 My name is Dr. Vishal Kumar. I am from Nasik. This is my peripheral center at TGPRI. My expertise are ultrasound and guided intervention. And specifically today I will be discussing USG guided toolkit biopsies and how they are done. Now we are going to come to the intervention part, USG guided FNAC and biopsies. We will just see what are the prerequisites for these guided interventions and what kind of material we need to have before we start the procedure. These are a lot of gauze and cotton here. These are some gauze and cotton holders. These are some green towels here which are useful. Some more gauze. This is a specific needle which is around 26 gauge. It is a very small needle used mainly for neck, breast lesions where the amount of skin which we have to infiltrate is very small. This is the local anesthesia which I use. This is 2% lignokine. And here we come to the section of the two-cut guns which I use. Most of the times I use a barred company automatic guns which fire automatically and take a piece automatically. So you do not need to do anything for this. I will show you how it works. Let us take a gun. This is a barred needle. It is around 16 cm and the gauge is around 18. And on this it is written 22 mm that is the throw. That is the amount of tissue it will capture when it is taken to shoot inside the lesion. So how it works basically? The first notch is to lock it half. When you press the second notch the gun is loaded now. And now when you enter the lesion and press either this or this button it makes a firing sound. And what it does is while it goes inside the lesion it takes a small 2 cm piece with it. So if I just press the single nozzle here and you can see here if you can see clearly you can see some amount of tissue will be taken in this area of the needle. It is a little cord area where the piece will get settled here. You just have to take this and put it into formalin base solution and we are done with the procedures. I will show you some other guns also which are utilized in the market. This is a multi-core gun from a different company. How it works is by pressing it once it locks it first time pressing it to it locks it completely. Now the only thing you have to do is just press this nozzle so that it shoots and you get this third sound. You again press this and you can see you can get the tissue in this small area and you can put it in the formalin base. This is one more locally made gun. I will just show you how it works. This is a thin needle it is around 16 cm. You have to lock it from both sides lock it from both sides and there is a notch here. This is written off so it won't shoot when you take it from the off side to the other side and you just press this nozzle and makes a shooting sound. You take the sample out and you take it in the formalin specific. So we just saw three different types of biopsy guns which are semi-automatic to automatic. There is one more method which many people use for doing biopsies is a trocar based needle trocut needle. So this is a trocar. What happens is this trocar goes inside the lesion. This entire inner steel plate is removed and what we have here is a small shooting gun. You just go inside whatever cm you want. You have to load it and you have to just press. Similar to what we had seen in the previous guns. But in this case what is the advantage of this over other guns is you don't have to take multiple passes. You don't have to pierce the skin multiple times. Only this trocar remains inside the skin and you can take multiple passes just putting the needle through the trocar. If you can see clearly this is the first case of biopsy which I am performing. This lady has multiple nodes mainly in the level 2 and level 3 large nodes around 2 or 3 cm in size. So I am just preparing this entire area. First I will be using solution of beta-deen to clean this off. I will just use some spirit. This area up here is clean now. Just to have some good opposition I am using lignokine jelly. That is also inert. I will just first locate where the node is. This node is located at the bifurcation of the carotid arteries. I think we have a good window to biopsy it. So we will just start giving some local anesthesia in that direction. I am just giving some local anesthesia. As you can see I am infiltrating the adjacent tissues and the muscle just close to the lymph node. I will just create some good track here using this needle so that while I have to enter I do not have to put much pressure. Gun loaded. Always always always when you want to start up biopsy always check the triggering of the gun. I have just checked it like this. You just press both knobs and just see whether it is firing well. If it is not firing well you will create a mess when you go inside. I have just checked it is firing well. Now I am going to enter the node. I have entered the node. PMS the bike. I will just leave the PMS. Thank you. Can you see this? I am just behind the node. My needle is just touching the node itself. I am going to shoot now to get a good chunk. Just see how I remove the piece now. Just taking the trocar behind this and just moving this gun. You can see some pieces have come out. Maybe the node is not entirely solid. There must be some kind of breakdown within it. We will take one more piece just for our benefit from the same site where we have punctured. What happened here? I have entered a wrong plane. The node is down. My probe is also down and I have entered in the wrong direction. So what you do is just remove the needle and try again. Rather than searching for it all the while. Just take it from a different angle. Can I have some lignokine? Taking from a different angle. I have just taken one more nice piece. If you see this I think this will be an entire long piece. This is a better, longer piece and I hope this will be diagnostic for what the disease this lady has. Okay, so we are done with our two pieces being taken. We just clean this area up. Cotton please. Gun. What I follow standard protocol is clean the entire area. See how much it is bleeding. If it is not bleeding too much I do not give too much thick bandages. I just give a single non specific single bandage. And instruct the patient that it might pain a little in the entire day. They can have cold fermentation for it or a small painkiller for one day. And next day we ask them to remove the bandage while they have a bath. Okay, we have just put a bandaid here for this lady. Okay, and she can remove it tomorrow when she has a bath. We have just painted and read a second biopsy patient. This lady has two has multiple nodes on both sides. But these nodes are along the carotid chain. So it becomes a little challenging. We do not touch the carotid artery of the jugular vein and still get a good sample. Let's give it a go how we can do it. Okay, I am now injecting local to one of the nodes from the skin up to the muscle strap muscles of the neck. We have to infiltrate from the muscle layer to the skin in all directions. And it takes around a minute or a half to act that area to get numb. Okay, we are going to use bad biopsy needle again. Okay, you must be wondering why I am using bad needle for every biopsy. The reason being the kind of throw and the cutting of the bad needle is much much superior to any of the other needles, which I have tried. So when you use bad needles, you are definitely sure you're going to get a good chunky piece and that helps you in giving a good estopa diagnosis to. So we are going to use a bad needle again. This time, this is around 7 to 8 centimetres in length. Okay, I think we can now start doing the biopsy. Just enter. So a good point. Laga? Kya waa? Dukha gaya? Thoda na? Okay, thoda dukhaya. Just trying to get the right plane. Okay, just got a good chunky piece. We will remove it. So I will just show you how the sample is removed. Okay, we got at least one and a half centimetre sample. It's clearly visualised, okay. And some part of the muscle was also removed because the node is not more than two centimetres. This procedure was a bit difficult because the nodes were small and parallelly wanted to the blood vessels. So we had to take a different angle. But I think we have got what we have decided and I am very sure we will get a good diagnosis here. We just put a small bandaid here and the patient can remove this bandaid next day when she has a mark. So both the procedures went well. One more thing I want to add in these procedures, specially true cut biopsies. We ask the patients to stay nearby at least for 20-30 minutes or ask them to have some food, any kind of beverage and come back to see whether they are having any kind of reaction maybe to the local anesthetic or a kind of procedure related for complications. So within the first, often our most complications arise during that time. So we ask them to come back in that time and see you again.