SPECIALIZED SURGICAL
INSTRUMENTS & TECHNIQUES
BIOPSY
LASER
ENDOSCOPY
Biopsy and Mass Removal
Indications
• Biopsy is usually recommended before mass removal
• Gives information about the behavior of the mass and allows
for development of a treatment plan and prognosis
Biopsy and Mass Removal: Fine-Needle Aspiration
• FNA is on of the simplest methods for cytologic evaluation of a
mass.
• Easy to perform
• Minimal morbidity
• No sedation required
• Disadvantage: low diagnostic yield
Biopsy and Mass Removal: Impression Smears
Indications, appropriate use
• As simple to perform as FNA
• Useful for ulcerated surface tumors & freshly cut surfaces
• Can be made from excised masses prior to placing in formalin
Biopsy and Mass Removal: Needle Punch
Indications, appropriate use
• Generally requires sedation
• Usually guided by ultrasound to take samples of internal organs such as
liver, spleen, prostate
Biopsy and Mass Removal:
Needle Punch
Biopsy and Mass Removal:
Needle Punch
Biopsy and Mass Removal: Punch
Indications, appropriate use
• Used primarily for external and oral skin masses
• Does not penetrate deeply into the mass
• Patients are generally under general anesthesia
Biopsy and Mass Removal:
Punch
Biopsy and Mass Removal: Bone
Indications, appropriate use
• Often painful and require general anesthesia
Michele Trephine:
Larger sample size, but increases likelihood of
Pathologic fracture at the biopsy site
Jamshidi needle:
less invasive, but smaller sample size
BONE BIOPSY
BONE BIOPSY
Biopsy and Mass Removal:
Bone
Biopsy and Mass Removal:
Incisional vs. Excisional
Indications, appropriate use
• INCISIONAL BIOPSY
– Generally performed only after cytology or needle core biopsies have
failed to provide a diagnositic sample
– A small wedge of the tumor is removed from the mass and submitted for
histopathology
• EXCISIONAL BIOPSY
– Involves complete removal of the mass
– Generally performed only on benign skin tumors or when removal of the
organ is indicated
Biopsy and Mass Removal:
Excisional
Indications, appropriate use
Biopsy Sample
Handling and Fixation
Importance of proper handling:
• Impression smears
• Mark margins of surgical excision sample
• Allow sample to dry for at least 20 min
• Place sample in fixative
–
–
–
•
10% neutral buffered formalin
1 part tissue to 10 parts formalin
Large samples (>1cm in thickness) should be sliced like
a loaf of bread prior to fixing
Properly label sample container (date, patient
name, site of sample removal) Paperwork should
include the history, signalment, clinical findings, and
tentative diagnosis
Laser Surgery
• How it works
– Clinical functions: ablation, incision, excision
• Laser light is absorbed and transformed into heat within the tissue
• Different tissues/substances absorb different wavelengths of light
causing the tissue to heat
– Appropriate use
• From minor to more extensive procedures (feline declaw, lumpectomy,
castration, amputation)
– Three types: CO2, diode, & Nd:YAG (neodymium:yttrium-aluminumgarnet) will not be discussed here
– Lasers are classified as I-IV according to the degree of possible
safety hazards to patients and users
Laser Surgery: CO2
•Class IV laser
•Available at wavelength of 10,600nm
•Most use a noncontact mode in which the laser tip
never comes in contact with the tissue
•Highly absorbed by water – most tissues have high
water content, so the laser energy is absorbed very
close to the surface
Laser Surgery: Diode
•Class IV laser
•Available at wavelengths of 805nm to
980nm
•Can be used as a contact or noncontact
Mode
•Absorbed better in hemoglobin and
Melanin
•More collateral thermal damage may
occur due to the deeper penetration
•May provide more efficient hemostasis
And incisions
Laser Surgery
• Differences between CO2 and diode
(e.g., contact vs. noncontact, wavelengths)
• Mode tips
– Both come with a variety of tips that are chosen based on the procedure
• Spot size
– Refers to the diameter of the aperture on the tip
– Moving the tip closer to the target tissue decreases the spot size; moving
the tip further from the target tissue increases the spot size
• Exposure
– Refers to the duration of the laser beam or how long the tissue is exposed
to the beam
• Charring
– refers to carbonization of tissue – char, that occurs at temps greater than
100°C
– Occurs when tissue absorbs heat faster than it can be released
• The clinician uses spot size, power, and exposure to control the
interaction of the CO2 laser beam and its effects on the tissue.
Laser Surgery:
Advantages and Disadvantages
Laser Surgery
•
Safety standards: Set by the American National Standard Institute (ANSI)
– Warning sign should be posted on the surgery room door and all doors leading to it
– Dangers associated with class IV lasers include eye, skin, fire, and smoke plume hazards
•
A record or log should be kept of each procedure performed as well as
the power and duration settings
– This will help the surgeon choose settings to use for future procedures.
Laser Surgery Precautions
•Everyone in the laser surgery room must wear
Eye goggles specific for the particular laser light
• corneal or retinal damage can occur from scattered
Reflections
•The eyes of the patient should be protected as well
•Moistened sponges can be placed over the eyes
•Patient eye shields are available
Eye goggles
Laser Surgery Precautions
• Skin – damage may occur from direct or scattered laser beams.
– Clinicians should wear gloves and a gown for added protection
• Fire in surgery room – hazards include the surgical drapes,
anesthetic agents, oxygen, animal’s fur, alcohol, methane from
flatulence
– Place moistened sponges around the surgical area
– Be sure ET tube cuff is properly inflated
– Have fire extinguishers readily available
• Smoke plume
– Contains toxic and carcinogenic chemicals as well as bacteria and
viral particles.
– An evacuator is usually purchased with the laser machine & should
be placed within 1-2 inches of the smoke’s origin
– Wear laser surgery masks as regular surgical masks may not be
sufficient
Laparoscopy
• To examine peritoneal cavity and its viscera
– A type of endoscope called a laparoscope is placed
through a small midline incision or opening into the
abdominal wall (lateral to midline)
• Necessary equipment
–
–
–
–
–
–
–
Laparascope
Trocar-cannula unit
Fiberoptic light cable
Light source
Veress insufflation needle
Gas insufflator
Camera/video system (optional)
Laparoscopy:
Advantages and Contraindications
Laparoscopic Equipment
Usual sizes
Laparoscopic Equipment
Trocar–cannula units
Trocar punctures
through the
abdominal wall, and the
cannula for the insertion
of a laparacope
Laparoscopic Equipment
Fiberoptic light cable and light source
The fiber optic light
cable emits light from
the light source to the
scope
Laparoscopic Equipment
Veress insufflation needle
Used for insufflation of the peritoneal cavity. This lifts the
abdominal wall away from the abdominal organs.
Laparoscopic Equipment
Gas insufflators
CO2 – recommended due to rapid absorption
Nitrous oxide
Room air
Tubing is connected from the gas insufflator to the Veress needle.
Insufflation should not exceed 15mmHg
Laparoscopic Equipment
Camera video system
Laparoscopic Equipment
Camera video system
Laparoscopic Equipment
Special instruments
These instruments can be
Passed through cannulas
of accessory ports to aid
in biopsy retrieval or to
Perform surgical
procedures.
Laparoscopic Equipment
Special instruments
Biopsy and grasping instrument tips
Laparoscopy Procedure
•
•
•
•
•
•
•
•
Patient prep: fasting, bladder expressed
Clip from xiphoid process to pubis
Recumbency depends on procedure
Draping
Remove scope from glutaraldehyde solution
Sterile saline over scope and light cable
Dried by member of surgical team
Sterile sleeve used to cover the camera; scope placed on
the head of the camera
• Entry of Veress needle
Laparoscopy Procedure
• Outer trocar of needled is retracted
• Insufflation tubing can be connected to the
needle
• NOTE: Insufflation of the abdomen can never
exceed 15 mm Hg
• Place trocar–cannula
• View abdominal wall on the monitor
• Move scope as needed
• Additional cannula introduced if needed
Laparoscopic Procedure
Laparoscopic Procedure
Laparoscopic Procedure
Endoscopy
• Examine internal body structures via an
orifice and using optical instruments
• Examine tissues directly, remove foreign
bodies
• General anesthesia needed
• Proper fasting before procedure
Common Endoscopic Procedures
Types of Endoscopes
Standard flexible
Types of Endoscopes
Flexible
Types of Endoscopes
Fiberoptic
If any images are to be
taken, a camera head
can be attached from
the eyepiece on the
endoscope to the
endoscopy unit
Types of Endoscopes
Video
Similar to the fiberoptic
endosdcopes except
they do not have a direct
viewing lens aided
by an eyepiece.
Types of Endoscopes
• Rigid
• Best use – for procedures involving a direct
pathway that are better viewed with a
straight or direct line of sight such as the
ears, nose, bladder, joint spaces
Endoscopy Preparation
• Veterinary technician is responsible for prep:
–
–
–
–
–
–
Hook up endoscope
Enter patient data on computer
Turn on machine and check light source
Test machine
Get distilled water for flushing
Air–water valve covered, distal end of insertion
tube submerged in water, check for bubbles
– Leave tip submerged in water and test for
suctioning
Endoscopy Room
Endoscopy Room
Store endoscopes in a hanging position
Rather than in their original
custom-padded cases. Never place them
on a flat surface, even temporarily
Endoscopy Room
Handling the Endoscope
Two-finger grip
Handling the Endoscope
Three-finger grip
Biopsy Sampling
Flexible forceps
1.8- to 2.4-mm cup for specimens
Endoscopic Instrumentation
Biopsy forceps, graspers, and retrievers
Esophagoscopy
To examine the esophagus, normal
Esophagoscopy
To examine the esophagus, inflamed
Gastroscopy
To examine the stomach
Gastroscopy
Gastroscopy: Biopsy
Gastroscopy: Biopsy
Gastroscopy: Biopsy
Duodenoscopy
• Diagnosis and treatment of small intestine
disease
Colonoscopy
• Examine rectum, large intestine, and cecum
Colonoscopy
• Patient preparation:
– Fecal examination for parasites
– Fecal cytology
– Assays
– Fasted for 24 to 36 hours
– Lavage colon
• Biopsy sampling