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A guide for general practitioners in performing hepatic guillotine and punch biopsy techniques.
Liver biopsy is indicated for a number of hepatic disorders. While laparoscopic surgery is an excellent means of obtaining biopsy samples because of its reduced surgical morbidity, the instrumentation and training required to perform the procedure can limit its usefulness in general practice. Patients that require liver biopsy can be referred to specialists, especially patients at high risk or when a minimally invasive approach is desired. However, becoming familiar with techniques for open liver biopsy allows the general practitioner to perform this procedure when indicated.
Open surgical liver biopsy has many advantages:
Overall, histopathology is more accurate than cytology and is usually considered the gold standard for hepatic evaluation. In a study designed to determine the accuracy of diagnosis between hepatic cytology and histology, the two methods were found to be in agreement in only 15 of 56 canine patients and 21 of 41 feline patients.1
The guillotine technique is performed when attempting to sample the outer margin of a liver lobe.
The punch biopsy technique is best used when sampling centrally located areas of hepatic parenchyma and focal lesions. Keep in mind when using this method that six to eight portal triads at minimum are recommended for accurate results; this can be achieved using a 6-mm Baker’s biopsy punch.2
To improve access to the liver, be sure to extend the laparotomy incision to the xiphoid process of the sternum. Sterile laparotomy pads can also be placed gently between the diaphragm and the liver to improve visualization. Using radio-opaque gauze markers and counting the number of surgical sponges prior to closure of the abdomen are essential.
Before closure, it is important to ensure there is no evidence of hemorrhage. While the techniques described here should produce minimal bleeding, there is always a risk for serious complications. Furthermore, patients with significant hepatic dysfunction should always be evaluated for coagulation abnormalities prior to surgery.
Performing open surgical liver biopsy using a guillotine or punch biopsy technique is a valuable skill any general practitioner can learn. The diagnostic information obtained can ultimately improve the level of care provided to patients.
Dr. Steph Shaver is an ACVS board-certified veterinary surgeon and assistant professor of small animal surgery at Midwestern University in Arizona. She enjoys hiking, travel, friends, family and teaching veterinary students.
Marcus Marella is a third-year veterinary student at Midwestern University in Arizona. He has a strong interest in small animal surgery and hopes to complete a surgical residency in the future. In his free time, he enjoys golfing, skiing and spending time with friends and family.