Evolution of medical thoracoscopy - 100 years on

More than a century after Jacobaeus, medical thoracoscopy is being reshaped by demands for precise pleural diagnosis, adequate tissue for molecular characterisation, combined local treatment and efficient care. This review uses its historical evolution to examine current indications, instruments, biopsy strategies, anaesthetic design and service models, with emphasis on recent evidence.

Rigid and semirigid thoracoscopy achieve similarly high diagnostic yield but differ in access, force transmission, tissue size, pain and sedative requirements. Recent studies favour needs-led sampling: standard forceps for most visible lesions, with cryobiopsy or advanced tools when depth, invasion, fibrosis or molecular profiling is limiting. Trials support selective rather than routine use of pleurodesis, indwelling catheters, regional blocks, high-flow oxygen or first-line thoracoscopy for pleural infection. Image enhancement, artificial intelligence, hybrid instruments and single-use platforms remain promising but incompletely validated.

Medical thoracoscopy should remain a targeted pleural procedure that preserves spontaneous ventilation while integrating diagnosis, adequate tissue acquisition, selected therapy and pathway efficiency. Technology and anaesthetic intensity should be matched to clinical need and adopted only when they improve measurable patient or system outcomes.