Puncture

PUNCTURE (punctio), the piercing of a cavity with a syringe for diagnostic or therapeutic purposes. Puncture is used for evacuating various liquids and gases from tissues and cavities (evacuative puncture), determining their presence (diagnostic or trial puncture), for bacteriological, chemical, and cytological laboratory investigations (diagnostic puncture), for introducing medicinal substances (injective puncture), and for suction by means of apparatus with rarefied air (aspiratory puncture). The instruments for puncture are steel hollow needles and trocars. Trial punctures are performed with thin needles (0.3-0.5 mm), evacuative punctures with thick needles (1.5-2 mm) or trocars (3-6 mm). During puncture, all rules of strict asepsis must be observed. Puncture of the abdominal cavity is most frequently used in ascites, rarely in other diseases, and is contraindicated in tuberculous peritonitis, ovarian cyst, hydronephrosis, encapsulated accumulations of fluid, pus, etc. For the technique of puncture in ascites and its complications, see Ascites. The patient's position during puncture is semi-sitting. Before puncture, an orientation percussion is performed. Above and below the site of puncture, after disinfection of the skin, sterile towels are placed around the abdomen. After making a skin incision of 1-2 cm length under local anesthesia, the handle of the trocar is grasped with the palm of the right hand, with the index finger extended from the end for better fixation, and the abdominal wall is punctured with an energetic movement. Holding the trocar with the left hand, the stylet is withdrawn with the right hand and a rubber tube is placed on the end of the trocar to conduct the fluid into a measuring vessel. The fluid flowing out in a strong stream should be regulated to avoid too rapid emptying of the abdominal cavity, which is accompanied by a sharp drop in blood pressure due to passive hyperemia "ex vacuo" in the abdominal cavity (and cerebral anemia with its consequences). To avoid this, it is recommended to gradually draw the ends of the towels from behind as the fluid flows out. If the fluid ceases to flow due to the omentum or a loop of intestine obstructing the trocar opening, a button-catheter is inserted into it; if this procedure does not achieve the desired result, the direction of the trocar is changed, pulling it forward or moving it to the side. At the end of the procedure, one or two sutures are sometimes placed at the site of the puncture, or a collodium patch is applied and a bandage is placed on the abdomen. Puncture of the abdominal cavity is also used for "pneumoperitoneum" (see Aeroperitoneum). Puncture of the brain (punctio cerebri) is used as an evacuative procedure (hydrocephalus), for diagnostic purposes (abscess, hematoma, cyst), and for injection (see Brain, surgery of the brain). Puncture is performed in two stages or in three stages. Brain puncture was developed in detail by Middeldorf (1856) and practically applied in brain abscesses. More detailed technical and diagnostic data were published in 1904 by Neisser and Pollak, who proposed performing puncture in two stages: 1) after puncturing the skin under local anesthesia, all layers of bone are drilled through with a thin drill (with a flat pointed end 2-2.5 mm in diameter) to the dura mater; 2) after removing the drill, a hollow needle is used to puncture the meninges and brain. In three stages, puncture is performed as follows: 1) incision of the skin to the bone, 2) drilling with a trephine to the dura mater, and 3) puncture of the meninges and brain to the required depth. To avoid injuring the vessels of the dura mater as well as psychomotor and sensory centers, cranio-cerebral schemes of Krenlein, Schlo, Kocher, etc. are used (see Cranio-cerebral topography). The points for puncture of the frontal lobes of the brain are located in the middle of the upper edge of the orbit: one at a distance of 4 cm - the first frontal convolution, the other at 8 cm - the second frontal convolution. In the area of the central convolutions of the hemisphere, puncture is performed 1 cm in front of the fissura centralis (Rolandi), which is previously determined according to cranio-cerebral topography data. The temporal lobe is punctured 1-1.5 cm above the attachment of the auricle or 1 cm in front (the horn is located at a depth of 3 cm). For puncture of the cerebellum, the midpoint of a line drawn between the protuberantia occipitalis ext. and the apex of the processus mastoideus is taken. It should be noted that none of the proposed schemes of cranio-cerebral topography is exact, so during brain puncture it is possible to injure important brain centers and vessels. The possibility of infecting healthy parts during puncture of brain abscesses is also dangerous. Less dangerous are ventricular and suboccipital punctures (Schmieden, 1917). According to Neisser and Pollak, puncture of the lateral ventricle is performed 2.5-3 cm to the side of the bregma to a depth of 4-5 cm; according to Kocher, in front of the bregma at a point located 2 cm from the midline (depth 5-6 cm); according to Keen, it is better to make the puncture from the side at a point located 3 cm above and 3 cm behind the external auditory canal. In children (in hydrocephalus), puncture can easily be performed through the unossified fontanelles. Suboccipital puncture (Suboccipitalstich): the patient is in a sitting position or on the side with the head end of the table elevated. The head is maximally flexed forward exactly along the midline. After palpating the epistropheus, puncture is performed slightly above it (a few mm) through the skin and muscles in the direction of the posterior edge of the foramen magnum to the bone. After palpating the posterior edge of the foramen magnum with the needle, it is advanced through the membrana atlanto-occipitalis into the cisterna cerebellomedullaris. Spinal puncture - see Lumbar puncture. For the technique of cardiac puncture, see General anesthesia. Puncture of the synovial cavities is used in cases of accumulation of inflammatory effusions in joints, rarely in the cavities of tendon sheaths, bursae, etc. Puncture of the knee joint is performed through the joint space between the cond. int. femoris and cond. int. tibiae with the knee joint flexed, or into the protruding effusion in the recessus sup. above the patella, as well as along its edge. Puncture of the ankle joint is performed on both sides between the malleoli in the plantar flexion position. During puncture of the hip joint, the patient is placed on the back, the leg is adducted and slightly rotated inward. Puncture is performed from the outside above the apex of the greater trochanter (trocar 7-10 cm) until it stops in the femoral neck, penetrating the joint capsule. Puncture can also be performed through the midpoint of a line connecting the point of intersection of the a. femoralis and lig. Poupartii with the greater trochanter, making the puncture at the inner edge of the t. sartorii. Puncture of the wrist joint is performed from the outside through the "anatomical snuffbox," located between the styloid process of the radius and the tendon of the m. extensor pollicis longi, and from the inside between the styloid process of the ulna and the tendon of the extensor of the fifth finger. During puncture, the joint line (between the apices of the proc. styloidei ossis radii et ulnae) is used as a guide. Puncture of the elbow joint is performed from the outside through the so-called "fossa pulchritudinis" (between the humerus and radius) behind the olecranon or through the tendon of the triceps muscle. Puncture of the shoulder joint is performed in the adducted position between the proc. acromion and the head of the humerus or in front near the coracoid process. If following puncture the synovial cavity is not opened (abscess), then during puncture the skin is displaced so that the skin puncture opening does not coincide with the opening for further advancement of the needle (for example, in tuberculosis).