Medical Thoracoscopy

Rigid Thoracoscopy or Flexi-rigid Pleuroscopy?

Kim Hoong Yap; Martin J. Phillips; Y.C. Gary Lee


Curr Opin Pulm Med. 2014;20(4):358-365. 

In This Article

Abstract and Introduction


Purpose of review In managing pleural diseases, medical thoracoscopy is often performed as a diagnostic and/or therapeutic procedure, particularly in undiagnosed pleural effusions. Flexi-rigid pleuroscopes are now widely available as an alternative to conventional rigid thoracoscopes. There is an ongoing debate on which is the better instrument. This review analyses the current literature that compared rigid and flexi-rigid approaches, and outlines the medical advances that may influence the future role of thoracoscopy.

Recent findings Both rigid and flexi-rigid thoracoscopies are well tolerated. Although biopsies are smaller with flexi-rigid biopsy forceps, two small randomized trials reported similar diagnostic yield using either instrument. No studies have specifically examined patient comfort or the outcome of talc poudrage using the two devices. New techniques (e.g. insulated-tip knife and cryobiopsy) have been used as adjuncts with flexi-rigid pleuroscopy to overcome the difficulties in sampling thickened pleura.

Summary The rigid and flex-rigid instruments have different merits and limitations. Both approaches provide comparable diagnostic yields in the overall patient population undergoing diagnostic thoracoscopy, though their performances specifically in patients with fibrotic pleural thickening have not been examined. Operators using the flexi-rigid approach should have alternative strategies for sampling thickened pleura. Advances in cytopathology and imaging-guided biopsy will likely reduce the need of medical thoracoscopy in the future.


Thoracoscopy employs an optical system to examine the pleural cavity and perform diagnostic and therapeutic procedures.[1] It has traditionally been divided into surgical thoracoscopy, better known as video-assisted thoracic surgery (VATS), and medical thoracoscopy (pleuroscopy).

Historically, both VATS and medical thoracoscopy were performed using rigid instruments. VATS allows surgeons to replace open thoracotomy in most pulmonary (e.g. lobectomy) and pleural surgeries (e.g. pleural biopsy and pleurodesis). VATS is typically performed under general anesthesia and single-lung ventilation. Some centers, however, have performed VATS wedge resection under regional anesthesia.[2,3] Pleuroscopy or medical thoracoscopy is usually performed by pulmonologists under conscious sedation, most commonly in the workup of undiagnosed pleural effusions, through visual inspection and biopsy of parietal pleural lesions.

With the introduction of the flexi-rigid pleuroscope in the late 1990s, proceduralists performing thoracoscopy have the option of using either rigid or flexi-rigid instruments. Opinions have been polarized as to which is the better device, but comparative studies to address this question are limited. Many experienced thoracoscopists remain in favor of the rigid scope and its ability to provide sizeable biopsies, whereas advocates of flexi-rigid pleuroscopy embrace the flexibility of the instrument and its ease of use. It is a common dilemma for pulmonologists setting up a new pleural service to decide which scope to invest in.

This article aims to summarize the current literature and highlight the advantages and limitations of rigid vs. flexi-rigid approaches and emerging technologies that may alter the role of pleuroscopy in the foreseeable future.