Exploratory Celiotomy Biopsy Techniques Flashcards
Primary reason for doing an Exploratory Celiotomy Biopsy?
Most efficient path (DX tool) to a definitive DX
Causes for Exploratory Celiotomy
- Trauma → open to eval. internal damage
- Neoplasia → locate silent tumor
When do you perform an Exploratory Celiotomy?
- Timing depends on history & PE
- Critical w/ trauma P
- DPL (Diagnostic Peritoneal Lavage) reduced uncertainty
- higher accuracy than abdominocentesis
- P is not responding
- Need stable P for successful surgery → sometimes stabilization cannot be reached → OPTIMIZE P
How do you prep for an Exploratory Celiotomy?
- Wide clip
- Scrub SX site
- KY jelly →protects area from being soiled w/ fur
- Line incision w/ moist lap sponges →helps w/ sterility
- Towel drapes, then overdrape
How do you position your P for an exploratory celiotomy?
(4 options)
- **Trendelemburg → caudal abdomen exploration **
- Reverse Trendelemburg → cranial abdomen exploration
- Horizontal table → thorough exploration of entire abdomen
- Dorsal recumbency = most common
What approach do you take when performing an exploratory celiotomy?
(multiple options)
- Ventral midline = most common
- From xiphoid to pubis
- NO “keyhole” incisions!!!!
- Paracostal + ventral midline incision
Equipment needed for an exploratory celiotomy?
- Balfour or Gosset Retractors
- Gelpi Retractors
- Lap Sponges
- Suction
- Doyen Intestinal Foreps
- Electroscapel
- Delicate thumb forceps - less traumatic than Adson-Brown or Rat thooth forceps
Surgical Techniques for Exploratory Celiotomy
- Obtaind samples of free fluid after entering the peritoneal cavity
- Ignore obvious lesions unless life threatening
- Perform a thorough exploration
- Evaluation of size, shape, color, location, surface
- _Begin cranially w/ diaphragm _
- “Four quadrants” → cranial, caudal, left, right
- Always use the same technique
- **Utilize “anatomical” retractors **
Biopsy Techniques during an Exploratory Celiotomy
-
CLEAN tissues first!
- tissues w/ the LEAST potential for contamination (ex. biopsy of small nodule)
-
Dirty tissues last!
- tissues w/ greater potential for contamination (ex. draining abscess)
How does a P get chemical peritonitis?
From ruptured gallbladder
Term for excising tissue w/ minimal safety margin?
(send whole piece to Path)
Excisional Biopsy
What is the removal “protocol” for an excisional biopsy?
- Mark edges w/ sharpie or stitches
- Be careful w/ depth of biopsy
- don’t leave diseased tissue →may recur
- need 360 safety margin
Term for taking a V shape or little piece of tissue & send to pathologist
Incisional Biopsy
Why would you do an incisional biopsy over an excisional biopsy?
If you cant remove the entire mass b/c it is too big, but need to obtain a sample
5 organs that are commonly biopsied
- Liver
- Intestines
- Lymph nodes
- Kidneys
- Prostate
Why is the liver commonly biopsied?
- due to liver failure
- common site for metastasis
What are the biopsy techniques used on the liver?
- Finger crushing
- Ligature Fracture Technique (Guillotine)
- Instrument fragmentation
- Wedge resection
- Biopsy punch
- Tru-cut
How is the Finger crushing biosy technique done on the liver?
- One of the easiest techniques
- Best w/ dry sponge
- Squeeze w/ fingers
- **Double ligate any vessels **
How is the Ligature fracture technique performed on the liver?
- Pass suture around piece of liver and tie strongly → makes knot → ligate vessels
- Leave 0.5 - 1 cm from ligature when cutting
- Can place pre-cut sutures & tie them → if tied too tight, it will create another biopsy → just cut section out
Disadvantages of the Ligature Fracture Technique
(Guillotine Biopsy)
- Can only sample the margin of the hepatic lobe
- Requires a SX assistant
How do you achieve hemostasis with a liver biopsy?
- Surgically
- Vetspon
- Omentum
After finishing your liver biopsy and before you close, what should you check for?
Make sure there is NO biliary leakage!
When taken a liver biopsy, do NOT excede ____ of intestinal _____
**Do NOT excede 20% of intestinal circumference **
What suture pattern(s) do you use to close the intestines?
-
Single layer closure
- NO INVERTING SUTURE PATTERNS!!! (Lambert, Cushing, Connell)
Technique for taking an intestinal biopsy
- Clamp w/ Doyen → milk contents to the side →make parallel incision → take sample w/ scissors
- Finger clamp is less traumatic
- Obtain multiple full thickness samples along length of intestine (~ 1 cm long)
- Preserve luminal diameter
- if significantly reduced after biopsy→ make dog ear suture (dilates bowel)
- Water leak test (inject saline into clamped intestines)- may need to place another stitch & recheck
What tissue/organ can you biopsy to determine if there is extension to dz?
Lymph Nodes
What is the easiest methods to biopsy a lymph node
FNA
What is the preferred biopsy method for Lymph Nodes?
Excisional BX
What is the advantage of an excisional lymph node biopsy?
Provides morphologic information
When perfoming a biopsy on the kidney, how to you acheive hemostasis?
Digital pressure
What suture pattern do you use to close after taking a biopsy of the kidney?
Use a mattress or continuous suture pattern
What type of biopsy is usually done on the prostate?
FNA or Wedge Biopsy
When performing a biopsy on the prostate, what do you need to watch out for?
What do you need to avoid?
- Watch out for bleeders
-
Avoid:
- **penetrating urethra **
- dosal aspect (trigone of the bladder)
Organs that are less commonly biopsied
(5)
- Stomach
- Spleen
- Pancreas
- Urinary Bladder
- Greater Omentum
What is the disadvantage of using an endoscope to biopsy the stomach?
Can’t get full thickness BX
What procedure(s) do you use to perform a biopsy on the spleen?
Partial Spleenectomy
Wedge Resection
How do you perform a biopsy on the pancreas?
Partial Pancreatectomy - distal aspect
What should you do when removing an lymph node?
- Preserve regional blood supply
- Minimal handling
- Ligate blood supply
How do you perform an FNA of the kidney?
- Caudal → cranial direction
- Parallel to the cortex
How should you perfom a BX of the Urinary Bladder?
- Full thickness sample
- Inverting suture pattern
- (Lambert, Cushing, or Connell)
Where should you BX the Greater Omentum?
The distal aspect
Why should you ALWAYS perfrom an Abdominal Lavage before closing a contaminated abdomen?
- Removal of contaminants
- less chance of complications from foreign material in the abdomen
- Warms P
- shortens recovery time
- Increases survival & significantly reduces abscess formatino
What should you use for an Abdominal Lavage?
warm Isotonic fluid + heparin
(repeat until clear fluid is retrieved)
When do you NOT perfom abdominal closure?
when peritoneal drainage is provided
(??)
What is the technique for closing the abdomen?
- Use cruciate or simple interuppted pattern
- remove sutures after 7-10 d.
-
ONLY incoporate the External Abdominal Fasica
- Avoid the rectus abdominus mm. → incr. adhesions & complicates healing
- Internal sheath does NOT yield additional strength
- Avoid dead space → risks of seromas
What is this positioning technique called?
Trendelenburg
What is this positioning technique called?
Reverse Trendelenburg
Name the 5 structures that are located in BOTH CRANIAL Quadrants of the abdomen.
(likely won’t ask)
- Body of the stomach
- Transverse colon
- L limb of the pancreas
- Liver
- Diaphragm
Name the 8 structures that are located in the R CRANIAL Quadrant of the abdomen.
(likely won’t ask)
- Diaphragm
- Epiploic foramen
- Caudal lobe of Liver
- R lobe & body of pancreas
- Pylorus & pyloric antrum
- Descending duodenum
- R Adrenal gland
- Cranial lobe of R kidney
Name the 6 structures that are located in the L CRANIAL Quadrant of the abdomen.
(likely won’t ask)
- Diaphragm
- L liver lobes
- Fundus & body of stomach
- Cranial pole of L kidney
- Spleen
- L limb of the pancreas
Name the 8 structures that are located in the R CAUDAL Quadrant of the abdomen.
(likely won’t ask)
- Descending duodenum
- Cecum
- R uterine horn
- R ovary
- Caudal pole of R kidney
- R ductus deferens
- R vaginal ring
- R ureter
Name the 8 structures that are located in the L CAUDAL Quadrant of the abdomen.
(likely won’t ask)
- Descending colon
- Caudal mesenteric artery
- Mesocolon
- L uterine horn
- L ovary
- L ductus deferens
- L vaginal ring
- L ureter
Name the 6 structures that are located in BOTH CAUDAL quadrants of the abdomen.
(Likely won’t ask)
- Uterine body
- Bladder
- Prostate (if enlarged)
- Terminal branches of Aorta
- Caudal flexure of duodenum
- Ileum
