Use of Electromagnetic Navigational Transthoracic Needle Aspiration (E-TTNA) for Sampling of Lung Nodules

The overall goal of the following experiment is to percutaneously sample pulmonary lung lesions using an electromagnetic navigational guided transthoracic needle. This is achieved by first mapping the target lesion using computed tomography images and navigational software. Next, an electromagnetic navigational guided transthoracic needle is inserted through the chest wall following the virtual path, which allows the proceduralist to reach the target lesion.

Then once in position and stable, a fine needle aspiration is performed, followed by multiple core biopsies using the 20 gauge core needle in order to sufficiently sample the lesion. The results show a successful biopsy of the lung lesion as demonstrated by the pathological analysis of the biopsies Demonstrating the navigation guided percutaneous lung biopsy will be myself and Dr.Sto Aria interventional pulmonary fellow at the Johns Hopkins Hospital. On the day of the procedure, attach the electronic reference point pads to the contralateral hemothorax of the target lesion to minimize pad overlap with the T TT NA biopsy entrance point.

Obtain a baseline inspiratory and expiratory non-contrast chest tomography with 0.5 millimeter intervals and 0.67 to 1.25 millimeter thickness as per the manufacturer. After administering anesthesia and performing e ebus tbna for mediastinal staging, assemble the tools and instruments shown here. For the transthoracic needle aspiration, place the patient in a supine position similar to that used for chest CT skin imaging acquisition using white light bronchoscopy and the electromagnetic navigational trackable instrument.

Verify registration and navigate the target lesion. If the lesion cannot be diagnosed, bronchoscopically, prepare the patient for a transthoracic approach. Using a test electromagnetic navigational needle, select an entrance point on the test cavity that is superior to the surface of the nearest rib.

While avoiding osseous and vascular structures, mark it on the skin surface with a 2%chlorhexidine solution. Prepare the skin and use a sterile technique to drape it. Then administer a local anesthetic.

Next, place the sterile electromagnetic navigational needle on top of the entrance point and select the angle to the target. By observing the transverse and coronal views seen on the electromagnetic system screens, then stabilize the needle and firmly advance it through the chest wall into the target lesion. Remove the guidance needle stylet from the needle, taking extreme care to avoid moving the needle.

Then use the finger to cover the hub of the needle. Insert the 20 gauge FNA needle through the 19 gauge needle. Sample the lesion and provide the specimen to the cytotechnologist for rapid onsite evaluation.

Program the automatic needle biopsy to the desired distance or selected length of the biopsy needle based on the size of the lesion. Then insert the biopsy needle through the 19 gauge needle. Stabilize both the needle and biopsy gun Trigger the needle biopsy gun mechanism to perform the biopsy.

Then remove the gun from the electromagnetic navigational guide needle, making sure it remains in the appropriate position. Now gently advance the guidance probe back into the lumen of the percutaneous needle and keep it stable with the needle. Continuously stabilized.

Have an assistant use the scalpel blade to gently remove the specimen from the inner cannula of the core biopsy needle and place it on a half by half inch non-adherent pad. Then immerse the pad in formal and solution. Reconfirm the appropriate placement of the needle within the lesion, and then repeat the operation four to five times, making sure the core needle is rotated clockwise or counterclockwise to sample different areas.

Once satisfied with the specimens, remove the needle. Apply pressure and place a small bandage over the puncture site. Follow the post post-procedure steps according to the text protocol.

Pathological evaluation of the samples obtained by EBUS tb NNA and E-T-T-N-A includes cytological and histological assessment, including a modified romanowski stain that allows adequacy evaluation and cym morphological diagnostic of the pathological specimens. While performing this procedure, it's important to remember that appropriate mediastinal staging with endobronchial ultrasound guided transbronchial needle aspiration should be completed first. Then navigational bronchoscopy with radio ultrasound for peripheral lesions can be performed, followed by electromagnetic navigational transthoracic needle biopsy to complement the diagnostic armamentarium while performing the needle biopsy insertion.

It is critical to keep the needle as stable as possible following a straight trajectory delineated by the virtual path. Also, it's fundamentally important to prevent inadvertent needle displacement during activation of the biopsy gun to limit the risk of pneumothorax.