely performed procedure that has almost completely replaced the necessity of performing open thoracotomies. While the field of thoracic surgery has witnessed a rapid evolution from that point, including development in robotic-assisted thoracic surgery (RATS), medical thoracoscopy remains on the cusp of continued improvement and growth.

Several factors have influenced the potential for rapid evolution of medical thoracoscopy in the past few decades, including the consolidation of interventional pulmonology (IP) as a pulmonary subspecialty, the high prevalence of pulmonary diseases such as lung cancer and pulmonary infections which remain a leading cause of mortality worldwide, and finally, the increasing awareness of the benefits of minimally invasive procedures, including shorter hospital stay, faster recovery and reduced pain. Combined with outstanding diagnostic accuracy and therapeutic outcomes, these factors have influenced current global market forecasts, with models predicting an exponential growth in billions of United States Dollars (USD) in the thoracoscopy market.

This report will discuss procedural and instrument limitations, technical challenges, and areas of potential growth, such as the use of single use disposables. Furthermore, as techniques evolve, it is imperative that universal access and affordability of these procedures remain a priority to address global health inequity.

Innovation

Modern trends toward minimally invasive techniques have led to the development of IP into a rapidly maturing medical sub-specialty. As technological advances occur, interventional pulmonologists have played a role in offering minimally invasive diagnostic and therapeutic alternatives to several disease processes previously managed by other specialties. There has been particularly rapid growth and development within the realm of peripheral navigational bronchoscopy since Stephen Solomon developed the first electromagnetic navigation bronchoscopy (ENB) system in 1998 (1,2) which has now largely been replaced by robotic assisted bronchoscopy (RAB) since 2018 (3). With three Food and Drug Administration (FDA) approved RAB platforms on the market, there are several novel ablative alternatives and therapeutic interventions being actively developed.

The recent evolution of peripheral bronchoscopy is a stark contrast to medical thoracoscopy. While our practice of pleuroscopy has remained largely unchanged since its inception over a century ago, its surgical counterpart has been propelled by technological advancements, including the consolidation of VATS/RATS, and is moving toward the future with innovations such as miniaturized robotic platforms, soft robotics, artificial intelligence, and extended reality technologies. Herein we describe some of the technical modifications and areas of innovation that Los Angeles General Medical Center has implemented with success (4-6).

Scope diversity, versatility, and adaptability for thoracoscopy

Figure 1 summarizes “pros and cons” of various thoracoscopes, including traditional instruments, as well as modifications and adaptations explored by our group.

Figure 1 “Pros and cons” of various endoscopes, including traditional thoracoscopic instruments, as well as modifications and adaptations explored by our group.

From the very start, rigid thoracoscopes have been pivotal in developing what medical pleuroscopy is today (7). The Jacobaeus-Unverricht thoracoscope, manufactured by Wolf, was the most utilized in the early 1900’s (8). It has served the field well with its durable construct and excellent image quality. Building on its strengths, the rigid thoracoscope has continued to evolve with reduced dimensions, beveled tips and rotating prism mechanisms to improve visualization and versatility. Available diameters range from 1.8 mm up to 10 mm with incorporated working channels. The selection of thoracoscope size depends on underlying pathology and physician preference. Mini-thoracoscopes have the advantage of being associated with less pain during and after instrumentation requiring less local anesthetic and sedation and better cosmetic results. However, they may provide smaller biopsy samples and are more prone to damage (9).

Semi rigid thoracoscopes provide a flexible alternative to the classic rigid thoracoscope. This instrument is fashioned like a flexible bronchoscope and consists of a handle and a shaft with a 22-cm proximal rigid portion and 5-cm flexible distal end. The flexible tip is controlled by a lever on the handle, enabling flexion and retroflexion. As with any bronchoscope, it has a working channel to accommodate biopsy forceps, needles, and other accessories (7,10-12).

An optimized approach to medical thoracoscopy could involve integrating the strengths of both semi-rigid and rigid models. This combination would complement each technique, enhancing their respective advantages while addressing the limitations of the other—similar to how both rigid and flexible bronchoscopy are used to address a range of endobronchial indications.

Two groups in the literature have explored converting flexible instruments into semi-rigid ones for thoracoscopy. The first group, in a series of five cases, proposed passing a fiberoptic instrument through an Argyle intercostal chest drain to provide support for the scope. All procedures in this series successfully achieved a diagnosis using this technique (13). The second group, aiming to assess the feasibility of thoracoscopy performed by respiratory physicians in 30 patients, described converting a flexible bronchoscope into a semi-rigid instrument by encasing it in a snug-fitting siliconized polyvinyl tube, which was then introduced through a standard trocar. They learned that the flexibility of the bronchoscope, which typically made thoracic cavity examination more challenging compared to rigid instruments, was effectively mitigated by this approach. Regarding the diagnostic adequacy of the biopsy specimens obtained, the initial assessment suggested no significant differences between the two instruments. However, specimens obtained with the rigid thoracoscope were generally preferred, although in some instances, the bronchoscopic specimens proved more informative. The authors concluded that while the rigid thoracoscope is the more satisfactory instrument, a flexible bronchoscope, with minor adaptations, can serve as an acceptable alternative when a rigid thoracoscope is unavailable (14).

We propose a hybrid thoracoscopy utilizing readily available instruments to optimize tissue acquisition, maximize maneuverability, and prioritize patient tolerance of the procedure. We also hope that in resource limited institutions, our approach provides a viable alternative in which no capital investment is necessary. Ultimately, the end goal is to explore alternative methods to provide increased access to affordable medical thoracoscopy.

Below we present a series of simple, effective alternatives that combines both flexible and rigid approaches, both in and out of standard procedure suites and operating theaters.

Flexible bronchoscope through rigid telescope working channel

A combined rigid and flexible approach can resolve certain procedural limitations, facilitating a more comprehensive evaluation of the pleural cavity. Figure 2 depicts a patient where rigid thoracoscopy was used, but cavity assessment was limited due to the rigid telescope range of motion. This limitation was overcome by inserting a disposable flexible bronchoscope through the rigid instrument working channel, allowing for a more thorough evaluation of the pleural cavity, specifically the apex and paravertebral areas.

Figure 2 Flexible scope through rigid scope working channel. (A) A 10-mm rigid thoracoscope with a 6-mm working channel through which a disposable flexible bronchoscope is inserted. (B) The endoscopic image capture of the rigid telescope where the flexible bronchoscope can be seen. (C) The endoscopic image capture of the flexible bronchoscope further evaluating the pleural cavity, where the rigid instrument is limited.

Flexible bronchoscope or rhinoscope

Sterilized reusable and disposable flexible bronchoscopes have been used to perform pleuroscopies in the United States (13-16). We have used this approach when limited by equipment availability or when the procedure is unable to be performed in the procedure suite (i.e., the patient is in the intensive care unit). Given the limitations of flexible tools, we typically reserve this technique when there is high pretest probability of diffuse pleural disease, as biopsies at any site along the pleural lining can provide diagnosis and staging. The utilization of single-use disposable scopes serves as an alternative to a pleuroscopy set in institutions where upfront capital equipment acquisition is a barrier to patient care. Instead of being forced to invest in a video tower, pleuroscopy trays, and maintenance costs, an institution can use these already readily available disposable instruments. This may allow clinicians to continue providing care not just in an endoscopy suite or operating room, but in a variety of settings outside of procedure suites and operating theaters, as seen in Figure 3. Just as thoracenteses and tunneled pleural catheter placements are routinely being performed in the outpatient setting, we envision a future in which pleuroscopy may one day be considered just as accessible in the same setting. More importantly, in underserved regions in the world, this approach can have a large impact, as it may allow a center to forgo the large capital investments typically involved with medical thoracoscopy and utilize disposable instruments instead.

Figure 3 Use of flexible scope during medical thoracoscopy. (A) Disposable flexible bronchoscope used during a moderate sedation pleuroscopy in the intensive care unit. (B) Endoscopic view of the disposable flexible bronchoscope during the procedure. This image is published with the participants’ consent.

Flexible bronchoscope or rhinoscope + vascular sheath (flexible scope → semi-rigid scope)

To further improve limitations in technique, a flexible bronchoscope or rhinoscope can be easily converted into a semi-rigid instrument. In Los Angeles General Medical Center’s experience, various inexpensive vascular sheaths that are readily available in the market can be used as rigid overtubes. This allows for the transformation of the instrument into a semi-rigid structure if the distal end of the flexible instrument remains partially distal to the sheath, or into a fully rigid instrument if the sheath and the bronchoscope end at the same level. This comes with the same limitations as a flexible or semi-rigid instrument. Biopsies rely on instruments that can be passed through the scopes working channel, but it dramatically improves maneuverability compared to flexible scope, due to the sturdiness provided by the overtube sheath. As the market has already provided a myriad of flexible scope sizes, this allows the provider several choices in selecting the appropriate tool for each case. Flexible scope to semi-rigid configuration is seen in Figures 4,5.

Figure 4 Flexible scope to semi-rigid configuration. (A) Various disposable flexible endoscopes converted into semi-rigid instruments with cardiovascular sheaths. (B) Different instrument sizes configurations, ranging from scopes introduced through a 7, 10 and 16 Fr sheaths.

Figure 5 Modified semi-rigid thoracoscopy. (A,B) A disposable flexible rhinoscope inserted in a cardiovascular sheath to convert it into a semi-rigid scope. (C) The endoscopic image of this thin rhinoscope. Illumination and image quality is compromised with the smaller the scope used. This image is published with the participants’ consent.

Flexible bronchoscope or rhinoscope + optical forceps (flexible scope → rigid scope)

A flexible instrument can also be transformed into a rigid instrument by inserting a flexible scope into rigid optical forceps. With reusable optical forceps, a flexible scope can be inserted (instead of a rigid telescope) and convert the tool into a fully rigid instrument. This approach allows a flexible scope to perform rigid instrumentation, including adhesiolysis, dissection, and biopsies. Flexible scope to rigid configuration is seen in Figure 6.

Figure 6 Flexible scope to rigid configuration. (A,B) Two different brands of disposable flexible rhinoscopes inserted through the telescope channel of an optical forceps, effectively converting a flexible scope into a rigid instrument. (C) A parietal pleural biopsy. (D) Adhesionolysis on an empyema in the intensive care unit. (E) Adhesionolysis of a loculated malignant pleural effusion in the intensive care unit.

Conclusions

The increasing prevalence of lung diseases globally has renewed interest in thoracoscopy, reflecting a promising future for this technique. Market forecasts suggest exponential growth over the next decade, presenting a unique opportunity to establish thoracoscopy as a universally accessible and affordable procedure.

As we look ahead, we anticipate the rapid evolution of high-quality thoracoscopic instruments that harmoniously integrate the best features of traditional scopes, while prioritizing a more minimally invasive approach. This advancement could facilitate the use of thoracoscopy in various settings, including outside procedure suites and operating theaters at the bedside and office settings, ultimately enhancing patient care and outcomes.

By focusing on innovation and accessibility, we can ensure that this centennial technique remains relevant and a cornerstone of modern pulmonary diagnostics and interventions. The convergence of technology and healthcare provides an ideal landscape for thoracoscopy to thrive, expanding its reach and efficacy in diseases of the lung.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-226/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-226/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This manuscript did not require approval from an Institutional Ethics Board, as no patient data was collected or utilized.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Mehta AC, Hood KL, Schwarz Y, et al. The Evolutional History of Electromagnetic Navigation Bronchoscopy: State of the Art. Chest 2018;154:935-47. [Crossref] [PubMed]
2. Schwarz Y, Mehta AC, Ernst A, et al. Electromagnetic navigation during flexible bronchoscopy. Respiration 2003;70:516-22. [Crossref] [PubMed]
3. Rojas-Solano JR, Ugalde-Gamboa L, Machuzak M. Robotic Bronchoscopy for Diagnosis of Suspected Lung Cancer: A Feasibility Study. J Bronchology Interv Pulmonol 2018;25:168-75. [Crossref] [PubMed]
4. Lazar JF, Hwalek AE. A Review of Robotic Thoracic Surgery Adoption and Future Innovations. Thorac Surg Clin 2023;33:1-10. [Crossref] [PubMed]
5. Sadeghi AH, Mank Q, Tuzcu AS, et al. Artificial intelligence-assisted augmented reality robotic lung surgery: Navigating the future of thoracic surgery. JTCVS Tech 2024;26:121-5. [Crossref] [PubMed]
6. Jiang Y, Su Z, Liang H, et al. Video-assisted thoracoscopy for lung cancer: who is the future of thoracic surgery? J Thorac Dis 2020;12:4427-33. [Crossref] [PubMed]
7. Lee P, Colt HG. Pleuroscopy in 2013. Clin Chest Med 2013;34:81-91. [Crossref] [PubMed]
8. Jacobaeus HC. Uber die Moglichkeit, die Zystoskopie bei Untersuchung seroser Hohlungen anzuwenden. Munch Med Wschr 1910;40:2090-2.
9. Tassi G, Marchetti G. Minithoracoscopy: a less invasive approach to thoracoscopy. Chest 2003;124:1975-7. [Crossref] [PubMed]
10. Lee P, Mathur PN, Colt HG. Advances in thoracoscopy: 100 years since Jacobaeus. Respiration 2010;79:177-86. [Crossref] [PubMed]
11. Shojaee S, Lee HJ. Thoracoscopy: medical versus surgical-in the management of pleural diseases. J Thorac Dis 2015;7:S339-51. [PubMed]
12. Agarwal R, Aggarwal AN, Gupta D. Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions: a meta-analysis. Chest 2013;144:1857-67. [Crossref] [PubMed]
13. Senno A, Moallem S, Quijano ER, et al. Thoracoscopy with the fiberoptic bronchoscope. A simple method in diagnosing pleuropulmonary diseases. J Thorac Cardiovasc Surg 1974;67:606-11. [Crossref] [PubMed]
14. Davidson AC, George RJ, Sheldon CD, et al. Thoracoscopy: assessment of a physician service and comparison of a flexible bronchoscope used as a thoracoscope with a rigid thoracoscope. Thorax 1988;43:327-32. [Crossref] [PubMed]
15. Harris K, Alraiyes AH, Dhillon SS. Initial experience of medical pleuroscopy via the peel-away introducer of the indwelling pleural catheter using a thin bronchoscope. J Thorac Dis 2017;9:4108-13. [Crossref] [PubMed]
16. Hamilton BCS, Gesthalter YB. Keep it Clean: Novel Use of Sterile Disposable Flexible Bronchoscopes for Pleuroscopy. J Bronchology Interv Pulmonol 2022;29:e2-4. [Crossref] [PubMed]