1. SPECIALIZED SURGICAL INSTRUMENTS & TECHNIQUES
BIOPSY
LASER
ENDOSCOPY

2. 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

3. 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

4. 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

5. 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

6. Biopsy and Mass Removal: Needle Punch

7. Biopsy and Mass Removal: Needle Punch

8. 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

9. Biopsy and Mass Removal: Punch

10. 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

11. BONE BIOPSY

12. BONE BIOPSY

13. Biopsy and Mass Removal: Bone

14. 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

15. Biopsy and Mass Removal: Excisional
Indications, appropriate use

16. 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

17. 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

18. 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

19. 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

20. 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.

21. Laser Surgery: Advantages and Disadvantages

22. 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.

23. 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

24. 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

25. 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)

26. Laparoscopy: Advantages and Contraindications

27. Laparoscopic Equipment
Usual sizes

28. Laparoscopic Equipment
Trocar–cannula units
Trocar punctures through the
abdominal wall, and the cannula for the insertion of a laparacope

29. Laparoscopic Equipment
Fiberoptic light cable and light source
The fiber optic light cable emits light from the light source to the scope

30. Laparoscopic Equipment
Veress insufflation needle
Used for insufflation of the peritoneal cavity. This lifts the abdominal wall away from the abdominal organs.

31. 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

32. Laparoscopic Equipment
Camera video system

33. Laparoscopic Equipment
Camera video system

34. Laparoscopic Equipment
Special instruments
These instruments can be
Passed through cannulas of accessory ports to aid in biopsy retrieval or to
Perform surgical procedures.

35. Laparoscopic Equipment
Special instruments
Biopsy and grasping instrument tips

36. 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

37. 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

38. Laparoscopic Procedure

39. Laparoscopic Procedure

40. Laparoscopic Procedure

41. 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

42. Common Endoscopic Procedures

43. Types of Endoscopes
Standard flexible

44. Types of Endoscopes
Flexible

45. 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

46. Types of Endoscopes Video Similar to the fiberoptic endosdcopes except
they do not have a direct
viewing lens aided
by an eyepiece.

47. 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

48. 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

49. Endoscopy Room

50. 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

51. Endoscopy Room

52. Handling the Endoscope
Two-finger grip

53. Handling the Endoscope
Three-finger grip

54. 1.8- to 2.4-mm cup for specimens
Biopsy Sampling
Flexible forceps
1.8- to 2.4-mm cup for specimens

55. Endoscopic Instrumentation
Biopsy forceps, graspers, and retrievers

56. To examine the esophagus, normal
Esophagoscopy
To examine the esophagus, normal

57. To examine the esophagus, inflamed
Esophagoscopy
To examine the esophagus, inflamed

58. Gastroscopy
To examine the stomach

59. Gastroscopy

60. Gastroscopy: Biopsy

61. Gastroscopy: Biopsy

62. Gastroscopy: Biopsy

63. Duodenoscopy
Diagnosis and treatment of small intestine disease

64. Colonoscopy
Examine rectum, large intestine, and cecum

65. 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