0:01

Sven, uh, Sellinger is, uh, our friend who,

0:04

uh, invented this technique,

0:06

you know, with respect to the vascular system,

0:08

but it is the exact same technique.

0:11

So let's unpack this bad boy.

0:13

Okay, so the first thing we do is we get a needle

0:17

to essentially say, you know what, I got my

0:20

little needle here, I got my imaging guidance.

0:23

So, we'll use ultrasound for

0:24

the sake of comparison here.

0:26

And so, I know exactly, sort of,

0:29

wherewhere the skin is, which is what I have

0:31

to start as my origin, departure.

0:33

Departure, destination.

0:35

Destination being the abscess.

0:36

And I gotta, I gotta get

0:38

7.4 ccentimeters.

0:39

So maybe I'm going to start with a little UE

0:40

20 00:00:41,065 --> 00:00:42,755 Centesis Needle, okay, which has a little

0:43

sharp stylet, kind of like a little bevel

0:45

tip, and then it has a little outer catheter.

0:47

It comes in often sort of

0:49

7 centimeters and 10 centimeters.

0:50

So I was like, alright,

0:51

let me use the 10 centimeters one.

0:52

That'll give me a little distance.

0:53

So, got that marked out.

0:55

So then I'm going to get

0:55

in there, boom, I'm inside.

0:58

And so then, once I'm inside, I do the

1:00

exact same thing that we did in the trocar

1:02

technique, where we say, oh, you know

1:03

what, let's aspirate, alright, because,

1:05

who knows what this is.

1:07

This may be a hematoma, whatever.

1:08

So let's go ahead and aspirate that fluid.

1:10

We got the fluid out, sucked out.

1:12

So now we're in.

1:14

Looks yellow, smells like pus, it's pus, okay?

1:19

So let's move on now.

1:19

So now we're inside, we

1:21

confirm, destination, pus.

1:24

This is where we want to be

1:25

with our life at this moment.

1:26

So let's go ahead and send the

1:27

wire in, and we call this wire in.

1:29

So nice if we're using a Benson wire, which

1:32

usually has about 7 centimeters of a floppy tip.

1:34

So we get that 7 centimeters to coil, and then

1:36

it kind of hits and stops at that nice sort

1:39

of solid portion of the wire.

1:41

And then we sort of maintain

1:42

that as a little railroad, okay?

1:45

So then we take out the access catheter,

1:48

in this case perhaps a USES and TESIS

1:50

needle, USES and TESIS catheter, and

1:53

then we say, okay, well now we're in.

1:54

And so the next step may be to say, alright,

1:55

after we sort of place that guide

1:57

wire, now we may want to dilate, right?31 00:00:58,405 --> 00:01:00,205 And so then, once I'm inside, I do the

1:00

exact same thing that we did in the trocar

1:02

technique, where we say, oh, you know

1:03

what, let's aspirate, alright, because,

1:05

who knows what this is.

1:07

This may be a hematoma, whatever.

1:08

So let's go ahead and aspirate that fluid.

1:10

We got the fluid out, sucked out.

1:12

So now we're in.

1:14

Looks yellow, smells like pus, it's pus, okay?

1:19

So let's move on now.

1:19

So now we're inside, we

1:21

confirm, destination, pus.

1:24

This is where we want to be

1:25

with our life at this moment.

1:26

So let's go ahead and send the

1:27

wire in, and we call this wire in.

1:29

So nice if we're using a Benson wire, which

1:32

usually has about 7 centimeters of a floppy tip.

1:34

So we get that 7 centimeters to coil, and then

1:36

it kind of hits and stops at that nice sort

1:39

of solid portion of the wire.

1:41

And then we sort of maintain

1:42

that as a little railroad, okay?

1:45

So then we take out the access catheter,

1:48

in this case perhaps a USES and TESIS

1:50

needle, USES and TESIS catheter, and

1:53

then we say, okay, well now we're in.

1:54

And so the next step may be to say, alright,

1:55

after we sort of place that guide

1:57

wire, now we may want to dilate, right?

1:59

Right?

1:59

So we say, okay, we need to go from this five

2:01

French catheter to an eight French,

2:05

or what I prefer is to start with a ten French

2:08

drainage catheter. Or if you're

2:09

dealing with more viscous collections,

2:12

like in the case of peripancreatitis,

2:14

you might use a 14 or 16 French catheter.

2:18

But then you need to dilate up to that, right?

2:19

And so once you've dilated up, you're

2:21

like, okay, the pump has been primed.

2:24

So now we're ready to just melt that bad

2:26

boy through the skin, the catheter into the

2:29

collection, over the wire, nice little railroad.

2:31

And then once we're in, the catheter takes the path

2:35

of the wire, and then we pull the wire out.

2:39

If we started with a nice blunt stiffener

2:42

in the actual catheter, we then remove that.

2:45

Here we see an image of the plastic

2:48

stiffener that's typically in place,

2:49

which is used usually for exchanges.

2:51

And then the blunt metal stylet, which as you

2:55

can see, the blunt tip is actually ending here.

2:58

I kind of pulled it out a little bit

2:59

just so you can see that the minute you

3:00

pull it out, it kind of begins to form.

3:03

And there's that string that Dr.

3:04

Constance Cope sort of

3:06

developed very, very ingeniously.

3:09

So when this is pulled out, it naturally wants

3:12

to form because of memory, a little pigtail.

3:14

But then this little string, this

3:17

little suture, allows you to, um, just kind

3:19

of get it into position, so it kind of makes

3:21

a nice little piggy pigtail loop.

3:23

Okay?

3:23

Gotta love the little piggy pigtail loop.

3:26

So this is what it looks like.

3:28

You know, in my hands, in your hands, it looks

3:30

the same way, and once it's out, you know,

3:33

you sort of get that nice pigtail to form.

3:36

It's a nice little retention device.

3:37

It forms with the shape of an abscess,

3:39

which is typically round or spherical in nature.

3:42

And then you have this sort of ring.

3:43

In this case, this happens to be one of the

3:46

manufacturers that makes this, and it

3:48

has a little feature where you can kind

3:49

of throw the string around this, and then, boom,

3:52

just kind of lock it in place, cut the suture

3:55

at this tip here, and then you're off to help

3:58

the patient sort of move past this collection.

4:01

Alright, so what are the advantages

4:02

of the Sellinger Technique, and

4:04

let's talk about the disadvantages.

4:06

Well, you know, this technique can facilitate

4:09

the drainage of a large, multi-loculated collection.

4:12

It allows you to get that wire in,

4:14

and send your catheter wherever you want it to be,

4:16

dependently, or non-dependently. Although, you

4:19

might not want to go non-dependently, because fluid usually

4:21

falls and collects in the dependent areas.

4:24

So, it’s better to drain it from the bottom up,

4:26

or from the dependent area to the non-dependent area.

4:29

It allows for more control; you

4:30

know, I’m an expeditious person when it

4:32

comes to getting things done.

4:34

I think that safety is first, and

4:36

so for me, I tend to use the Sellinger technique

4:38

because I feel

4:39

it gives me a little bit more control.

4:41

I believe that planning, staging, and

4:44

ratcheting as I move forward with the

4:46

procedure while locking in safe, controlled,

4:48

and intentional steps is really the way I

4:51

like to care for my patients.

4:53

But we’re discussing advantages here for

4:54

the purpose of your appraisal as well.

4:57

So that you can determine

4:58

which technique is best for you.

4:59

For me, I feel like in cases

5:01

where there are difficult-to-access

5:02

collections, the Sellinger technique works pretty well.

5:04

Some people think it’s a little time-consuming,

5:06

you know, and it just depends on how pressed

5:08

for time you are to move from this patient

5:10

to the next. But it's completely up to you

5:12

in terms of your discretion, what

5:14

you think is time-consuming versus what’s not.

5:18

One of the things people talk about is,

5:19

sometimes there can be kinking

5:21

that occurs with the guide wire. If you’re

5:24

advancing a catheter with a stiffener through

5:26

the wire, you might not get that catheter to end

5:29

up in the abscess if you kink the wire.

5:32

My response to that is perhaps,

5:35

you should use a technique where you watch the

5:37

catheter as it advances over the wire.

5:40

What I teach our residents is that once you hit the trough or the

5:42

crest of the wire, depending on where

5:44

the wire’s going, you stop.

5:47

Stop at the apex or the point

5:49

of the trough or crest with the stiffener, and then

5:51

begin to feed the catheter off the stiffener.

5:53

Guide it onto the wire and into the collection,

5:55

which helps to bypass the kinking risk.