Surgical methods of tuberculosis

Surgical methods of research in phthisiology - various invasive manipulations or "small" operations with the use of special surgical instruments, equipment and diagnostic equipment.

Despite the great clinical experience of domestic phthisiatricians and the variety of diagnostic methods, in some cases, there is a need to apply such research methods that require special conditions and skills of surgical personnel.

The purpose of surgical methods of investigation is to establish or clarify the diagnosis of tuberculosis, the degree of prevalence and activity of the process, the presence or absence of complications. In some cases, surgical research methods can be used to establish concomitant or competitive diseases.

Tasks of surgical methods of research:

• obtaining pathological material for cytological, bacteriological or morphological studies;
• direct examination and palpation (including instrumental) of the lung, pleural cavity, mediastinum, lymph nodes and other organs;
• the introduction of diagnostic substances or drugs in the cavity and fistula.

All surgical methods of diagnosis (taking into account the degree of invasiveness of the means and methods used) are divided into 3 main groups: needle methods, "small" diagnostic operations and endosurgical interventions.

[1], [2], [3], [4], [5], [6], [7], [8], [9],

Acicular methods of tuberculosis research

To needle methods of research carry a puncture of a pleural cavity and a transthoracic needle biopsy.

Bringing the needle to the organ or tissue under investigation requires a preliminary assessment of the topografical and anatomic relationships and the establishment of an exact localization of the puncture site with the help of the methods of radiation diagnosis: polypositional fluoroscopy, radiography, CT and ultrasound.

[10], [11], [12], [13], [14], [15], [16], [17]

Puncture of the pleural cavity

Puncture of the pleural cavity - the introduction of a needle through the soft tissues of the chest wall into the pleural cavity to receive and remove fluid or air.

The main indications: exudative or drained pleurisy, empyema of the pleura, intrapleural bleeding, pneumothorax, hydropneumothorax.

Every phthisiatrician must know how to perform a pleural puncture. Special preparation of the patient is not needed. Pleural puncture is performed in the sitting position of the patient (if the patient's condition allows). To expand the intercostal spaces, the shoulder is pulled up and forward. Manipulation is performed under local infiltration anesthesia of the skin and soft tissues of the chest wall. If there is a free fluid in the pleural cavity, the classical place for the puncture of the chest wall is the seventh or eighth intercostal space between the middle axillary and scapular lines. The puncture of the encapsulated liquid is carried out taking into account the data of X-ray study or ultrasound. In pneumothorax, puncture is performed in the antero-superior parts of the pleural cavity.

Pleural puncture is performed with standard needles of different length and thickness. Connected with a syringe by a transitional tap or silicone tube (to avoid air entering the pleural cavity). The needle is passed through the intercostal space along the upper edge of the underlying rib. During the puncture it is desirable to completely remove the entire contents of the pleural cavity in order to achieve tightness. For a gradual displacement of the mediastinal organs, a large amount of liquid should be removed slowly. In some cases (purulent pleurisy, ongoing intrapleural bleeding, lack of tightness of the lung tissue), pleural puncture is terminated by thoracocentesis with washing the cavity with antiseptic solutions and draining. From the fluid obtained during the puncture, samples for bacteriological examination, determining the relative density of the liquid, the cell composition, the amount of protein and glucose are taken into sterile tubes.

The most common complication of pleural puncture is a lung puncture with the development of pneumothorax or bleeding. Pneumothorax is eliminated by repeated pleural punctures, bleeding usually ceases on its own or after the administration of haemostatic agents. Preventive maintenance of complications: careful definition of a site of a puncture and a direction of a needle, strict observance of a technique of a puncture.

Angular biopsy

An angular biopsy is sometimes the only method to establish an accurate morphological diagnosis for lesions of the lung, pleura, peripheral and intrathoracic lymph nodes. To obtain a biopsy, special needles are used. Various approaches can be used: conventional puncture of superficial formations, transbronchial, transthoracic, endosurgical approaches.

An aspiration aspiration biopsy is a diagnostic manipulation, a puncture of the organ or tissue being examined, in order to obtain a cellular material for cytological examination by aspirating it into the lumen of the needle.

Indications for needle aspiration biopsy: superficially located or peripheral lymph nodes, intrathoracic and intrapulmonary formations. Directly adjacent to the chest wall.

The puncture of superficial formations is performed taking into account the examination and palpation data, usually without anesthesia. Use conventional needles for intramuscular injections with a cannula from a disposable syringe.

With deep (in vaginopleural or intrapulmonary) arrangement of pathological education, the study is conducted under local anesthesia, under fluoroscopy or CT. Use thin needles 10-16 cm in length. The puncture site is determined by the shortest distance to the tissue site being examined. In a light needle is injected during a shallow inspiration, after which the patient is asked to breathe superficially and not to cough. To prevent obturation of its lumen with skin epidermis or soft tissue of the thoracic wall, the needle is inserted with the mandrel. The position of the needle in the tissues is monitored by fluoroscopy or CT. This allows you to determine the most accurate and if necessary change the position. The mandrin is removed, the needle is connected to a syringe and aspiration of the contents is carried out. The contents of the needle are removed to a skimmed preparation glass and a smear is prepared for cytological examination, which is performed immediately during puncture (if necessary, aspiration of tissues can be repeated immediately).

The effectiveness of cytological verification of diagnosis with needle aspiration biopsy is highest in the diagnosis of tumor processes and reaches 97%. For non-tumor diseases, the technique is less effective, since a precise diagnosis requires a histological examination.

Complications with aspiration biopsies occur usually only with transthoracic puncture. The most frequent complications are bleeding and pneumothorax. To avoid such complications, one should not puncture deeply located, radical lesions. A biopsy should be carried out as quickly as possible, not allowing a large amplitude of breathing during the study.

Contraindications to transthoracic aspiration biopsy - disorders of blood coagulation, severe emphysema, severe concomitant cardiovascular diseases, arterial hypertension.

Angular puncture (trepanation) biopsy is a diagnostic puncture of the pathological entity under study in order to obtain tissue material for its histological examination with the help of special needles.

Indications for needle puncture biopsy in phthisiatric practice: rounded lung formations (excluding the tumor nature of formation), superficially located intrapulmonary infiltrates or groups of foci, chronic recurrent pleurisies of unknown origin, accompanied by a sharp thickening of the pleura.

Contraindications are similar to contraindications to aspiration biopsy. Transthoracic puncture biopsy is performed with the help of special biopsy needles of various designs. The main requirements for needles: reliability of use, atraumatic and safety for the patient, the possibility of obtaining a tissue fragment sufficient for histological examination.

The structure of most biopsy needles is the same: they consist of the very needle and stiletto, with which the material is taken. During the manipulation, the stylet is removed from the needle, and the tissue site is cut and cut, then retracted into the lumen of the needle. The mechanism for capturing and cutting off a biopsy depends on the design of the stylet: more often split, hooked and finished stilettos are used. In some cases, borax, including ultrasonic, is used to collect the material.

Transthoracic puncture biopsy is more traumatic than aspiration. In this regard, the accuracy of needle entry into the test tissue is important, this is controlled by radiation diagnostic methods. The most accurate methods are CT and polyposive ultrasound scanning using puncture adapters.

Obtained at a puncture biopsy a site of a tissue can be investigated by means of cytological, histological, bacteriological, immunohistochemical, electron microscopic methods that considerably raises efficiency and reliability of diagnostics. Verification of the diagnosis with transthoracic needle biopsy is possible in 80-90% of cases. The effectiveness of the method in the diagnosis of malignant tumors is higher than when determining the diagnosis of inflammatory diseases.

Complications in the study of soft tissues of the chest wall and pleura are extremely rare. Puncture biopsy of the lung is more dangerous manipulation and in some cases can be complicated by pneumothorax, pulmonary hemorrhage, pleurisy, hemothorax, implantation metastases, air embolism.

[18], [19], [20], [21], [22], [23],

Open diagnostic operations

Open diagnostic operations are performed if necessary biopsies of both superficially located and intrathoracic formations. In phthisiosurgical practice, a biopsy of peripheral lymph nodes, a parasternal mediastinotomy, a diagnostic thoracotomy with an open lung and pleural biopsy are performed.

Biopsy of peripheral lymph nodes

Biopsy of peripheral lymph nodes is indicated in cases when earlier performed manipulations did not allow to establish a diagnosis, more often study cervical, axillary and inguinal lymph nodes. The operation is performed under local anesthesia or intravenous anesthesia.

Precalted (transcervical) biopsy - surgical removal of cellulose and lymph nodes located on the surface of the front staircase of the neck. The incision is 3-5 cm parallel to the clavicle above it. For histological examination, the tissue with lymph nodes is removed. Complication: damage to the subclavian or external vaginal vein, opening the pleural cavity with the development of pneumothorax.

With a biopsy of the axillary lymph nodes, an incision of 3-5 cm is performed in the armpit. Increased lymph nodes can not always be easily identified because of a significant amount of subcutaneous fat. Remove them carefully, so as not to damage the axillary vessels and nerves.

More accessible inguinal lymph nodes that are located directly under the skin and can be relatively easily removed through a small incision.

[24], [25], [26], [27], [28], [29], [30]

Open biopsy of the lung

Open biopsy - receiving a biopsy of the lung, pleura or lymph nodes by opening the thoracic cavity or mediastinum. The method is used for diffuse and disseminated diseases of the lungs, pleurisy and intrathoracic lymphadenopathy of an unknown genesis, and also in cases when previously performed manipulations prevented the diagnosis.

The operation is performed under anesthesia from intercostal or from parasternal access. During surgery, conventional surgical instruments are used. With a small incision (mini-thoracotomy), video equipment and endosurgical instruments (video assisting operations) are sometimes used to better examine the pleural cavity and biopsy of deep regions of the lung or radical lymph nodes. With diffuse or disseminated lung lesions, marginal resection of the affected lung is performed. When the pleura is affected, a gipoint biopsy is performed from several parts of the pleura. When the lymph nodes are affected - lymphadenectomy of one or more nodes of the root of the lung and mediastinum.

Advantages of open biopsy: a high degree of reliability, the possibility of obtaining large biopsy specimens from one and several sections of the pleura, lung or lymph nodes. The resulting material is placed in identified containers and used for various studies (morphological, bacteriological, immune). After the operation, a drainage silicone tube is left for 1-2 days in the pleural cavity. Complications of open biopsy are similar to complications of standard operations on the lungs (pneumothorax, hydrothorax, hemothorax, respiratory failure, infection), but are much less common (less than 1% of cases).

Endosurgical operations

Endosurgical operations are widely used in diagnosis. For their implementation, punctures or small incisions are used, through which illuminating and optical instruments, a television camera, special endosurgical instruments are introduced into the pleural cavity or mediastinum. In phthisiology the most widely used were thoracoscopy (pleuroskopia) and mediastinoscopy.

[31], [32], [33]

Thoracoscopy

Thoracoscopy allows you to study in detail any parts of the pleural cavity and (if necessary) to take a biopsy from different parts of the pleura, lung and mediastinum.

For video-thoracoscopy, thoracoscopes are used with different angles of view, a video camera. Illuminator, monitor with color image, recording equipment, additional surgical equipment for various therapeutic manipulations.

The absence of pleural fusion and the collapse of the lung by 1/2 - 1/3 of the volume are the necessary conditions for performing a videotorakoscopy. The operation is often performed under anesthesia with separate intubation of the bronchi and switching off one lung from the ventilation. If there is a stiff residual cavity in the chest, the rigid leg is rigidly compressed, the study is performed under local anesthesia. An optical thoracoscope is inserted into the pleural cavity through the trocar (thoracoport). Connect it with a video camera and conduct an examination of the pleural cavity. For the implementation of various surgical procedures 2-3 additional manipulative trocars are injected, through which special biopsy or necessary medical manipulations are carried out by special endosurgical instruments (separation of adhesions, sanation of cavities, removal of pathological formations). The thoracoscopic picture of the pleural cavity is photographed or recorded on a digital video camera.

Videotoracoscopy is widely used in the diagnosis of various exudative pleurisies and disseminated lesions of light vague etiology.

With exudative pleurisy, videotoracoscopy is performed at any time. In the initial stages of the disease (up to 2 months), it has only diagnostic value. In later terms (2-4 months), after the organization of the exudate with fibrin deposition, development of adhesions and the constriction of cavities with the help of videothoracoscopy, the pleural cavity is sanitized with partial pleurectomy and lung decortication.

With disseminated lung lesions, there is no strictly specific picture of the disease, so these patients often have a lung biopsy. Videotoracoscopy allows you to examine with increasing any "suspicious" part of the pleural cavity and lung. With superficially located lesions, the most simple and effective method is gingival lung biopsy. With foci located in the lungs, an edge resection is shown. With the help of a videothoracoscope, the lung portion is selected and resected with an endo-stapler.

Complications: bleeding, subcutaneous emphysema, prolonged absence of aerostasis. The frequency of complications when performed by a specialist with extensive experience of manipulation does not exceed 1%. Contraindications to videothoracoscopy: respiratory failure and obliteration of the pleural cavity. Disadvantages of the method: the need for separate ventilation of the lungs and the inability to palpate the lung and other structures of the chest cavity.

Mediastinoscopy

Mediastinoscopy is a diagnostic operation with an examination of the anterior mediastinum with a mediastinoscope or a video mediastinoscope connected to the monitor.

Mediastinoscopy is performed under general anesthesia. On the front surface of the neck along the edge of the sternum, the skin and soft tissues of the neck are cut to the front wall of the trachea. The finger forms a tunnel in the pre-tracheal space, into which a mediastinoscope is inserted and under the vision control, puncture or removal (paratracheal and bifurcation lymph nodes.) Advantages of video technology: accessibility of the image not only to the surgeon but also to the assistant, the possibility (training, optimal illumination and clarity of the image, possibility its increase and storage in a computer database.The perfect tool for mediastinoscopic operations contributes to increasing the safety of the operation.

Mediastinoscopy in phthisiology is used to clarify the cause of mediastinal lymphadenopathy of unclear etiology. Often it is performed in sarcoidosis, tuberculosis and lymphogranulomatosis. The frequency of complications with mediastinoscopy does not exceed 1-2%. Possible bleeding, pneumothorax, nerve damage to the larynx.