SPECIALIZED SURGICAL INSTRUMENTS & TECHNIQUES

BIOPSYLASER

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 PunchIndications, 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: BoneIndications, appropriate use

• Often painful and require general anesthesia

Jamshidi needle: less invasive, but smaller sample size

Michele Trephine:Larger sample size, but increases likelihood of Pathologic fracture at the biopsy site

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-aluminum-garnet) 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 to980nm

•Can be used as a contact or noncontactMode

•Absorbed better in hemoglobin and Melanin

•More collateral thermal damage may occur due to the deeper penetration

•May provide more efficient hemostasisAnd 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 PrecautionsEye goggles•Everyone in the laser surgery room must wear

Eye goggles specific for the particular laser light

• corneal or retinal damage can occur from scatteredReflections

•The eyes of the patient should be protected as well

•Moistened sponges can be placed over the eyes

•Patient eye shields are available

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 unitsTrocar punctures through theabdominal 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 oxideRoom 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 EquipmentSpecial instruments

These instruments can bePassed through cannulas of accessory ports to aid in biopsy retrieval or toPerform surgical procedures.

Laparoscopic EquipmentSpecial 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 EndoscopesFiberoptic

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

VideoSimilar to the fiberopticendosdcopes except they do not have a direct viewing lens aidedby 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 positionRather 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 forceps1.8- 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