Abdominal Biopsy Techniques KAKUI Shigeru DVM Miyazaki JAPAN

Abdominal Biopsy TechniquesKAKUI Shigeru DVMMiyazaki JAPAN

Good Oncology PracticeBiopsy,Biopsy,Biopsy

Accuracy of Biopsy(Low to High)FNANeedle PunchIncisional biopsyExcisional biopsy

Patient Risk(Low to High)FNANeedle PunchIncisional biopsyExcisional biopsy

BiopsyAlways the surgeons responsibility!

Value of BiopsyIf the histological diagnosis is incorrect,every subsequent step in the management of the patient may also be incorrect

Positive Attitudegive the patient the benefit of doubtdo not doom the patient without knowing what you are treating

Common Excuses for not Performing Biopsythe owner refuse to pay for itthe result will not matter anywayI know the owners will not elect adjunctive therapy anywayno matter what it is, the animal will eventually die from it anywaypathologists are always wrong

Withrowif a mass warrants surgical removal, it warrant tissue analysis

Medical Oncologistthere is no body cavity which cannot be reached by a strong arm and a 16 gauge needle

Multidisciplinaly Approach-CancerOncologistNutritionistSurgeonRadiologistPathologist

Abdominal ExplorationComplete your exploration first unless:

Active hemorrhageGross contaminationLesion obstructs vision

Incisional vs. Excisional BiopsyDecision Making:

1.Will full excision be potentially curative?2.Will excision of entire lesion improve patients condition

Incisional vs. Excisional BiopsyDecision Making:

3.Will excision cause significant problems? Hemorrhage, ischemia, increase operative time4.Is there hope for success with non surgical treatments?

Excisional Biopsy-AdvantagesIf in doubt, cut it out

1.Less seeding tumor cells2.Diagnostic and therapeutic

Incisiosional Biopsy ConciderationsNeed diagnosis before excision?

Type or extent of treatment alteredClient consent for treatment alteredReconstruction difficult Likelihood for morbidity or mortality

When to BiopsyAbnormal tissue Appearance

Supports reason for exploratoryTumor staging; metastatic involvement

When to BiopsyNormal tissue Appearance

Potential for involvement of normal appearing tissueDiagnostics indicate disease in normal appearing tissue

Where to BiopsySample lesion including normal adjacent tissue Sample various areas in diffuse conditions, Inflammatory or infected tissue

Equipment and MaterialsBakers biopsy punchNeedle punch biopsyGelfoamSuture materialGeneral surgery pack

Principles of BiopsyLimit tumor seedingControl contaminationMinimize manipulationProvide representative sampleDo not limit Surgicul excision

Biopsy TipsHemorrhage Control

Digital pressureLigate local supplying vesseslsGelfoamOmental tacktechnique

Biopsy TipsMinimize Sample Artifact

Stay suture manipulationUse 4x4 sponges as cutting board

Liver BiopsyGeneral indications

Liver size changesAbnormal laboratory testsBenign vs. Malignant processes Assess liver diseaseEvaluation treatment of liver disease

Open Liver BiopsyExcisional biopsy; primary hepatic neoplasms, singular metastatic nodulesIncisional biopsy; diffuse diseases, multiple nodules

Liver BiopsyContraindication;

Coagulation abnormalities

No bleeding tendencies;Screen activated clotting time,platelet count Suspect bleeder; coagulation profile treat first.

Bakers Biopsy Punch TechniqueIsolated liver lesionDeeply located lesion

Guillotine MethodDifuse liver diseaseIsolated lesion at periphery

Spleen BiopsyIndications;

Excisional biopsy Large splenic masses

Incisional biopsy Difuse disease Regenerative vs. malignant processes

Spleen BiopsyBakers Punch TechniqueGuillotine TechniqueMattress Suture TechniqueTA stapler Technique

Hollow Organ BiopsyPrinciples;

Gentle Tissue HandlingFull thickness samplesProtect against contaminationProtect otomy site?

Intestinal Biopsy IndicationsSingle BiopsySolitary, viable, and nonobstructive amendable to resection

Multiple biopsiesDiffuse processes

Intestinal Biopsy TechniqueProper preparation1-2cm length antimesenteric enterotomyPrevent excess mucosal eversionDo not remove >20% circumference

Intestinal ClosureRemove everted muccosaAppositional, noncrushing patternTransverse vs. longitudinal closureOmentum or serosal patch coverage

Pancreatic BiopsyPrinciples;

Gentle handlingPreserve blood supplyAvoid duct areasNo electrocoagulation

Pancreatic Biopsy IndicationsExcisional BiopsySolitary nodules

Incisional BiopsyDiffuse involvement Benign vs. malignant processesLesions near duct areas

Pancreatic Biopsy TechniquesShave biopsy technique

Guillotine or suture fracture Peripheral tissue lesions Diffuse lesions

Pancreatic Biopsy TechniquesWedge incision technique

Needle punch technique Parencymal lesions in body Nonresectable masses

Lymph Node biopsy Indications;

LymphadenopathyBenign vs. malignant proccessesClinical stagingParaneoplastic proccess

Lymph Node biopsyLiac and mesentric nodes most biopsiedExcisional biopsies unless risk vascular compromiseStay suture technique

Kidney BiopsyPrinciples

Adequate patient prep.Ensure normal coagulation functionAvoid hilar area

Kidney BiopsyIndications

Acute vs. chronic diseaseGlomerulonephropathies

Kidney BiopsyTechniques

Needle Punch Biopsy Less hemorrhage, easier

Wedge Biopsy(Preferred) More consistent samples More hemorrhage

Prostatic BiopsyPrinciples

Avoid central located urethral areaContain contamination, tumor cellsExamine median iliac LNMinimal peripheral dissection

Incisional Prostatic BiopsyIndications

Benign vs. malignant diseaseObtain culture specimen,refractory prostatitis

Prostatic BiopsyTechniques

Needle Punch Poorly exposed areas Difficult disease

Wedge incision Requires good exposure More hemorrhage

ConclusionsFull benefits of biopsy:

Surgeons ability to fully explore the abdomen and recognize abnormalitiesProper indications and technique