Disposable peel-away sheaths for pleural space access: a minimally invasive conduit for medical thoracoscopy and chest tube insertion

Introduction

Thoracoscopy is a centennial technique that allows the physician to thoroughly explore the pleural cavity through a small window. This procedure enables diagnostic, staging and therapeutic opportunities to a wide variety of thoracic pathologies, including both pleural and lung parenchymal diseases. Noteworthy, pleural illnesses have shown a significant and steady increase globally, impacting both individuals and healthcare systems. Conditions such as pleural effusion, pneumothorax, and pleurisy cause symptoms like pain, shortness of breath, and cough, and can lead to reduced quality of life. The rising incidence is attributed to factors like an aging population and increased life expectancy with chronic diseases (1). The impact is not only clinical but also economic. In the USA alone, pleural diseases accounted for 42,215 emergency room treat-and-discharge visits and 361,270 hospital admissions in 2016, amounting to a national healthcare cost of $10.1 billion (2). These numbers underscore the urgency of addressing this complex and heterogeneous group of conditions through advanced, coordinated care.

Modern trends towards minimally invasive techniques have led interventional pulmonology (IP) into a rapidly maturing sub-specialty. As ingenuity and technological advances develop, interventional pulmonologists have played a key role in providing less invasive diagnostic and therapeutic alternatives for a myriad of disease processes. Additionally, there is an increasing focus on ensuring universal access and affordability to these medical interventions, addressing health inequities on a global scale (3). In this article, we describe the successful, safe, and straightforward use of various peel-away sheaths (Cook Medical^®) as instrument conduits for accessing the pleural space during medical thoracoscopy, offering an alternative to blunt dissection for trocar insertion. Due to the widespread familiarity with the Seldinger technique, this minimally invasive approach is not only more universally applicable but also easier to implement, with potential advantages including a small skin incision footprint with minimal tissue disruption and an excellent perioperative pain profile. Furthermore, the availability of different sheath sizes allows for a tailored and individualized approach to specific patients’ needs. These sheaths enabled the unrestricted use of various scopes and instruments, contributing to the success of medical thoracoscopies.

Pleural access techniques have been described since ancient times, with cleverness and resourcefulness playing a pivotal role in advancing the medical field. Two thousand years ago, Hippocrates introduced the use of hollow reeds to access the pleural space and treat empyemas (4). The first documented thoracoscopy was described in 1866, when Francis Richard Cruise examined the pleural space of an 11-year-old girl with empyema through a pleurocutaneous fistula, using a cystoscope. In 1882, Italian physician Carlo Forlanini made a groundbreaking contribution by proposing the creation of an artificial pneumothorax using a needle and insufflating air into the pleural space as a pioneering treatment for pulmonary tuberculosis. However, the need for more advanced interventions became apparent when adhesions hindered lung collapse, limiting the procedure’s effectiveness. To address this challenge, Hans Christian Jacobaeus introduced thoracoscopy as a solution, and in 1910, he described his two-cannula technique to induce complete lung collapse by visualizing and removing adhesions between the parietal and visceral pleurae. Following this innovation, thoracoscopy gained widespread use for several decades, primarily for lysis of adhesions in the treatment of tuberculosis (5-9).

Since that time over a century ago, the method of collapsing the lung to further explore the pleural cavity continues to be adapted and can be performed using various needles or catheters with different variations of the same principle initially described by Forlanini. Once the space is accessed, air is introduced into the pleural space by opening the access instrument to atmospheric pressure until equilibrium is reached or by actively injecting gas. This process can be guided and monitored in real time with sonography and fluoroscopy. As air enters the pleural space, the lung collapses, creating a space for trocar insertion (5). Care must be taken in a complex pleural space when dense adhesions are present, as it may prevent the lung from deflating, eliminating the creation of a safe space for instrument entry. A widely used and well-established technique for accessing the pleural space during thoracoscopy involves blunt chest wall dissection with a Kelly clamp until the pleural cavity is entered. When performed through an appropriately sized incision, this method provides the operator with direct tactile feedback, helping to confirm a safe entry point and ensuring that no lung tissue is adherent to the chest wall. However, this technique has some limitations. It may be less comfortable or familiar for practitioners outside of surgical specialties, and it typically requires a larger skin incision, which can result in greater tissue disruption and potentially increased perioperative pain. Once the pleural space is entered, the influx of air facilitates lung collapse, allowing for the safe introduction of the trocar.

With the near-universal availability of ultrasound, operators today can easily assess the complexity of the pleural space, allowing them to choose the entry technique and the optimal position for instrument insertion (5,6,10). In cases of large pneumothorax or pleural effusion, a trocar can be introduced directly, bypassing the need for further lung collapse. A wide variety of trocars are now available for accessing the pleural space; they are offered in different sizes and materials, including disposable plastic and reusable stainless steel. While the design of these trocars has remained largely unchanged over time, there has been a growing preference for disposable, plastic, ribbed trocars (5,6). Recently, there has been increased interest in alternative access techniques and trocar designs. Joy and colleagues successfully described the use of an optical trocar to access a “dry pleural space” in a patient (11). Two other reports explored the use of PleurX™ introducer sheaths as a trocar to access the pleural cavity and obtain biopsies, with only flexible instruments used through this single-size sheath (12-14). We present this article in accordance with the SUPER reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-870/rc).

Preoperative preparations and requirements

In this manuscript, we describe the use of peel-away sheaths to access the pleural space in 45 consecutive patients as an alternative to the classic blunt dissection technique, as shown in Figure 1. The procedures were conducted at Los Angeles General Medical Center, a tertiary care institution and the largest county hospital in the city, between April 2024 and February 2025 by first-year pulmonary-critical care fellows, under the direct supervision of an interventional pulmonologist attending. Clear and simple inclusion criteria were established: patients aged 18 years or older were eligible for inclusion, while pregnant patients or those requiring thoracoscopy in a “dry” space were excluded from the study. Furthermore, areas of skin infection, tumor infiltration, or open wounds were avoided. All 45 patients requiring thoracoscopy at our center during the specified time frame were consecutively included in this retrospective study. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the University of Southern California Institutional Review Board (IRB) (No. #HS-25-00112). Publication of this study, accompanying images, and video was waived from patient/participant consent according to the ethics committee due to the retrospective nature of this study.

Figure 1 Pleural space access techniques. Traditional blunt dissection on the right hemithorax and proposed peel-away sheath insertion via Seldinger technique on the left hemithorax. Illustration courtesy of Daniel Garcia Cosademama.

The procedures were conducted in three distinct hospital areas: the endoscopy suite, intensive care unit (ICU), or step-down unit (SDU), with a mix of inpatient and outpatient populations. The type of procedural sedation and anesthesia was determined based on factors such as case complexity, anesthesiologist availability, and individual anesthesiologist preference. This ranged from local anesthesia or moderate sedation without the presence of an anesthesiologist, to monitored anesthesia care (MAC) or general anesthesia (GA), which could include total intravenous anesthesia (TIVA) or inhaled anesthesia with a single or double lumen endotracheal tube (ETT).

Prophylactic antibiotics were administered during the preoperative period unless the patient was already receiving appropriate antibiotic coverage. The procedure was performed with the patient either in the lateral decubitus or supine position. Ultrasound guidance, anatomical landmarks, and radiographic images were used to identify the site for peel-away sheath insertion, which was then marked. The marked area was subsequently sterilized using chlorhexidine or iodine-based preparation.

Step-by-step description

Figure 2 and Video 1 provide a summary of the key steps involved in accessing the pleural space using peel-away sheaths for medical thoracoscopy and chest tube insertion.

Figure 2 Step-by-step overview of pleural space access using a minimally invasive peel-away sheath technique for medical thoracoscopy and chest tube insertion. (A) The white arrow indicates insertion of an 18 G needle into the pleural cavity, the initial step for peel-away sheath placement. The dotted white line outlines the visceral pleura, marking the pneumothorax border. (B) The white arrow shows the guidewire introduced through the 18 G needle. (C) The white arrow highlights the insertion of the peel-away introducer set into the pleural space. (D) The white arrow shows the peel-away sheath after dilator removal; the black arrow indicates a 4 mm rigid telescope inserted through the sheath. (E) The white arrow points to a 14Fr chest tube inserted through the peel-away sheath (now removed), with complete evacuation of the pneumothorax.

Using strict aseptic and antiseptic techniques, 5–10 mL of 2% lidocaine was locally injected with either a 25 G or 21 G needle. Next, an 18 G needle from the peel-away introducer set was inserted into the pleural space. Once accessed, a flexible guidewire was passed through the needle and into the pleural space. A skin incision, sized according to the diameter of the sheath to be placed, was then made with a scalpel. The peel-away introducer sheath and dilator assembly were inserted over the wire into the pleural space, followed by the removal of the dilator. In some cases, when a large sheath was used, initial dilation was performed with a 14Fr dilator before inserting the peel-away introducer sheath and dilator assembly.

Once the dilator was removed from the assembly, a conduit was available for pleural interventions. These interventions included pleural biopsies, adhesiolysis, empyema evacuation, pleurodesis, and the insertion of tunneled, conventional small-bore or surgical chest tubes, among others. The various sheath diameters allowed for the use of different instruments tailored to each case based on the patient’s needs. These instruments included flexible and rigid scopes, various dissecting and cautery instruments (both rigid and articulated), suction devices, and small-bore or surgical chest tubes. Figure 3 shows endoscopic and external views of peel-away sheath insertion and the use of various instruments introduced through the sheath. Most of the time, whenever pleural biopsies were needed, we used a rigid optical forceps that could accommodate telescopes of 2.9 and 4.0 mm. Figure 4 shows how low-profile and versatile this rigid configuration is, allowing us to perform complex procedures with minimal footprint. Depending on the case complexity, a second port was occasionally required to achieve the procedural goals. Figure 5 presents both aerial and endoscopic views of a two-port thoracoscopy, highlighting its minimally invasive nature and expanded procedural capabilities. After the pleural cavity was instrumented, a chest tube was inserted through the sheath, similar to a “finger in glove” system, ensuring a tight fit and minimizing any excess or redundant space between the hole created and the chest tube. Once inserted, the sheath was peeled away, and a drainage system was then connected to suction, as shown in Figure 6. The chest tube is then secured with a single interrupted skin suture, the insertion site is cleansed with an alcohol-based solution, and the area is covered with sterile gauze and an adhesive dressing to ensure tube stability.

Figure 3 Endoscopic and external views of peel-away sheath insertion and the use of various instruments introduced through the sheath. (A) The sequence of steps for inserting the peel-away sheath: from left to right, a needle is first inserted into the patient’s pleural cavity, followed by threading a guidewire through the needle. Next, the dilator and peel-away trocar are introduced into the pleural cavity. Finally, after removing the guidewire and dilator, the peel-away sheath serves as the trocar cannula. (B) Different instruments inserted through a 16Fr peel-away sheath during medical thoracoscopy: from left to right, rhinoscope (3.2 mm outer diameter, Vathin^®), flexible bronchoscope (4.9 mm outer diameter, Vathin^®), disposable rigid articulated Maryland dissector (5 mm outer diameter, Artisential, LivsMed^®), and rigid optical forceps (Karl Storz^®).

Figure 4 Low-profile and minimally invasive procedural capabilities using a rigid scope and peel-away sheath. (A) A 4 mm rigid telescope is inserted through an optical forceps, which is then inserted through a 16Fr (5.3 mm) peel-away sheath. (B) Endoscopic views demonstrating the use of rigid optical forceps in a patient with a complex pleural space, ultimately diagnosed with mesothelioma. B1, endoscopic view of dense pleural adhesions; optical forceps were used effectively to lyse the adhesions. B2, prominent nodularity of the parietal pleura observed prior to biopsy. B3, a pleural nodule following successful large-forceps biopsy using the rigid optical forceps.

Figure 5 Aerial and endoscopic views of a two-port thoracoscopy, highlighting its minimally invasive nature and expanded procedural capabilities. (A) Two low-profile 16Fr (5.3 mm) peel-away sheaths were in place during a complex thoracoscopic case. (B) Endoscopic view of a complex pleural space in the context of empyema. One port accommodates the rigid thoracoscope, while the second allows insertion of a 5 mm rigid articulated instrument to facilitate adhesiolysis and evacuation of purulent material.

Figure 6 Insertion and securing of a small-bore chest tube after all diagnostic and therapeutic pleural interventions were completed. (A) A small-bore 14Fr chest tube is guided into the pleural space through the peel-away sheath and, once it’s in the desired position, the sheath is peeled away. (B) A small-bore chest 14Fr chest tube is being secured to the skin at the end of the procedure.

Postoperative considerations and tasks

Once the procedure is finished, the patient wakes up from anesthesia (if used) and the chest tube is secured, the patient is transferred to the post-anesthesia care unit (PACU) for further monitoring. After a chest X-ray confirmed the complete evacuation of the pneumothorax, the chest tube is removed (if no further fluid drainage is needed). No sutures were required to close the skin when using 14Fr chest tubes. At this point, patients were discharged home or sent back to their inpatient units, an average of 1–2 hours after procedure completion.

A survey assessing access site pain was conducted at two intervals: two hours after the procedure and 48 hours later via telephone encounter. Pain scores were recorded on a linear scale from 1 to 10, with 1 representing minimal pain and 10 indicating the worst pain imaginable.

All the patients had a scheduled follow-up appointment within 2 weeks of the procedure, where pathology results, wound healing, and overall clinical state were evaluated.

Tips and pearls

The proposed minimally invasive technique for accessing the pleural space and establishing a low-profile conduit for thoracoscopy offers a safe, effective, and straightforward alternative to traditional chest wall blunt dissection. Our approach employs the widely recognized Seldinger technique to introduce a sheath for thoracoscopic instrumentation. This method requires only a small skin incision, results in minimal tissue disruption, and is associated with an excellent perioperative pain profile. Furthermore, the availability of multiple sheath sizes allows for a tailored, patient-specific approach, enhancing both safety and procedural versatility.

This technique provides reliable and efficient access to the pleural space, enabling the use of both flexible and rigid instruments with excellent maneuverability. As a result, complex thoracoscopic procedures can be performed virtually anywhere along the chest wall. The simplicity of the technique, combined with the affordability and accessibility of standard disposable tools, holds great promise for expanding access to medical thoracoscopy across a wide range of clinical environments.

In our experience, the technique demonstrated a strong safety profile, with no major complications or procedure-related mortality. All procedures were well tolerated, and none required conversion to traditional blunt dissection for trocar insertion. Importantly, there were no instances of bleeding, incidental lung injury, or insertion site infection observed.

Discussion

In this manuscript, we describe the successful, safe, and straightforward use of peel-away sheaths as an instrument conduit into the pleural space in 45 consecutive patients, treated at our institution between April 2024 and February 2025.

As initially described, these sheaths were introduced effortlessly using the Seldinger technique by junior Pulmonary-Critical Care fellows, likely due to their familiarity with this approach, which is commonly used in routine procedures such as central line, arterial line, and chest tube insertion. Additionally, there were no limitations regarding case complexity selection or anatomical insertion site; the sheaths were successfully placed in the lateral (84.4%), posterior, and even anterior chest wall. The authors acknowledge that the traditionally described “triangle of safety” for accessing the pleural cavity serves as a general guideline to minimize complications. However, in many cases, complex or small effusions or pneumothoraces may fall outside these safety landmarks yet still require diagnostic or therapeutic procedures. With near-universal access to ultrasound and fluoroscopy, clinicians can make informed decisions about the space to be accessed, particularly focusing on vasculature. Precision access using needle puncture and the Seldinger technique, which eliminates the need for blunt dissection in small or complex spaces, provides a valuable opportunity to safely and effectively access the pleural space, especially in non-conventional anatomical areas.

The mean patient age was 59 years, with 64.4% being male. Most procedures (72.5%) were performed during inpatient encounters, primarily on patients with an American Society of Anesthesiologists (ASA) physical status classification of III (55%) or IV (25%). The majority of cases took place in the bronchoscopy suite (84.4%), although some were conducted in the ICU or SDU.

We utilized sheath sizes ranging from 10Fr to 20Fr (shown in Figure 7), with a 16Fr (5.33 mm) peel-away sheath being the preferred conduit in most cases (73.4%). This size allowed for the introduction of a wide range of instruments without compromising tool selection or maneuverability. Although the peel-away sheaths are sufficiently rigid for pleuroscopy, they are less rigid than metal trocars, which may lead to occasional kinking. In our 45-case series, we observed only two instances of minor, non-obstructive distal tip kinks that did not require sheath exchange. While rare, this finding is worth noting. Instruments that could be used through this minimally invasive sheath included various sizes of rigid telescopes, disposable flexible bronchoscopes, suction cannulas, cautery, and both rigid and articulated devices, enabling us to perform virtually any procedure within our field. If clinical circumstances required the insertion of a second port, this was easily accomplished using the same technique, with the option to select the appropriate sheath size for the specific task.

Figure 7 Different peel-away sheath sizes are used in different clinical scenarios. (A) Minimally invasive diagnostic approach in the ICU. A 10Fr (3.3 mm) peel-away sheath was inserted in a patient with a high pre-test probability of malignant pleural effusion. Endoscopic imaging shows pleural nodularity consistent with malignancy. This image was captured via an ultra-slim disposable flexible bronchoscope inserted through the 10Fr peel-away sheath. After these findings, this patient received a PleurX catheter for palliation, instead of a diagnostic thoracentesis as initially requested by the primary team. (B) Endoscopic view of a 20Fr chest tube being inserted through a 20Fr peel-away sheath like a “finger-in-glove”. After its insertion, the trocar is peeled away, and the chest tube is sutured in position. ICU, intensive care unit.

It is important to note that the discrete, low-profile skin incision and tract dilation not only resulted in favorable postoperative pain scores but also provided excellent cosmetic outcomes; the average incision size was 7.2 mm. When 16Fr sheaths or smaller were used, no sutures were required except for the one securing the chest tube. However, when 20Fr sheaths were used, only a single interrupted stitch was needed to close the skin defect left by the chest tube after its removal. None of the patients included in the study required standing pain medications, and only three patients required as-needed breakthrough medications for pain at the insertion site in the first two hours after the procedure. Furthermore, because the pleural space was accessed using the Seldinger technique rather than a Kelly blunt dissection, the space between the trocar and surrounding tissue was minimized. This hypothetically reduces the risk of air escaping around the trocar or chest tube, potentially lowering the incidence of subcutaneous emphysema or fluid extravasation. Additionally, as is standard practice after a medical thoracoscopy, a chest tube was inserted to drain the air introduced during the procedure. While traditional approaches typically involve the insertion of larger-bore chest tubes, ranging from 20 to 28Fr, our experience with the peel-away sheath technique has demonstrated that air can be successfully drained using much smaller-bore chest tubes. Of the tubes placed, 14Fr chest tubes were the most commonly placed (68.88%) tubes, followed by tunneled indwelling pleural catheters (24.4%). Both were sufficient to drain the introduced air and further fluid drainage as needed. Lastly, no major complications such as lung parenchymal laceration, bleeding related to sheath insertion, or site infections were observed. A comprehensive table summarizing patient characteristics, procedural details, and outcomes is included in the supplementary material (Table S1).

The advantages and disadvantages of using this technique are presented in Box S1.

This report has inherent limitations given its relatively small sample size and retrospective analysis. Larger prospective studies are needed to further examine outcomes and economic impact compared to conventional modalities.

Conclusions

As medical thoracoscopy appears to become more widespread and relevant in our practice, it is vital that we continue to prioritize the advancement and innovation of this discipline. This report describes the feasibility, practicality, and safety of using peel-away sheaths to access the pleural space and use them as instrument conduits. The ability to select different access sizes tailored to patient needs, along with its versatile use in various hospital settings, from endoscopy suites to SDUs, and its easy insertion profile, make it an appealing tool in our practice. Additionally, its ready availability could enable more widespread access to medical thoracoscopy.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-870/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-870/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-2025-870/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. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the University of Southern California Institutional Review Board (IRB) (No. #HS-25-00112). Publication of this study, accompanying images, and video was waived from patient/participant consent according to the ethics committee due to the retrospective nature of this study.

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/.

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