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-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 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 Eye goggles 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

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

1.8- to 2.4-mm cup for specimens Biopsy Sampling Flexible forceps 1.8- to 2.4-mm cup for specimens

Endoscopic Instrumentation Biopsy forceps, graspers, and retrievers

To examine the esophagus, normal Esophagoscopy To examine the esophagus, normal

To examine the esophagus, inflamed 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: Biopsy sampling Fecal examination for parasites Fecal cytology Assays Fasted for 24 to 36 hours Lavage colon Biopsy sampling So all tests prior to administering the lavage solution