The endoscopic extraction of a foreign body is a mechanical problem pure and simple, and must be studied from this viewpoint. Hasty, ill-equipped, ill-planned, or violent endoscopy on the erroneous principle that if not immediately removed the foreign body will be fatal, is never justifiable. While the lodgement of an organic foreign body (such as a nut kernel) in the bronchus calls for prompt removal and might be included under the list of emergency operations, time is always available for complete preparation, for thorough study of the patient, and localization of the intruder. The patient is better off with the foreign body in the lung than if in its removal a mediastinitis, rupture into the pleura, or tearing of a thoracic blood vessel has resulted. The motto of the endoscopist should be "I will do no harm." If no harm be inflicted, any number of bronchoscopies can be done at suitable intervals, and eventually success will be achieved, whereas if mortality results, all opportunity ceases.
The first step in the solution of the mechanical problem is the study of the roentgenograms made in at least three planes; (1) anteroposterior, (2) lateral, and (3) the plane corresponding to the greatest plane of the foreign body. The next step is to put a duplicate of the foreign body into the rubber-tube manikin previously referred to, and try to simulate the probable position shown by the ray, so as to get an idea of the bronchoscopic appearance of the probable presentation. Then the duplicate foreign body is turned into as many different positions as possible, so as to educate the eye to assist in the comprehension of the largest possible number of presentations that may be encountered at the bronchoscopy on the patient. For each of these presentations a method of disimpaction, disengagement, disentanglement or version and seizure is worked out, according to the kind of foreign body. Prepared by this practice and the radiographic study, the bronchoscope is introduced into the patient. The location of the foreign body is approached slowly and carefully to avoid overriding or displacement. A study of the presentation is as necessary for the bronchoscopist as for the obstetrician. It should be made with a view to determining the following points: 1. The relation of the presenting part to the surrounding tissues. 2. The probable position of the unseen portion, as determined by the appearance of the presenting part taken in connection with the knowledge obtained by the previous ray study, and by inspection of the ray plate upside down on view in front of the bronchoscopist. 3. The version or other manipulation necessary to convert an unfavorable into a favorable presentation for grasping and disengagement. 4. The best instruments to use, and which to use first, as, hook, pincloser, forceps, etc. 5. The presence and position of the "forceps spaces" of which there must be two for all ordinary forceps, one for each jaw, or the "insertion space" for any other instrument.
Until all of these points are determined it is a grave error to insert any kind of instrument. If possible even swabbing of the foreign body should be avoided by swabbing out the bronchus, when necessary, before the region of the intruder is reached. When the operator has determined the instrument to be used, and the method of using it, the instrument is cautiously inserted, under guidance of the eye.
[160] The lip of the bronchoscope is one of the most valuable aids in the solution of foreign-body problems. With it partial or complete version of an object can be accomplished so as to convert an unfavorable presentation into one favorable for grasping with the forceps; edematous mucosa may be displaced, angles straightened and space made at the side of the foreign body for the forceps' jaw. It forms a shield or protector that can be slipped under the point of a sharp foreign body and can make counterpressure on the tissues while the forceps are disembedding the point of the foreign body. With the bronchoscopic lip and the forceps or other instrument inserted through the tube, the bronchoscopist has bimanual, eye-guided control, which if it has been sufficiently practiced to afford the facility in coordinate use common to everyone with knife and fork, will accomplish maneuvers that seem marvelous to anyone who has not developed facility in this coordinate use of the bronchoscopic instruments.
The relation of the tube mouth and foreign body is of vital importance. Generally considered, the tube mouth should be as near the foreign body as possible, and the object must be placed in the center of the bronchoscopic field, so that the ends of the open jaws of the forceps will pass sufficiently far over the object. But little lateral control is had of the long instruments inserted through the tube; sidewise motion is obtained by a shifting of the end of the bronchoscope. When the foreign body has been centered in the bronchoscopic field and placed in a position favorable for grasping, it is important that this position be maintained by anchoring the tube to the upper teeth with the left, third, and fourth fingers hooked over the patient's upper alveolus (Fig. 63)
The Light Reflex on the Forceps.—It is often difficult for the beginner to judge to what depth an instrument has been inserted through the tube. On slowly inserting a forceps through the tube, as the blades come opposite the distal light they will appear brightly illuminated; or should the blades lie close to the light bulb, a shadow will be seen in the previously brilliantly lighted opposite wall. It is then known that the forceps are at the tube mouth, and the endoscopist has but to gauge the distance from this to the foreign body. This assistance in gauging depth is one of the great advances in foreign body bronchoscopy obtained by the development of distal illumination.
Hooks are useful in the solution of various mechanical problems, and may be turned by the operator himself into various shapes by heating small probe-pointed steel rods in a spirit lamp, the proximal end being turned over at a right angle for a controlling handle. Hooks with a greater curve than a right angle are prone to engage in small orifices from which they are with difficulty removed. A right angle curve of the distal end is usually sufficient, and a corkscrew spiral is often advantageous, rendering removal easy by a reversal of the twisting motion (Bib. 11, p. 311).
The Use of Forceps in Endoscopic Foreign Body Extraction.—Two different strengths of forceps are supplied, as will be seen in the list in Chapter 1. The regular forceps have a powerful grasp and are used on dense foreign bodies which require considerable pressure on the object to prevent the forceps from slipping off. For more delicate manipulation, and particularly for friable foreign bodies, the lighter forceps are used. Spring-opposed forceps render any delicacy of touch impossible. Forceps are to be held in the right hand, the thumb in one ring, and the third, or ring finger, in the other ring. These fingers are used to open and close the forceps, while all traction is to be made by the right index finger, which has its position on the forceps handle near the stylet, as shown in Fig. 78. It is absolutely essential for accurate work, that the forceps jaws be seen to close upon the foreign body. The impulse to seize the object as soon as it is discovered must be strongly resisted. A careful study of its size, shape, and position and relation to surrounding structures must be made before any attempt at extraction. The most favorable point and position for grasping having been obtained, the closed forceps are inserted through the bronchoscope, the light reflex obtained, the forceps blades now opened are turned in such a position that, on advancing, the foreign body will enter the open V, a sufficient distance to afford a good grasp. The blades are then closed and the foreign body is drawn against the tube mouth. Few foreign bodies are sufficiently small to allow withdrawal through the tube, so that tube, forceps and foreign body are usually withdrawn together.
[FIG. 78.—Proper hold of forceps. The right thumb and third fingers are inserted into the rings while the right index finger has its place high on the handle. All traction is made with the index finger, the ring fingers being used only to open and close the forceps. If any pushing is deemed safe it may be done by placing the index finger back of the thumb-nut on the stylet.]
Anchoring the Foreign Body Against the Tube Mouth.—If withdrawal be made a bimanual procedure it is almost certain that the foreign body will trail a centimeter or more beyond the tube mouth, and that the closure of the glottic chink as soon as the distal end of the bronchoscope emerges will strip the foreign body from the forceps grasp, when the foreign body reaches the cords. This is avoided by anchoring the foreign body against the tube mouth as soon as the foreign body is grasped, as shown in Fig. 79. The left index finger and thumb grasp the shaft of the forceps close to the ocular end of the tube, while the other fingers encircle the tube; closure of the forceps is maintained by the fingers of the right hand, while all traction for withdrawal is made with the left hand, which firmly clamps forceps and bronchoscope as one piece. Thus the three units are brought out as one; the bronchoscope keeping the cords apart until the foreign body has entered the glottis.