TUGAS MATA KULIAH

ILMU BEDAH KHUSUS VETERINER

TEKNIK OPERASI BIOPSI PANKREAS

KELAS 2015 D
DISUSUN OLEH :

Stefanus Andre Gunawan 1509005095

I Kadek Toto Sugita 1509005097
Archie Leander Maslim 1509005098
Reydanisa Noor Madania 1509005106
Yeyen Fami Gressia Br Surbakti 1509005108
I Nyoman Kusumajaya 1509005109

LABORATORIUM BEDAH VETERINER

FAKULTAS KEDOKTERAN HEWAN
UNIVERSITAS UDAYANA
DENPASAR
2018

i
 RINGKASAN
Biopsi pankreas adalah teknik untuk mendiagnosa suatu penyakit / kelainan
pada pankreas dengan teknik sitologi dengan cara mengambil sebagian atau lesi
yang ada di pankreas. Teknik pembedahan membutuhkan peralatan bedah standar
dan dapat melihat dengan mudah dari seluruh pankreas. Tergantung pada jenis
biopsi yang dilakukan, tindakan ini dapat digunakan untuk mengetahui tingkat
invasi penyakit, yaitu apakah penyakit telah menyebar ke bagian tubuh lainnya. Ada
banyak cara untuk melakukan biopsi, tergantung pada jenis jaringan yang
dibutuhkan oleh dokter, penyakit yang diduga menyebabkan gangguan, atau hasil
dari tes awal yang mendorong dokter untuk meminta agar biopsi dilakukan.
Gangguan – gangguan yang terjadi bisa seperti kanker yang tumbuh pada organ
pankreas maupun pankreatitis yang terjadi pada hewan.

Kata Kunci: Bedah, Biopsi, Pankreas

SUMMARY
Pancreatic biopsy is a technique for diagnosing a disease / abnormality in
the pancreas by cytology techniques with taking a portion or lesion in the pancreas.
Surgical techniques require standard surgical equipment and can be seen easily
from the entire pancreas. Depending on the type of biopsy performed, this action
can be used to determine the level of disease invasion, namely whether the disease
has spread to other parts of the body. There are many ways to do a biopsy,
depending on the type of tissue needed by the doctor, the disease that is thought to
cause the disorder, or the results of an initial test that encourages the doctor to
request that a biopsy be performed. Disorders - disorders that occur can be like
cancer that grows in the pancreas organ or pancreatitis that occurs in animals.

Keyword: Surgery, Biopsy, Pancreas

ii
 KATA PENGANTAR
Puji syukur penulis panjatkan kehadirat Tuhan Yang Maha Esa atas berkah
dan rahmat-Nya sehingga penyusunan paper Ilmu Bedah Khusus Veteriner ini
dapat diselesaikan tepat pada waktunya. Judul paper ini adalah “Teknik Operasi
Biopsi Pankreas”.
Paper ini dibuat untuk memenuhi tugas mata kuliah Ilmu Bedah Khusus
Veteriner. Melalui penulisan paper ini, diharapkan mahasiswa mengetahui
mengenai teknik operasi biopsi pankreas. Terima kasih penulis sampaikan kepada
seluruh dosen mata kuliah Ilmu Bedah Khsuus Veteriner yang telah membimbing
dan memberikan kuliah demi lancar dan terselesaikannya tugas paper ini.
Segala kritik dan saran sangat penulis harapkan demi perbaikan penulisan
paper ini. Demikianlah tugas ini penulis susun. Penulis berharap semoga
bermanfaat, dan dapat memenuhi tugas mata kuliah Ilmu Bedah Khusus Veteriner.
Akhir kata, penulis ucapkan terimakasih.

Denpasar, 23 September 2018

Penulis

iii
 DAFTAR ISI

HALAMAN JUDUL................................................................................... i
RINGKASAN ............................................................................................. ii
KATA PENGANTAR ................................................................................ iii
DAFTAR ISI ............................................................................................... iv
DAFTAR GAMBAR .................................................................................. v
DAFTAR LAMPIRAN ............................................................................... vi
BAB I PENDAHULUAN
1.1 Latar Belakang ................................................................................. 1
1.2 Rumusan Masalah ............................................................................ 1
1.3 Tujuan Tulisan .................................................................................. 2
1.4 Manfaat Tulisan ............................................................................... 2
BAB II TINJAUAN PUSTAKA
2.1 Preoperasi ........................................................................................ 3
2.2 Teknik Operasi ................................................................................ 6
2.3 Pasca Operasi .................................................................................. 9
BAB III PEMBAHASAN
3.1 Pengertian Biopsi Pankreas .............................................................. 10
3.2 Tujuan Operasi Biopsi Pankreas ...................................................... 10

BAB IV SIMPULAN DAN SARAN

4.1 Simpulan ........................................................................................... 11
4.2 Saran ................................................................................................. 11
DAFTAR PUSTAKA ................................................................................. 12
LAMPIRAN ............................................................................................... 13

iv
 DAFTAR GAMBAR

Gambar 1. Instrumen Bedah Biopsi Pankreas ............................................ 4

Gambar 2. Posisi Dorsal Recumbency ........................................................ 6
Gambar 3. Penutup Kain Drape .................................................................. 6
Gambar 4. Incisi Cranial Abdominal ......................................................... 7
Gambar 5. Jahitan Guillotine ..................................................................... 8
Gambar 6. Biopsi Pankreas ........................................................................ 8

v
 DAFTAR LAMPIRAN

Case, J.B. Fox-Alvarez, W.A. 2015. Pancreatic Biopsy. Clinician’s Brief.

K. L. Cosford, C. L. Chosmon, S. L. Myers, S. M. Taylors, A. P. Carr, J. M. Steiner,
J. S. Suchodolski, F. Mantovani. 2010. Pancreatic Biopsy in Cat. Journal of
Veterinary Internal Medicine. 24, 104-113.
Webb, C.B., Trott. C. 2008. Laparoscopic Diagnosis of Pancreatic Disease in Dogs
and Cats. J Vet Intern Med 2008;22:1263–1266

vi
 BAB I

PENDAHULUAN

1.1 Latar Belakang

Biopsi adalah pengambilan jaringan dari tubuh makhluk hidup untuk mendapatkan
spesimen histopatologi dalam upaya membantu menegakkan diagnosis. Biopsi merupakan
metode penting untuk membantu menegakkan diagnosis lesi yang dicurigai mengalami
keganasan, seperti pembesaran jaringan, ulkus yang kronis, kerapuhan jaringan, atau
kekerasan saat palpasi.

Tergantung pada jenis biopsi yang dilakukan, tindakan ini dapat digunakan untuk
mengetahui “tingkat invasi penyakit” – yaitu apakah penyakit telah menyebar ke bagian
tubuh lainnya. Tindakan ini juga dapat digunakan untuk mengeliminasi keberadaan kanker
atau mengetahui apakah tumor bersifat jinak. Namun, istilah biopsi sangatlah luas. Istilah
ini meliputi semua tes pada jaringan yang bertujuan untuk mendeteksi kelainan, termasuk
ukuran dan bentuk fisik sampel yang berbeda dari populasi umum.

Ada banyak cara untuk melakukan biopsi, tergantung pada jenis jaringan yang
dibutuhkan oleh dokter, penyakit yang diduga menyebabkan gangguan, atau hasil dari tes
awal yang mendorong dokter untuk meminta agar biopsi dilakukan. Contohnya saja pada
organ pankreas yang mengalami gangguan perlu dilakukannya biopsi pankreas. Gangguan
– gangguan yang terjadi bisa seperti kanker yang tumbuh pada organ pankreas maupun
pankreatitis yang terjadi pada hewan. Oleh karena itu, pentingnya pula mengetahui
mengenai teknik bedah sebagai dasar melakukan biopsi pankreas.

1.2 Rumusan Masalah

1.2.1 Bagaimana prosedur pre-operasi biopsi pankreas hewan.
1.2.2 Bagaimana prosedur teknik operasi biopsi pankreas hewan.
1.2.3 Bagaimana hasil dan pasca operasi biopsi pankreas hewan.

1
1.3 Tujuan
1.3.1 Untuk mengetahui prosedur pre-operasi biopsi pankreas hewan.
1.3.2 Untuk mengetahui prosedur teknik operasi biopsi pankreas hewan.
1.3.3 Untuk mengetahui hasil dan pasca operasi biopsi pankreas hewan.

1.4 Manfaat Tulisan

Manfaat dari penulisan paper ini yaitu agar mahasiswa dapat mengetahui bagaimana
prosedur pre-operasi biopsi pankreas, prosedur teknik operasi biopsi pankreas, hingga hasil
dan pasca operasi biopsi pankreas hewan dilakukan, dan juga pembuatan paper ini untuk
melengkapi tugas Ilmu Bedah Khusus Veteriner tentang teknik biopsi pankreas hewan.

2
 BAB II
TINJAUAN PUSTAKA

2.1 Pre Operasi

Adapun hal-hal yang perlu dipersiapkan sebelum melakukan operasi biopsi

pankreas yaitu meliputi persiapan alat, bahan, dan obat, kemudian persiapan ruang
operasi, persiapan pasien (hewan) dan persiapan operator.

a. Persiapan alat, bahan, dan obat

Alat-alat atau instrument bedah yang diperlukan dalam operasi biopsi pankreas ini
harus di sterilisasi. Pada masing-masing metode atau teknik operasi alat-alat bedah
yang diperlukan berbeda yaitu sebagai berikut.
a. Guillotine Biopsy via Laparotomy
Alat yang dibutuhkan yaitu Basic surgery pack ( seperti : needle holders,
DeBakey thumb forceps, mosquito hemostats, Metzenbaum scissors)
b. Biopsi Laparoscopi
 Videolaparoscopy (A)
 camera (B)
 insufflation tubing (C)
 lampu cable (D)
 2 5-mm trocars and cannulas (E)
 5-mm laparoscopic clamshell biopsy forceps (F)
 5-mm laparoscope 0° (G)
 5-mm laparoscopic blunt probe (H)

Namun, kedua metode tersebut membutuhkan tempat steril untuk meletakkan

sampel diagnostik (histopathology, culture), culture media, 10% formalin untuk
histopathologi dan microscope slides untuk sitologi.

3
 Gambar 1. Instrument bedah pada metode Biopsi Laparoscopi
(Sumber : Case, J. Brad., et al. 2015)

Hewan diberikan premedikasi dengan atropine (0.02– 0.04 mg/kg IV) dan jika
di butuhkan dengan tambahan acepromazine (0.01–0.05 mg/kg IV). Dan anestesi dapat
di induksi dengan thiopental (15 mg/kg) yang dibantu dengan pemberian oxygen dan
dengan isoflurane 1.2–1.7%
b. Persiapan ruang operasi
Tempat operasi harus dalam keadaan bersih dan steril, letakkan alas plastik di
atas meja operasi dan suhu ruangan operasi harus stabil.
c. Persiapan pasien (hewan)
Pemeriksaan secara menyeluruh yang meliputi pulsus, frekuensi nafas,
temperatur, dan pemeriksaan seluruh sistema. Selain pemeriksaan fisik juga dilakukan
pemeriksaan laboratorium. Pada kasus-kasus yamg memerlukan konfirmasi rontgen
bisa dilakukan rotngen. Pelaksanaan operasi dilakukan jika hewan stabil tetapi jika
hewan tidak stabil maka distabilkan terlebih dahulu.

4
 Hewan dengan kondisi menderita diabetes harus dievaluasi dengan cermat
sebelum operasi, termasuk hitung darah lengkap (CBC), panel biokimia serum
(termasuk glukosa darah puasa, nitrogen urea darah, dan kreatinin), urinalisis, dan
kultur urin. Konsentrasi glukosa darah idealnya harus dipertahankan antara 100 dan 300
mg / dl selama operasi. Hewan dengan diabetes harus diberi makan sehari sebelum
operasi, dan pemberian insulin harus diberikan. Hewan tersebut harus dipuasakan 6
hingga 8 jam sebelum operasi dan operasi harus dilakukan di pagi hari. Konsentrasi
glukosa darah harus diukur pagi hari saat operasi. Satu hingga dua jam sebelum operasi,
jika konsentrasi glukosa darah antara 150 dan 300 mg/ dl, maka hewan tersebut harus
diberikan setengah dari dosis pagi hari insulin secara subkutan. Glukosa darah harus
diperiksa pada saat induksi dan setiap jam sesudahnya. Jika kadar glukosa darah rendah,
0,45% garam dan 2,5% dextrose (10 hingga 15 ml / kg untuk jam pertama, kemudian 5
ml / kg setelahnya jika darah dan kehilangan cairan evaporatif kecil) harus diberikan.
Jika kadar glukosa darah normal, berikan larutan Ringer laktat (pada tingkat yang
sama). Cairan harus diubah menjadi 5% dextrose dan tambahan dosis kecil insulin
reguler diberikan jika konsentrasi glukosa darah lebih besar dari 300 mg / dl. Kunci
untuk manajemen pasien diabetes adalah seringnya pemeriksaan glukosa darah dan
apresiasi variabilitas tanggapan pasien terhadap terapi insulin.

d. Persiapan Operator
Sebelum melakukan operasi, operator maupun co-operator terlebih dahulu
melepas aksesoris yang dapat mengganggu jalannya operasi. Tangan operator dan co-
operator harus steril dalam melakukan operasi untuk menghindari timbulnya infeksi
bawaan dari luar tubuh hewan. Tangan dicuci menggunakan air bersih dan sabun.
Selanjutnya di sterilisasi menggunakan alkohol 70%. Operator dan co-operator juga
harus memperhatikan penghitungan dosis obat yang diberikan untuk tujuan
premedikasi dan anastesi sehingga dosis pemberian tepat dan pengunaan alat-alat
sterilisasi individu digunakan dengan benar serta menjalankan operasi sesuai SOP.

5
2.2 Teknik Operasi

2.2.1 Guillotine Method Via Laparotomy

 Langkah 1
Tempatkan pasien di posisi dorsal recumbency. Selanjutnya diikuti dengan
persiapan aseptik standar, seperti pemberian alkohol 70% yang selanjutnya diberikan juga
larutan Iodine pada daerah yang akan dilakukan pembedahan. Selanjutnya, daerah yang
akan dilakukan bedah ditutupi dengan kain drape dengan daerah yang
terbuka adalah daerah yang akan dilakukan pembedah. Tujuan dilakukannya penutupan
dengan kain drape adalah untuk menjaga sterilisasi daerah yang akan dilakukan
pembedahan.

Gambar 2. Posisi Dorsal Recumbency

Gambar 3. Penutupan dengan kain drape

6
  Langkah 2
Surgical approach

Jika hanya pankreas yang akan di evaluasi, maka menginsisi cranial midline
abdomen dapat dilakukan. Neoplasia adalah diagnosis banding untuk penyakit pada
pankreas, dan biasanya dianjurkan mengeksplorasi keseluruhan abdomen untuk
mengevaluasi bukti patologi pada organ lain.

Gambar 4. Incisi pada bagian kranial abdominal

 Langkah 3
Exploration and pancreatic biopsy
Evaluasi viscera abdomen dan permukaan peritonial. Jaringan abnormal harus
dijadikan sampel untuk histopatologi. Bagian pankreas yang tepat terkandung dalam
mesenterium dari duodenum, yang digunakan untuk manipulasi pankreas secara tidak
langsung. Isolasi area 5 mm dari lesi pankreas atau bagian kanan distal (jika terjadi
penyakit menyebar), dan letakkan ligature melingkar (mirip dengan biopsi hati). Sebagai
alternatif, bursa omental dapat dibuka dan foramen epiflo untuk masuk mengakses
ekstremitas pankreas kiri untuk biopsi. Untuk mendapatkan akses ke ekstremitas pankreas
kiri, tarik ke perut, gunakan jari asisten atau sepasang tang Babcock atraumatik. Seluruh
pankreas (tungkai kiri, sudut, dan tungkai kanan) dapat terlihat jika limpa ditarik ke arah
ventral dan tengkorak. Begitu lokasi pankreas yang diinginkan telah dipilih, kencangkan
ligatur untuk menghancurkan parenkim pankreas dan ligase pembuluh pankreas kecil. Jika
terjadi penyakit pankreas, gunakan ujung distal tungkai kiri untuk pengambilan sampel
untuk menghindari saluran pankreas. Kumpulkan spesimen biopsi yang mentransmisikan
distal jaringan ke ligature dengan pisau bedah

7
 Gambar 5. Jahitan Guillotine ditempatkan (panah). Tangani sampel biopsi secara
perlahan untuk menghindari penghancuran

Gambar 6. Biopsi pankreas telah dihilangkan dan tidak ada perdarahan yang
diamati

 Langkah 4
Control hemorrhage and close

Perdarahan biasanya terhindari karena ligatur melingkar. Jika terjadi pendarahan,

dapat dikendalikan dengan melakukan tekanan yang stabil selama 3 sampai 5 menit atau
steker busa gelatin hemostatik. Tutup abdomen secara rutin, jahit mulai dari peritoneum
hingga kulit menggunakan pola jahitan terputus (simple interrupted).

8
2.3 Perawatan Pasca Operasi

Adapun perawatan pasca operasi biopsi pankreas yang dapat dilakukan yaitu sebagai
berikut.

1. Terapi cairan intravena

Terapi ini adalah prioritas yang paling penting pada hewan dengan tingkat
dehidrasi yang parah, di mana pemeliharaan perfusi jaringan dan pankreas sangat
penting. Cairan yang paling umum digunakan adalah larutan Ringer laktat dan larutan
garam 0,9%. Cairan infus berfungsi untuk meningkatkan perfusi organ, dan
memperbaiki ketidakseimbangan elektrolit tubuh. Hipokalemia sering terjadi akibat
kehilangan potasium dari kombinasi diare, muntah, terapi fluida, dan kekurangan
makanan atau anoreksia. Oleh karena itu, potasium serum harus selalu diukur, dan
kalium harus ditambahkan ke cairan intravena bila diperlukan.
2. Obat nyeri yang disediakan, biasanya opioid seperti butorfanol, buprenorfin,
oxymorphone, meperidine, mengingat bahwa ini dapat menghambat motilitas
gastrointestinal yang normal
3. Jika muntah atau mual terjadi, maka antiemetik (miropitant, odansetron,
dolasetron, metoclopramide, butorfanol sebagai infus kronis)
4. Hewan biasanya tidak diberi makanan atau air selama 24-48 jam (atau kadang kadang
lebih lama), untuk memberikan saluran pencernaan dan pankreas waktu untuk
proses penyembuhan; Namun pemberian pakan dianjurkan jika hewan tidak
muntah dan tidak terasa kesakitan. Pemberian air kemudian pemberian makanan harus
dimulai dengan sejumlah kecil makanan rendah lemak (mungkin kurang dari 2 hingga
3 gram lemak / 100 kkal), makanan lunak (misalnya, nasi, ayam putih yang dihilangkan
lemaknya atau kalkun putih tanpa kulit) dan makanan yang mudah dicerna (karbohidrat
sederhana) makanan yang ditawarkan selama beberapa hari, sampai hewan tersebut
dianggap "normal" di mana saat itu diet normal secara bertahap diperkenalkan kembali.

9
 BAB III
PEMBAHASAN

3.1 Pengertian Biopsi Pankreas

Biopsi pankreas adalah teknik untuk mendiagnosa suatu penyakit / kelainan pada
pankreas dengan teknik sitologi dengan cara mengambil sebagian atau lesi yang ada di
pankreas (pankreatektomi parsial). Biopsi pankreas dapat dilakukan dengan teknik
pembedahan ataupun laparoskopi. Teknik pembedahan hanya membutuhkan peralatan
bedah standar dan dapat melihat dengan mudah dari seluruh pankreas. Namun, teknik
pembedahan menghasilkan cedera jaringan yang lebih besar dan rasa sakit dibandingkan
dengan laparoskopi dan mungkin tidak disukai oleh beberapa klien atau dalam beberapa
kasus. Jika sudah dinyatakan adanya penyakit pankreatik secara difusa, maka biopsi dapat
dilakukan dengan memperoleh sedikit sampel saja. Sedangkan jika penyakit belum
diketahui dengan pasti, maka biopsi secara ganda perlu dilakukan, karena penyakit bisa
fokal ataupun multifokal (Fossum et al., 2013).

3.2 Tujuan Operasi Biopsi Pankreas

Pelaksanaan biopsi pankreas adalah suatu standar yang mutlak perlu dilakukan dalam
mendiagnosis neoplasia pankreatik dan pankreatitis (Case dan Fox-Alvarez, 2015). Biopsi
pankreas kadang-kadang dilakukan pada anjing untuk membedakan kondisi pankreas jinak
(misalnya, pankreatitis, fibrosis pankreas) dari penyakit neoplastik. Pankreatektomi parsial
diindikasikan pada hewan dengan tumor yang mensekresikan insulin atau mensekresi
gastrin dan pada adenokarsinoma pancreas.

10
 BAB IV
SIMPULAN DAN SARAN

4.1 Simpulan
Biopsi pankreas dapat dilakukan dengan teknik pembedahan ataupun
laparoskopi. Teknik pembedahan hanya membutuhkan peralatan bedah standar dan
dapat melihat dengan mudah dari seluruh pankreas. Pada pre operasi biopsy
pankreas, hewan diberikan premedikasi dengan atropine dan jika di butuhkan
dengan tambahan acepromazine. Teknik operasi yang dipakai untuk biopsi
pankreas ini adalah Guillotine Method Via Laparotomy terdiri dari 4 langkah
operasi. Adapun perawatan pasca operasi biopsi pankreas yang dapat dilakukan
yaitu terapi cairan intravena, pemberian obat analgesik (anti nyeri), pemberian obat
anti mual dan muntah, serta puasakan hewan 24-28 jam setelah operasi.

4.2 Saran
Saran memperhatikan didalam melakukan bedah digesti terutama operasi biopsi
pankreas harus memperhatikan semua aspek dan kondisi dari pasien, karena bedah
digesti biopsy pankreas memiliki kekurangan dan kelebihan dalam praktiknya.

11
 DAFTAR PUSTAKA

Case, J.B. Fox-Alvarez, W.A. 2015. Pancreatic Biopsy. Clinician’s Brief.

Fossum, T.W. Dewey, C.W. Horn, C.V. Johnson, A.L. MacPhail, C.M. Radlinsky, M.G.
Schulz, K.S. Willard, M.D. Small Animal Surgery. 4th Edition. Elsevier: Missouri.

K. L. Cosford, C. L. Chosmon, S. L. Myers, S. M. Taylors, A. P. Carr, J. M. Steiner, J. S.

Suchodolski, F. Mantovani. 2010. Pancreatic Biopsy in Cat. Journal of Veterinary
Internal Medicine. 24, 104-113.

Webb, C.B., Trott. C. 2008. Laparoscopic Diagnosis of Pancreatic Disease in Dogs and Cats.
J Vet Intern Med 2008;22:1263–1266

12
LAMPIRAN JURNAL

13
PROCEDURES PRO > DIAGNOSTICS / SURGERY > PEER REVIEWED

Pancreatic Biopsy

J. Brad Case, DVM, MS, DACVS

W. Alexander Fox-Alvarez, DVM
University of Florida

Antemortem diagnosis of pancreatic
disease is a challenge. Histopathology
remains the gold standard of diagnosis
for pancreatic neoplasia and pancreatitis.
Pancreatic biopsy provides a definitive
diagnosis of pancreatitis, assuming a rep-
resentative sample is obtained. An open
or laparoscopic approach can be made to
collect samples.
Open approaches require only standard
surgical equipment and allow easy man-
ipulation of tissue and visualization of the
entire pancreas (important when sam-
pling focal disease involving the left limb).
However, open surgery results in greater
tissue injury and pain compared with a
laparoscopic approach and may not be
favored by some clients or in some cases.
Studies in both human and veterinary
medicine have demonstrated laparoscopic
procedures to have less tissue trauma and
systemic inflammation, lower pain indi-
ces, and reduced patient convalescence
when compared with analogous proce-
dures performed using an open approach.
This decrease in the healing and inflam-
matory demand postoperatively may be

continues

What You Will Need A

Guillotine Biopsy via Laparotomy
n Basic surgery pack (ie, needle
B C D
holders, DeBakey thumb forceps,
mosquito hemostats, Metzenbaum
scissors)

Laparoscopic Biopsy
n Videolaparoscopy tower (A), camera
(B), insufflation tubing (C), and light E
cable (D)
n 2 5-mm trocars and cannulas (E)

n 5-mm laparoscopic clamshell biopsy

forceps (F)
n 5-mm laparoscope 0° (G)

n 5-mm laparoscopic blunt probe (H)

F
Both Methods
n Sterile sample cups for separate
diagnostic samples (histopathology,
culture) G
n Culture media
H
n 10% formalin for histopathology

n Microscope slides for impression

cytology

March 2015 • Clinician’s Brief 19

PROCEDURES PRO

particularly important in patients with STEP-BY-STEP n GUILLOTINE METHOD VIA LAPAROTOMY

delayed healing from metabolic derange-
ments, such as hypoproteinemia, second- STEP 1
ary to their pancreatic disease. While this
Place patient in dorsal recumbency position and follow standard aseptic
approach provides a magnified, illumi-
nated view of the right limb of the pan- preparation.
creas, the left limb of the pancreas is
difficult to evaluate laparoscopically and
may require dissection of the omental
bursa and repositioning of the patient
(beyond the scope of this article). In addi-
tion, laparoscopy requires the use of spe-
cialized equipment and may take slightly
longer to perform for learning practi-
tioners; however, once the procedure can
be completed with confidence, the time
required can be comparable with that for
an open method.

STEP 2
When biopsying the pancreas, if not tar-
geting a specific lesion, the distal aspect Surgical approach. If only the pancreas is to be evaluated, a midline cra-
of the right or left limb of the pancreas is nial abdominal approach can be made. Neoplasia is a differential diagnosis
preferred to decrease the risk for damag- for pancreatic disease, and it is usually advisable to explore the entire
ing important vascular and pancreatic abdomen to evaluate for evidence of pathology in other organs.
structures. Care should be taken to avoid
major blood vessels (eg, caudal pancreati-
coduodenal artery and its branches).

Pancreatic biopsy is a safe procedure.

Despite concerns for adverse sequelae
after pancreatic biopsy, studies suggest
that significant clinical or biochemical
abnormalities are uncommon postopera-
tively.1-4 Patients should be monitored
closely for signs of pancreatitis.

Cranial abdominal approach to the pancreas.

20  cliniciansbrief.com • March 2015

 STEP 3

Exploration and pancreatic biopsy. Evaluate the abdominal viscera and perito-
neal surfaces. Abnormal tissue should be sampled for histopathology. The right
pancreatic limb is contained within the mesentery of the duodenum, which is
used for indirect manipulation of the pancreas. Expose the pancreas and evalu-
ate for gross abnormalities. Isolate a 5-mm area of the pancreatic lesion or distal
right limb (if diffuse disease), and place an encircling ligature in guillotine fashion
(similar to liver biopsy; A and B).
Alternatively, the omental bursa can be opened and the epiploic foramen
entered to access the left pancreatic limb for biopsy. To gain access to the left
pancreatic limb, retract the stomach ventrally, using an assistant’s fingers or a
pair of atraumatic Babcock forceps. The entire pancreas (left limb, angle, and
right limb) can be revealed if the spleen is retracted in a ventral and cranial direc-
tion. Once the desired pancreatic location has been selected, tighten the ligature
to crush the pancreatic parenchyma and to ligate small pancreatic vessels. If dif-
fuse pancreatic disease is present, use the distal tip of the left limb for sampling
to avoid pancreatic ducts. Collect the biopsy specimen transecting tissue distal
to the ligature with a scalpel blade.

A B

Guillotine suture being placed (arrow). Handle biopsy sample gently to Pancreatic biopsy has been removed and no bleeding is observed.
avoid crushing.

STEP 4

Control hemorrhage and close. Hemorrhage is typically avoided because of the Author Insight
encircling ligature. If residual bleeding occurs, it can be controlled using 3 to 5 Large malleable retractors and
minutes of steady digital pressure or a plug of hemostatic gelatin foam. Evaluate laparotomy sponges are useful to
the abdomen for hemorrhage. Close the abdomen routinely. retract the visceral surface of the
stomach to improve exposure during
biopsy of the left pancreatic limb.

continues

March 2015 • Clinician’s Brief 21

PROCEDURES PRO

STEP-BY-STEP n CLAMSHELL BIOPSY FORCEPS METHOD VIA LAPAROSCOPY

STEP 1

Position patient. Reverse Trendelenburg position (ie,
dorsal recumbency, body tilted with head up and feet lower
than head, at approximately 15 degrees) with leftward
obliquity is the authors’ preferred position for descending
limb pancreatic biopsy.
Many endoscopists, however, prefer a right lateral approach
as it provides an immediate view of the pancreas. The
major disadvantage of the right lateral approach is the lack
of ability to view the entire liver, which is often indicated
given the possibility of concomitant inflammatory or neo-
plastic disease and limitations of ultrasonography.
The approach described here can provide excellent visual-
ization of the duodenum, liver, extrahepatic biliary system,
right kidney, and right limb of the pancreas. The left limb of
the pancreas is challenging to view laparoscopically and
should not be attempted without significant training and
experience.

Reverse Trendelenburg and left lateral oblique position. Black lines represent the patient’s position in reverse Trendelenburg and left lateral obliquity.

STEP 2

Surgical approach. Place the initial port 1 to 2 cm caudal to the umbilicus. Port Author Insight
placement is achieved after making an incision through the skin no longer than
Following initial port insertion,
the diameter of the cannula. Continue the incision to the linea alba. A Veress nee-
place all subsequent ports under
dle, 5-Fr catheter, or Hasson method can be used to achieve pneumoperitoneum.
laparoscopic visualization. Once both
Place apposing stay sutures at the margins of the linea. Use a number 11 blade to ports have been placed, reduce the
make a 2- to 3-mm deep stab incision into the linea alba. If a Veress needle is
insufflation pressure to 8 mm Hg to
used, insert it through the incision, being sure to angle the tip approximately 30°
reduce cardiovascular and pulmonary
caudal and to the right of midline to minimize risk of splenic puncture. If a Veress
needle is not available, or if preferred, a modified Hasson method can be per-
effects of pneumoperitoneum.
formed at this point, whereby the blunt trochar and cannula unit are placed into
the incision into the abdomen at the same angle recommended for Veress needle
placement. Alternatively, the catheter technique can be used. A mosquito hemo-
stat is used to insert the tip of a 5-Fr malleable catheter into the abdominal cav-
ity. Once the catheter is inserted, flush 3-mL sterile saline through the catheter to
ensure that no resistance is felt (resistance is an indication of catheter malposi-
tion). If resistance is felt, withdraw the catheter and reinsert. Once saline is

22  cliniciansbrief.com • March 2015

flushed without resistance, attach CO2 insufflation tubing to
the catheter to pressurize the peritoneal cavity to a maxi-
mum of 10–12 mm Hg. The same procedure is performed if
using a Veress needle. Subsequent to pneumoperitoneum,
remove the catheter (or Veress needle) and insert a blunt
trocar-cannula assembly or threaded screw in cannula via
the original stab incision. In some cases, minimal extension
(1–2 mm) of the incision may be needed to facilitate inser-
tion of the cannula.
Trocars should also be inserted in a caudolateral orientation
to reduce the risk of splenic injury. Insert the laparoscope
into the cannula and observe the peritoneum to ensure no
iatrogenic trauma or hemorrhage has occurred. Place a sec-
ond 5-mm instrument cannula under laparoscopic visualiza-
tion 5 cm craniad in a similar fashion to the initial port.

Correct orientation of the Veress

needle during insertion.

Image of correct port position.

STEP 3

Exploration and pancreatic biopsy. Evaluate the perito-

neal cavity by pivoting the laparoscope clockwise around
the port site. Insert the blunt probe under laparoscopic visu-
alization. The laparoscope is used to visualize and guide the
probe into the cranial abdomen.
Inspect the liver and the gall bladder to document any sec-
ondary changes from the pancreatic disease. Evaluate the
pancreas carefully, looking closely for evidence of nodules
or masses. Use the blunt probe to manipulate the duode-
num, omentum, stomach, or spleen as needed to improve
visualization of the right pancreatic limb.
If distinct lesions are noted, plan to biopsy these areas. If no
gross disease or if diffuse disease is present, plan to take 1
Isolation of the distal right limb of the pancreas.
or 2 samples from the distal tip of the right pancreatic limb.

continues

March 2015 • Clinician’s Brief 23

PROCEDURES PRO

After determining an avascular location for biopsy, insert the clamshell

biopsy forceps in place of the blunt probe.
Position the forceps to isolate the desired biopsy site, then close the for-
ceps and maintain pressure for 60–90 seconds. Gentle axial rotation of
the forceps will help release the biopsy sample from the parenchyma. A
caudal tug on the sample while keeping the forceps closed will remove
the sample. Observe the biopsy site for hemorrhage. Repeat this step as
desired for sample collection.

Author Insight A blunt probe is used to retract the duodenum, provid-

If an avascular location at the tip of the right limb cannot be ing better exposure of the pancreas.
identified, consider an open approach with biopsy of the distal
left limb.

Author Insight
The clamshell forceps can be held open and the lower jaw can be
used to gently manipulate the pancreas into position for biopsy.

Clamshell biopsy forceps ready to engage chosen

biopsy sample.

STEP 4

Control hemorrhage and close. Hemorrhage is typically

minimal, and the biopsy site should be observed for 3 min-
utes to ensure hemostasis. If minor hemorrhage occurs,
place a small piece of hemostatic foam into the biopsy
site. Evaluate all biopsy sites for hemorrhage and photo-
document hemostasis and lesions. Release residual gas
from the peritoneal cavity prior to closure. Remove all ports
and close incisions routinely. n cb

References
1. Prospective evaluation of laparoscopic pancreatic biopsies in 11
healthy cats. Cosford KL, Shmon CL, Myers SL, et al. JVIM 24:104-113,
2010. Laparoscopic image after biopsy showing adequate hemostasis at the
2. Laparoscopic diagnosis of pancreatic disease in dogs and cats. biopsy site.
Webb CB, Trott C. JVIM 22:1263-1266, 2008.
3. Evaluation of pancreatic forceps biopsy by laparoscopy in
healthy beagles. Harmoinen J, Saari S, Rinkinen M, Westermarck E.
Vet Ther 3:31-36, 2002.
4. Effect of pancreatic tissue sampling on serum pancreatic
enzyme levels in clinically healthy dogs. Cordner AP, Armstrong PJ,
Newman SJ, et al. J Vet Diagn Invest 22:702-707, 2010.

24  cliniciansbrief.com • March 2015

J Vet Intern Med 2008;22:1263–1266

L a p a r o s c o p i c D i a g n o s i s o f Pa n c r e a t i c D i s e a s e in Do g s a n d C a t s
C.B. Webb and C. Trott

Background: Histopathology is the gold standard for the diagnosis of pancreatic disease. Laparoscopy offers a minimally
invasive route by which to obtain pancreatic biopsies.
Hypothesis: Laparoscopy is a safe and effective technique for evaluating the pancreas in small animal patients.
Animals: Medical records of 18 dogs and 13 cats examined between 1999 and 2007 that underwent laparoscopy during
which observation or biopsy of the pancreas was recorded.
Methods: The database for the Laparoscopy Laboratory at Colorado State University was searched for records that con-
tained ‘‘pancreatitis,’’ ‘‘pancreas,’’ or ‘‘pancreatic.’’ The presenting complaints, imaging studies, and histopathologic findings of
animals were recorded. All hospital admissions were searched for animals with the same presenting complaints and of those it
was determined which animals had exploratory surgery and their pancreas biopsied.
Results: Thirteen cats and 18 dogs underwent laparoscopy for presumptive pancreatic disease or had the appearance of the
pancreas described, pancreatic biopsies obtained, or both. In 14 animals a laparoscopic biopsy of the pancreas resulted in a
histopathologic diagnosis when the sonographic findings or the gross assessment failed to do so. In 35% of the animals a biopsy
of the pancreas was not obtained despite findings consistent with pancreatic disease. Those animals examined for vomiting or
anorexia were significantly more likely to have a biopsy of the pancreas obtained through laparoscopy versus surgery (P o
.0001).
Conclusions and Clinical Importance: Laparoscopy and pancreatic biopsy is useful for evaluation of pancreatic disease.
Key words: Histopathology; Pancreatic biopsy; Ultrasonography.

laparoscopy is a safe and effective technique for evaluat-

he diagnosis of exocrine pancreatic insufficiency is
T relatively straightforward while the diagnosis of
other exocrine pancreatic diseases remains problematic.1
ing the pancreas in dogs and cats.

The introduction of the pancreatic-lipase immunoreac-

tivity (PLI) assay offers a noninvasive blood test reported
to be a sensitive and accurate indicator of exocrine pan-
creatic disease.2–4 But even in animals in which an
increase in PLI suggests pancreatic inflammation, the
source of that inflammation remains unidentified and
could be acute nonsuppurative or chronic lympoplas-
macytic pancreatitis, pancreatic tissue necrosis, culture-
confirmed infection, pancreatic pseudocyst or abscess,
neoplasia, or pancreatitis secondary to another disease
process such as inflammatory bowel disease or bile duct
obstruction. Noninvasive imaging studies such as radio-
graph, ultrasonography, or computed tomography have
variable degrees of sensitivity and specificity, are often
dependent on the experience of the person performing
the study, and cannot provide a tissue diagnosis.5–10 The
gold standard for the diagnosis of exocrine pancreatic
disease in animals remains histopathology.
Laparoscopy offers a minimally invasive route by
which to obtain pancreatic biopsies and allows direct
evaluation of the pancreas and surrounding tissues, aid-
ing in the diagnosis of exocrine pancreatic disease. The
purpose of this retrospective study was to determine if
From the Department of Clinical Sciences, College of Veterinary
Medicine and Biomedical Sciences, Colorado State University, Fort
Collins, CO.
Corresponding author: Dr Craig B. Webb, DVM, PhD, Depart-
ment of Clinical Sciences, College of Veterinary Medicine and
Biomedical Sciences, Colorado State University, Fort Collins, CO
80523; e-mail: cbwebb@colostate.edu.
Submitted December 3, 2007; Accepted June 30, 2008.
Copyright r 2008 by the American College of Veterinary Internal
Medicine
10.1111/j.1939-1676.2008.0176.x
Materials and Methods
Selection of Cases
The electronic database for the Laparoscopy Laboratory at Col-
orado State University (CSU) was searched for cases that contained
‘‘pancreatitis,’’ ‘‘pancreas,’’ or ‘‘pancreatic’’ in the patient Problem
List or Laparoscopic Diagnosis/Findings section of the Laparos-
copy Case Report; a standardized document completed by the
clinician performing the laparoscopic procedure. The CSU elec-
tronic medical record was then accessed for each animal identified in
the laparoscopy search. Information was recorded from the lap-
aroscopy report and the medical record corresponding to the time of
the laparoscopic procedure and included signalment, presenting
complaint, radiographs and ultrasonographic imaging report, lap-
aroscopic diagnosis, complications associated directly with the lap-
aroscopic procedure, and histopathology of the pancreatic biopsy
when taken. All ultrasound imaging studies and histopathologic as-
sessments were reviewed by board-certified radiologists and
pathologists, respectively. This study was not designed to assess the
variability in interpretation between different radiologists or pa-
thologists, but instead to identify the information available to the
clinician performing the laparoscopy on each animal.
Thirty-one animals where the pancreas was evaluated during a
laparoscopic procedure were identified between 1999 and 2007. It
was determined whether the laparoscopic procedure was used to vi-
sualize or biopsy the pancreas. The relative degree of congruity
between laparoscopic and ultrasonographic results for each individ-
ual animal was also determined.
For the same time period the CSU electronic medical records
were searched for any hospital admissions of dogs or cats with any
of the 5 presenting complaints identified most frequently by the
Laparoscopy Laboratory data base search (vomiting, anorexia,
weight-loss, elevated liver enzymes, and icterus). It was determined
how many of those animals had exploratory abdominal surgery (not
including those that had surgery to remove a foreign body or for
gastric dilatation and/or volvulus), and of those, how many had a
pancreatic biopsy (Table 1).
1264 Webb and Trott

Table 1. Summary of pancreatic biopsies for cats and dogs from 1999 through 2007.
Presenting Hospital Laparoscopy Pancreatic Surgical Pancreatic
Complaint Admissions Search Criteria Biopsy (LAP) Explore Biopsy (SX)
Vomiting 2,418 19 13 42 2
Anorexia 133 16 13 4 0
Wt loss 323 6 5 3 1
" Liver enzymes 186 10 5 4 1
Icteric 5 3 3 0 0

The total number of cats and dogs who presented for each of the 5 most common presenting complaints identified by the search of the
Laparoscopy Laboratory database for pancreatic disease is summarized. The number of those animals that underwent laparoscopy or ex-
ploratory abdominal surgery are presented as well as the number of pancreatic biopsies that were obtained with those procedures.
LAP, number of pancreatic biopsies obtained during a laparoscopy procedure; SX, number of pancreatic biopsies obtained during ab-
dominal exploratory surgery; wt, weight.

Statistical Analysis 1 Miniature Schnauzer with a prior history of diabetes

A contingency table was used to compare the prevalence of
pancreatic biopsy during laparoscopy versus abdominal surgery
in patients presenting for vomiting or anorexia. Probability and
significance (P o .05) by a Fischer’s exact test was determined by
standard statistical software.a
Results
Animals
This search identified 31 animals in which 1 or more of
the 3 key words were included in 1 or more of the iden-
tified sections of the Laparoscopy Case Report. There
were 13 cats (9 domestic shorthair, 2 domestic longhair, 1
Maine Coon, and 1 Siamese) and 18 dogs (6 mixed-breed
and 12 purebred canines, with only the Labrador Re-
triever being represented twice). The mean age of the cats
was 11.8
3.1 years; the mean age of the dogs was 7.8

4.6 years.
Pancreatitis appeared in the Problem List in 6/31
(19%) animals. Other Problem List entries identified by
the search criteria included an ultrasonographic descrip-
tion of the pancreas as enlarged (3 animals) or thickened
(1 animal). At least 1 of the search criteria terms ap-
peared in the Laparoscopic Diagnosis section of the
record for every animal. Pancreatitis appeared in the
Laparoscopic Diagnosis in 13/31 (42%) animals with 3
of those being described as chronic. Other descriptions
associated with the 3 search criteria terms in the Lap-
aroscopic Diagnosis portion of the record included
edematous (10 animals), enlarged (8 animals), omental
adhesions involving the pancreas (5 animals), nodular (6
animals), neoplasia (3 animals), saponification (2 ani-
mals), and hypoplasia (2 animals). The pancreas was
described as normal in 5/31 (16%) animals.
Presenting Complaint
The most common presenting complaint was vomiting
(19 animals), followed by anorexia (16 animals), elevated
liver enzymes (10 animals), weight loss (6 animals),
and icterus (5 animals). Only 2 animals had diarrhea as
part of their presenting complaint. Other presenting com-
plaints described in single animals included fever, melena,
abdominal effusion, PU/PD, hepatic encephalopathy, in-
continence, and phenobarbital administration. There was
mellitus, and 1 mixed-breed dog with a prior history of
pancreatitis.
Abdominal Radiographs and Abdominal Ultrasound
Eight of 31 (26%) animals had radiographs taken
shortly before the laparoscopic procedure. In 3 animals
the radiographs were of the thorax to rule-out metastatic
disease and were reported as normal. In 5 animals the ra-
diographs were of the abdomen; 2 were normal, the other
3 identified hepatomegaly.
In 26/31 (84%) animals an abdominal ultrasound was
performed shortly before the laparoscopic procedure. In
8 animals the pancreas was not mentioned or could not
be found and recorded as ‘‘not seen’’ by the ultrasonog-
rapher, in 5 animals the pancreas was reported to be
normal. Abnormalities of the pancreas listed in the re-
maining ultrasonographic reports included pancreatic
enlargement (7 animals) or other changes that were con-
sidered consistent with pancreatitis (10 animals), changes
that were thought to be consistent with pancreatic neopl-
asia (3 animals), or an abnormal pancreatic echogenicity
(4 animals). Nonpancreatic abnormalities were noted in
the liver (14 animals), kidneys (6 animals), gallbladder (4
animals), stomach or intestines (3 animals), omental fat
or mesenteric lymph nodes (3 animals), spleen (2 ani-
mals), and prostate (1 animal).
Histopathology of the Pancreas
Histopathology of pancreatic tissue was obtained
in 20/31 animals (65%). In 7 animals the pancreatic
tissue was normal. Pancreatic abnormalities noted on the
histopathology report included pancreatitis (4 animals),
nodular hyperplasia (3 animals), fibrosis (3 animals),
atrophic exocrine acini (3 animals), inflammatory
infiltrates including lymphocytes, neutrophils and/or
plasma cells (2 animals), neoplasia; either carcinoma (2
animals) or adenocarcinoma (1 animal), or lobular
atrophy (2 animals).
Compilation of Results
In 11/18 dogs (61%) and 9/13 cats (69%) that under-
went laparoscopy a biopsy was taken of the pancreas and
a histopathologic diagnosis was obtained.
 Laparoscopy and Pancreatic Disease
Histopathology of the pancreas was available for 11
dogs. In 9 of the dogs, an ultrasound was performed be-
fore laparoscopy, and in 2/9 (22%) the ultrasound report
was in agreement with the pancreatic histopathology.
In 7/9 (78%), the laparoscopic appearance was in accor-
dance with the histopathologic diagnosis. Histopatho-
logy of the pancreas was available for 9 cats. In 6 of the
cats, an ultrasound was performed before laparoscopy,
and in 3/9 (33%) the ultrasound report was in agreement
with the pancreatic histopathology. In 5/9 (56%), the
laparoscopic appearance was in accordance with the
histopathologic diagnosis.
In 14 animals, a laparoscopy-assisted biopsy of the
pancreas resulted in a histopathologic diagnosis of dis-
ease where either the sonographic findings or the gross
assessment failed to do so or were wrong, for example,
finding pancreatic carcinoma in cases of suspected pan-
creatitis.
Comparing laparoscopy to exploratory surgery, con-
tingency tables showed a significantly greater probability
that a biopsy of the pancreas would be obtained for
animals examined for vomiting (P o .0001) or anorexia
(P 5 .007) that underwent laparoscopy (Table 2).
There were no reports of any complications associated
with the laparoscopy-assisted pancreatic biopsy proce-
dure in any of the 31 laparoscopy reports reviewed.
Discussion
Laparoscopy offers a minimally invasive route by
which pancreatic biopsies can be obtained. Results of
this retrospective study suggests that laparoscopy is a
safe and potentially underutilized diagnostic tool in ani-
mals where exocrine pancreatic disease is a prominent
differential diagnosis, as in dogs and cats examined for
vomiting, anorexia, or both.11 A biopsy of the pancreas
was obtained in 65% of the animals identified by the
search criteria used in this study. That leaves 35% of the
animals where a histopathologic diagnosis was not ob-
Table 2. Contingency tables.
LAP SX
a
Vomiting
Biopsy 13 3 16
No biopsy 6 31 37
19 34 53
Anorexiab
Biopsy 13 0 13
No biopsy 3 4 7 ated with laparoscopy. Contingency tables show that
16 4 20
Contingency tables showing the number of pancreatic biopsies
that were obtained during laparoscopy compared with exploratory
abdominal surgery for all hospital admissions between 1999 and
2007. A separate table is shown for the 2 most common presenting
complaints identified by the search of the laparoscopy database,
vomiting, and anorexia.
a
Pb with LAP 5 68%, Pb with SX 5 9%, P o .0001.
b
Pb with LAP 5 81%, Pb with SX 5 0%, P 5 .007.
Pb, probability; LAP, laparoscopy; SX, exploratory abdominal
surgery; Biopsy, biopsy of the pancreas.
1265
tained. For those animals where a pancreatic biopsy was
not obtained, possible explanations include the search
parameters themselves, the clinicians judgment regarding
the likelihood of pancreatic disease, or even the clinicians
position regarding the safety or yield of laparoscopy-
assisted pancreatic biopsies.12 There were 4 animals
where both sonographic findings and gross observation
were consistent with a diagnosis of pancreatitis, but no
pancreatic biopsy was obtained. There were an addi-
tional 6 animals where ultrasound was either not
performed or no pancreatic abnormalities were reported,
but gross observation was consistent with pancreatitis,
and yet still no pancreatic biopsy was taken.
Histopathology identified 3 animals with pancreatic
neoplasia: in 1 of those animals the sonographic findings
were suggestive of pancreatic disease, but in the other 2
animals the pancreas was either not mentioned or de-
scribed as normal. There were 6 animals where the
sonographic findings were reported as being consistent
with pancreatitis while histopathology revealed either
normal pancreas or pancreatic hyperplasia. Both scenar-
ios illustrate the important role that laparoscopy-assisted
biopsy of pancreatic tissue could have on decisions re-
garding an animal’s prognosis or medical management.
None of the laparoscopic reports recorded the number
of pancreatic biopsies taken, or if multiple biopsies were
obtained, from what regions of the pancreas. Review of
the histopathologic blocks showed that in only 4 animals
was more than 1 piece of pancreas submitted, and never
more than 2. Several reports show that histological sec-
tions of pancreatic biopsies obtained at necropsy reveal
that pancreatic disease is often not diffuse.13,14 Although
it could be assumed that the clinician biopsied an area of
tissue that appeared grossly abnormal, it cannot be as-
sumed that a single or very small number of biopsies
would necessarily identify focal pathology in all animals.
Some of the animals where pancreatic histopathology
was described as normal may still have had pancreatic
pathology that went undetected.
The number of cats and dogs that present for vomit-
ing, anorexia, weight loss, or elevated liver enzymes far
exceeds the number of cats and dogs for which laparos-
copy is performed as a diagnostic procedure. Expla-
nations for this disparity include the diagnostic pursuit
of differentials for which laparoscopy would not be indi-
cated such as renal failure, diabetes, or hyperthyroidism;
the opportunity for more extensive intervention possible
with abdominal surgery such as removal of a mass; the
cost of the procedure; or the morbidity and risks associ-
dogs and cats presented for vomiting or anorexia are sig-
nificantly more likely to have a pancreatic biopsy if they
undergo laparoscopy than if they undergo abdominal ex-
ploratory surgery, even excluding those cases in which
surgery was performed for the express purpose of remov-
ing a foreign body or correcting a gastric dilatation and/
or volvulus. This may be a reflection of the fact that pan-
creatic disease is, for most part, considered a medical
condition, and at this institution diagnostic laparoscopy
is performed by members of the small animal medicine
staff.
1266 Webb and Trott
Being cognizant of shortcomings in the current use of
laparoscopy should help guide the more effective and
productive utilization of this tool in the diagnosis of pan-
creatic disease. Inherent weaknesses in retrospective
studies that are particularly relevant to these results in-
clude the dependence on different clinicians filling out
forms and the reliance on thorough and accurate report-
ing of observations. The unwritten assumption that the
pancreas is most likely normal if not observed during a
sonographic study or not noted in a laparoscopy report
are 2 examples of potentially lost data points.
Footnote
a
SAS/STAT statistical software, Cary, NC
References
1. Zoran DL. Pancreatitis in cats: Diagnosis and management of
a challenging disease. J Am Anim Hosp Assoc 2006;42:1–9.
2. Steiner JM, Williams DA. Development and validation of a ra-
dioimmunoassay for the measurement of caning pancreatic lipase
immunoreactivity in serum of dogs. Am J Vet Res 2003;64:1237–1241.
3. Steiner JM, Wilson BG, Williams DA. Development and an-
alytical validation of a radioimmunoassay for the measurement of
feline pancreatic lipase immunoreactivity in serum. Can J Vet Res
2004;68:309–314.
4. Forman MA, Marks SL, De Cock HE, et al. Evaluation of
serum feline pancreatic lipase immunoreactivity and helical com-
puted tomography versus conventional testing for the diagnosis of
feline pancreatitis. J Vet Intern Med 2004;18:807–815.
5. Manczur F, Vörös K. Gastrointestinal ultrasonography
of the dog: A review of 265 cases (1996–1998). Acta Vet Hung 2000;
48:9–21.
6. Moon ML, Biller DS, Armbrust LJ. Ultrasonographic ap-
pearance and etiology of corrugated small intestine. Vet Radiol
Ultrasound 2003;44:199–203.
7. Jaeger JQ, Mattoon JS, Bateman SW, et al. Combined use of
ultrasonography and contrast enhanced computed tomography to
evaluate acute necrotizing pancreatitis in two dogs. Vet Radiol Ul-
trasound 2003;44:72–79.
8. Hess RS, Saunders HM, Van Winkle TJ, et al. Clinical, clin-
icopathologic, radiographic, and ultrasonographic abnormalities in
dogs with fatal acute pancreatitis: 70 cases (1986–1995). J Am Vet
Med Assoc 1998;213:665–670.
9. Saunders HM, Van Winkle TJ, Drobatz K, et al. Ultrasono-
graphic findings in cats with clinical, gross pathologic, and
histologic evidence of acute pancreatic necrosis: 20 cases (1994–
2001). J Am Vet Med Assoc 2002;221:1724–1730.
10. Gerhardt A, Steiner JM, Williams DA, et al. Comparison
of the sensitivity of different diagnostic tests for pancreatitis in cats.
J Vet Intern Med 2001;15:329–333.
11. Washabau RJ. Feline acute pancreatitis—Important species
differences. J Feline Med Surg 2001;3:95–98.
12. Marmoinen J, Saari S, Rinkinen M, et al. Evaluation of pan-
creatic forceps biopsy by laparoscopy in healthy beagles. Vet Ther
2002;3:31–36.
13. De Cock HE, Forman MA, Farver TB, et al. Prevalence and
histopathologic characteristics of pancreatitis in cats. Vet Pathol
2007;44:39–49.
14. Newman S, Steiner J, Woosley K, et al. Localization of pan-
creatic inflammation and necrosis in dogs. J Vet Intern Med 2004;
18:488–493.