Hepatic biopsy (Liver biopsy)
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Requirements
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Introduction Surgical biopsy of liver via cranial midline abdominal incision. Uses Establish specific diagnosis (neoplasia, infectious, copper storage disease, inflammatory, etc). Help develop therapeutic plan. Evaluate response to therapy. Prognostic indicator. Advantages Excellent visualization of liver. Representative tissue sample obtained. Decreased risk of surgical trauma to important liver structures. Accurate hemostasis. Several techniques available. Disadvantages Requires general anesthesia. Incisional hernia (hypoproteinemia). Invasive. Alternative techniques Percutaneous needle biopsyultrasound guided. Fine needle aspirate (no architectural information). Decision taking Criteria for choosing test Suitable for small samples. Wedge resection 'Finger fracture' method Larger biopsy or neoplasia. Repair of laceration. Personnel Anesthetist expertise For anesthetic considerations see anesthesia for hepatic insufficiency Materials required Minimum equipment Standard laparotomy kit Minimum consumables Chromic gut suture or monofilament absorbable suture. Other requirements Hemostatic agents, eg Gel-foam or Surgicel. Culturettes. Dietary preparation Fast animal for 12 hours prior to anesthesia to prevent reflux esophagitis. Site preparation Midline cranial ventral abdomen. Preparation Standard aseptic (clip, clean, swab, drape). Other preparation Hematology Biochemistry Protein levels - nutritive status. Pre-operative management Correction fluid, electrolyte, acid-base imbalances. Treat for coagulopathy: whole blood, plasma, Vitamin K. Restraint Approach Step 1 -
Cranial midline laparotomy Standard laparotomy Core Procedure Step 1 -
Locate liver pedicle or lobe Pull involved liver caudally and ventrally to abdominal incision. Step 2 -
Take biopsy specimen Place ligauture of absorbable suture material at base of pedicle. Hemostat placed next to ligature to stop slippage as ligature slowly tightened. Ligature crushes parenchyma and ligates bile ducts and vessels. Cut hepatic vessels and bile ducts distal to ligature. OR Interlocking mattress suture method Preplace interlocking mattress of absorbable suture material through area of affected liver. Pull ligatures tight to restrict blood supply/bile ducts to isolate area of interest. Excise hepatic parenchyma distal to ligatures. OR Wedge resection Place full thickness, overlapping interrupted mattress sutures of absorbable suture material through parenchyma in 'V' shape to achieve hemostasis. Cut liver wedge within 'V' shape. May elect to place Gel-foam or Surgical (hemostatic materials) into incision prior to tightening sutures. OR Cutaneous biopsy punch method Similar to wedge resection. Cylindrical defect is closed with interrupted mattress sutures. OR 'Finger fracture' method Support lobe with one hand. Thumb and finger of other hand worked through parenchyma in rubbing motion. Bile ducts and vessels ligated using absorbable suture material when detected by palpation. Exit Step 1 -
Examine biopsy site for hemorrhage. Cauterize or ligate bleeding vessels. Step 2 -
Omental patch - optional Tack piece of omentum over raw/cut surface of liver. Step 3 -
Wound closure See also Standard laparatomy Fluid requirements Especially if large volume of ascitic fluid removed. May replace ascitic fluid, if collected aseptically, prior to linea closure. Peritoneal fluid replacement may help prevent post-operative fluid shifts. Antimicrobial therapy If cholangiohepatitis or hepatic abscess is suspected. Prophylaxis against coliforms and anaerobes is suggested. Change antibiotics as needed based on culture and sensitivity results. Culture hepatic/tissues and/or bile. Potential complications Hemorrhage from biopsy site. Publications Refereed papers Cole T L, Center S A, Flood S N, Rowland P H, Valentine B A, Warner K L & Erb H (2002) Diagnostic comparison of needle and wedge biopsy specimens of the liver in dogs and cats. JAVMA 220 (10), 1483-1490 PubMed . Roth L (2001) Comparison of liver cytology and biopsy diagnoses in dogs and cats: 56 cases. Vet Clin Pathol 30 (1), 35-38 PubMed . Twedt D C (1998) Diagnosis of liver disease in companion animals. Vet Q 20 (Suppl 1), 44-46. Vetstream contributor(s) Dr Kyle Mathews DVM , North Carolina State University, College of Veterinary Medicine, 4700 Hillsborough Street, Raleigh, NC 27606, USA.
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