Abdominal Biopsy Techniques

KAKUI Shigeru DVMMiyazaki JAPAN

Good Oncology Practice Biopsy,Biopsy,Biopsy

Accuracy of Biopsy(Low to High) FNA Needle Punch Incisional biopsy Excisional biopsy

Patient Risk(Low to High) FNA Needle Punch Incisional biopsy Excisional biopsy

Biopsy Always the surgeons responsibility!

Value of Biopsy “If the histological diagnosis is

incorrect,every subsequent step in the management of the patient may also be incorrect”

Positive Attitude “give the patient the benefit of

doubt” “do not doom the patient without

knowing what you are treating”

Common Excuses for not Performing Biopsy “the owner refuse to pay for it” “the result will not matter anyway” I know the owners will not elect

adjunctive therapy anyway” “no matter what it is, the animal will

eventually die from it anyway” “pathologists are always wrong”

Withrow “if a mass warrants surgical

removal, it warrant tissue analysis”

Medical Oncologist “there is no body cavity which

cannot be reached by a strong arm and a 16 gauge needle”

Multidisciplinaly Approach-Cancer Oncologist Nutritionist Surgeon Radiologist Pathologist

Abdominal Exploration

Complete your exploration first unless:

Active hemorrhage Gross contamination Lesion obstructs vision

Incisional vs. Excisional Biopsy

Decision Making:

1.Will full excision be potentially curative?

2.Will excision of entire lesion improve patient’s condition

Incisional vs. Excisional BiopsyDecision Making:

3.Will excision cause significant problems?

Hemorrhage, ischemia, increase operative time 4.Is there hope for success with non surgi

cal treatments?

Excisional Biopsy-Advantages

“If in doubt, cut it out”

1.Less seeding tumor cells 2.Diagnostic and therapeutic

Incisiosional Biopsy Conciderations

Need diagnosis before excision?

Type or extent of treatment altered Client consent for treatment altered Reconstruction difficult Likelihood for morbidity or mortality

When to Biopsy

Abnormal tissue Appearance

Supports reason for exploratory Tumor staging; metastatic involvement

When to Biopsy

Normal tissue Appearance

Potential for involvement of “normal” appearing tissue

Diagnostics indicate disease in “normal” appearing tissue

Where to Biopsy Sample lesion including “normal”

adjacent tissue Sample various areas in diffuse

conditions, Inflammatory or infected tissue

Equipment and Materials Bakers biopsy punch Needle punch biopsy Gelfoam Suture material General surgery pack

Principles of Biopsy Limit tumor seeding Control contamination Minimize manipulation Provide representative sample Do not limit Surgicul excision

Biopsy Tips

Hemorrhage Control

Digital pressure Ligate local supplying vessesls Gelfoam Omental “tack”technique

Biopsy Tips

Minimize Sample Artifact

Stay suture manipulation Use 4x4 sponges as “cutting board”

Proper Biopsy Preparation Cut into sections after excision Specimens<1cm thick 1:10 ratio formalin: tissue volume

Liver Biopsy

General indications

Liver size changes Abnormal laboratory tests Benign vs. Malignant processes Assess liver disease Evaluation treatment of liver disease

Open Liver Biopsy Excisional biopsy; primary hepatic neoplas

ms, singular metastatic nodules Incisional biopsy; diffuse diseases, multipl

e nodules

Liver Biopsy

Contraindication;

Coagulation abnormalities

No bleeding tendencies;Screen activated clotting time,platelet count

Suspect bleeder; coagulation profile treat first.

Baker’s Biopsy Punch Technique Isolated liver lesion Deeply located lesion

Guillotine Method Difuse liver disease Isolated lesion at periphery

Spleen Biopsy

Indications;

Excisional biopsy Large splenic masses

Incisional biopsy Difuse disease Regenerative vs. malignant processes

Spleen Biopsy Bakers Punch Technique Guillotine Technique Mattress Suture Technique TA stapler Technique

Hollow Organ Biopsy

Principles;

Gentle Tissue Handling Full thickness samples Protect against contamination Protect “otomy” site?

Intestinal Biopsy Indications

Single Biopsy Solitary, viable, and nonobstructive amend

able to resection

Multiple biopsies Diffuse processes

Intestinal Biopsy Technique Proper preparation 1-2cm length antimesenteric enterotomy Prevent excess mucosal eversion Do not remove >20% circumference

Intestinal Closure Remove everted muccosa Appositional, noncrushing pattern Transverse vs. longitudinal closure Omentum or serosal patch coverage

Pancreatic Biopsy

Principles;

Gentle handling Preserve blood supply Avoid duct areas No electrocoagulation

Pancreatic Biopsy Indications

Excisional Biopsy Solitary nodules

Incisional Biopsy Diffuse involvement Benign vs. malignant processes Lesions near duct areas

Pancreatic Biopsy Techniques Shave biopsy technique

Guillotine or suture fracture Peripheral tissue lesions Diffuse lesions

Pancreatic Biopsy Techniques Wedge incision technique

Needle punch technique Parencymal lesions in body Nonresectable masses

Lymph Node biopsy

Indications;

Lymphadenopathy Benign vs. malignant proccesses Clinical staging Paraneoplastic proccess

Lymph Node biopsy Liac and mesentric nodes most biopsied Excisional biopsies unless risk vascular co

mpromise Stay suture technique

Kidney Biopsy

Principles

Adequate patient prep. Ensure normal coagulation function Avoid hilar area

Kidney Biopsy

Indications

Acute vs. chronic disease Glomerulonephropathies

Kidney Biopsy

Techniques

Needle Punch Biopsy Less hemorrhage, easier

Wedge Biopsy(Preferred) More consistent samples More hemorrhage

Prostatic Biopsy

Principles

Avoid central located urethral area Contain contamination, tumor cells Examine median iliac LN Minimal peripheral dissection

Incisional Prostatic Biopsy

Indications

Benign vs. malignant disease Obtain culture specimen,refractory prostat

itis

Prostatic BiopsyTechniques

Needle Punch Poorly exposed areas Difficult disease

Wedge incision Requires good exposure More hemorrhage

Conclusions

Full benefits of biopsy:

Surgeon’s ability to fully explore the abdomen and recognize abnormalities

Proper indications and technique