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Application of intraoperative navigation and positioning system in the removal of deep foreign bodies in the limbs

Liang, Hai-Dong1; Li, Hong2; Feng, Hao1; Zhao, Zheng-Nan1; Song, Wen-Ji1; Yuan, Bo1

Section Editor(s): Lyu, Peng

doi: 10.1097/CM9.0000000000000253
Correspondence
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1Department of Hands and Feet Microsurgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116023, China

2Department of Pharmacy, Fushun Central Hospital, Fushun, Liaoning 113006, China.

Correspondence to: Dr. Bo Yuan, Department of Hands and Feet Microsurgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116023, ChinaE-Mail: yuanbodl@163.com

How to cite this article: Liang HD, Li H, Feng H, Zhao ZN, Song WJ, Yuan B. Application of intraoperative navigation and positioning system in the removal of deep foreign bodies in the limbs. Chin Med J 2019;00:00–00. doi: 10.1097/CM9.0000000000000253

Received 23 January, 2019

Hai-Dong Liang and Hong Li contributed equally to this work.

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

Online date: April 9, 2019

To the Editor: Secondary trauma and patient discomfort resulting from residual foreign bodies in the human body is a common occurrence and most of the time, surgical interventions are required for their removal. Usually, foreign bodies lying just beneath the skin surface can be easily retrieved. The major issue is when such foreign bodies lie deep in the soft tissues and become more complicated when they are of small sizes. It may lead to consequences such as tissue damage, delayed wound healing, infection, allergic reactions, and late injury as a result of migration.[1] Surgical interventions for removal of such deep-lying and/or small foreign bodies are not only known to be highly time-consuming but also involve higher levels of trauma to the surrounding tissues. The incidence of the retained foreign body widely varies from one case in every 1000 to 10,000 procedures [Table 1].[2]

Table 1

Table 1

Our team has used the intraoperative and navigation and positioning system for removal of deep-seated foreign bodies. A 41-year-old man turned up at the department with a history of a metallic machine needle incarcerated in his left thigh for 3 days. Standard anteroposterior and lateral X-rays were done, confirming the presence of a deep-seated radio-opaque foreign body in the thigh [Figure 1A and 1B]. Surgical intervention was planned. Following anesthesia, radio-opaque threads and plastic film were used to make a grid construct which was stuck over the approximate site of the foreign body [Figure 1C], and then X-ray was taken to display the position of the foreign body in the grid [Figure 1D]. Precise localization with a needle and C-arm X-ray machine (Insight2, Shawnee, KS, USA; C-arm) was carried out in different planes and 0.3-mL methylene blue was injected [Figure 1E and 1F]. The skin was incised and carefully dissected to protect the neurovascular bundle; the foreign body was found in the blue-stained area and removed successfully [Figure 1G]. C-arm was used to confirm removal of the object and the wound was closed after tourniquet release, hemostasis, and washout [Figure 1H and 1I].

Figure 1

Figure 1

Till date, no standardized surgical procedures for removal of foreign bodies from limbs have been stated.[3] Wen et al[4] used enhanced computed tomography and three-dimensional angiography to show the accurate location and spatial relationship between foreign bodies and important blood vessels, which provide guidance for surgery. Ultrasound-guided extraction of soft-tissue foreign bodies was shown by Fu et al.[5] These procedures have had undisputed success but the technique largely depends on the use of special equipment; also, the amount of radioactivity is quite substantial. Therefore, the use of these technologies cannot be generalized.

Our system makes use of a double positioning system by combining the use of the sterile syringe needle, film, and C-arm with the use of methylene blue for more accurate localization. Removal of impacted foreign bodies with the use of the above-mentioned technique has several advantages. The technique is simple, fast, cost-effective, and highly accurate, thereby shortening the operation time and reducing radiation exposure to patient and operation theater staff. Furthermore, with the small incision and minimal exploration required and also the high success rate, it is a technique worth generalizing for the extraction of foreign bodies from extremities.

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s)/patient's guardians has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients/patient's guardians understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

None.

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References

1. Hocaoğlu E, Kuvat SV, Özalp B, Akhmedov A, Doğan Y, Kozanoğlu E, et al. Foreign body penetrations of hand and wrist: a retrospective study. Turkish J Trauma Emerg Surg 2013; 19:58–64. doi: 10.5505/tjtes.2013.04453.
2. O’Brien L, Eyster KM, Hansen KA. Retained foreign body: “Needle in a Haystack”. J Patient Safe 2015; 11:228–229. doi: 10.1097/pts.0000000000000078.
3. Nan GX, Cai WQ, Su YX, Qin JQ, Liu X, Wang ZL, et al. Use of methylene blue marking for removal of tiny foreign metal in soft tissue in children. Chin J Pediatr Surg 2013; 34:119–122. doi: 10.3760/cma.j.issn.0253-3006.2013.02.011.
4. Wen YH, Hou WJ, Lei WB, Chen FH, Zhu XL, Wang ZF, et al. Clinical characteristics and endoscopic endonasal removal of foreign bodies within sinuses, orbit, and skull base. Chin Med J 2017; 130:1816–1823. doi: 10.4103/0366-6999.211545.
5. Fu Y, Cui LG, Romagnoli C, Li ZQ, Lei YT. Ultrasound-guided removal of retained soft tissue foreign body with late presentation. Chin Med J 2017; 130:1753–1754. doi: 10.4103/0366-6999.209910.
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