TUGAS KELOMPOK

ILMU BEDAH KHUSUS VETERINER

BEDAH SISTEM DIGESTI I

TEKNIK OPERASI BIOPSI HATI PADA HEWAN KECIL

OLEH:

KELOMPOK 1

KELAS A

REYNARA WILDAN PRATAMA 1809511111

ADITHYA FAUZAN 1909511001

LILY SIN INA INDAYANI 1909511002

NI LUH PUTU SUARNITI 1909511003

SITI PUTRINDAH MENTARI 1909511004

RAHMA ANISSA PRAYOKO 1909511005

FAKULTAS KEDOKTERAN HEWAN

UNIVERSITAS UDAYANA

2022
 KATA PENGANTAR

Segala Puji dan syukur kami panjatkan atas kehadiran Tuhan Yang Maha
Esa yang telah melimpahkan segala rahmat-Nya sehingga kami dapat
menyelesaikan makalah bedah sistem digesti I dengan judul “Teknik Operasi
Biopsi Hati pada Hewan Kecil” guna memenuhi kebutuhan tugas Ilmu Bedah
Khusus Veteriner.
Seiring dengan berakhirnya penyusunan makalah ini, sepantasnyalah kami
mengucapkan terima kasih kepada berbagai pihak yang telah turut membantu dalam
penyusunan makalah ini.
Kami juga menyadari masih banyaknya kekurangan dalam penyusunan
makalah ini, oleh karena itu kami memohon maaf apabila terdapat kesalahan atau
kekurangan pada makalah ini. Selain itu, kami berharap adanya kritik dan saran
yang membangun dari pembaca agar makalah ini menjadi lebih baik. Semoga
makalah ini dapat bermanfaat bagi penulis maupun pembaca.

Denpasar, 26 Maret 2022

Kelompok 1

ii
 DAFTAR ISI

KATA PENGANTAR......................................................................................... ii
DAFTAR ISI .....................................................................................................iii
DAFTAR GAMBAR ......................................................................................... iv
I. PENDAHULUAN ........................................................................................... 1
1.1 Latar Belakang ......................................................................................... 1
1.2 Rumusan Masalah ..................................................................................... 2
1.3 Tujuan...................................................................................................... 2
1.4 Manfaat .................................................................................................... 2
II. PEMBAHASAN ............................................................................................ 3
2.1 Definisi Biopsi Hati .................................................................................... 3
2.2 Pre-operasi dan Anestesi............................................................................ 4
2.3 Prosedur Operasi ...................................................................................... 7
2.4 Hasil dan Pasca Operasi........................................................................... 15
III. KESIMPULAN .......................................................................................... 16
3.1 Kesimpulan............................................................................................. 16
3.2 Saran...................................................................................................... 16
DAFTAR PUSTAKA........................................................................................ 17

iii
 DAFTAR GAMBAR

Gambar 1: Jatuhkan loop jahitan di atas ujung hati ke dalam celah alami di
sepanjang margin (Sumber: Tobias, K.M. 2010).................................................. 8
Gambar 2: Jika margin dibulatkan, hancurkan tepi margin hati dengan hemostat . 8
Gambar 3: Tarik hemostat tertutup dengan lembut menjauh dari tepi untuk
membuat celah (Sumber: Tobias, K.M. 2010). .................................................... 9
Gambar 4: Kencangkan loop jahitan di sekitar pangkal jaringan sampai itu
menghancurkan semua parenkim tertutup (Sumber: Tobias, K.M. 2010). ............. 9
Gambar 5: Transeksi jaringan distal ke pengikat (gbr a. dengan gunting, gbr.b
dengan pisau scalpel ) ........................................................................................ 9
Gambar 6: Ambil tusukan jaringan hati melalui lobus hati tegak lurus dengan
margin (Sumber: Tobias, K.M. 2010). .............................................................. 10
Gambar 7: Ikat satu atau dua lemparan, kencangkan untuk memotong parenkim.
Potong ujung jahitan menjadi pendek (Sumber: Tobias, K.M. 2010). ................. 10
Gambar 8: Ambil tusukan kedua sejajar dengan yang pertama. Kencangkan
lemparan, biarkan kedua ujungnya Panjang (Sumber: Tobias, K.M. 2010). ........ 11
Gambar 9: Lewati jahitan melalui celah yang dibuat oleh dua pengikat dan di sekitar
pangkal jaringan (Sumber: Tobias, K.M. 2010). ................................................ 11
Gambar 10: Ikat loop jahitan dan transek jaringan di luar ligature (Sumber: Tobias,
K.M. 2010). ..................................................................................................... 11
Gambar 11: Putar punch ke parenkim hati, lalu miringkan pukulan sedikit sambil
maju lebih jauh untuk memutuskan dasar jaringan (Sumber: Tobias, K.M. 2010).
....................................................................................................................... 12
Gambar 12: Lubang punch yang dihasilkan (Sumber: Tobias, K.M. 2010). ........ 12
Gambar 13: Buat sayatan 2 sampai 4 cm melalui kulit, jaringan subkutan, dan linea
tepat di kaudal xiphoid (Sumber: Tobias, K.M. 2010)........................................ 13
Gambar 14: Pegang tepi hati yang terbuka dengan tang clamshell biopsy forceps;
tahan rahang tertutup selama 10 sampai 20 detik sebelum menarik forsep menjauh
dari hati (sumber: Tobias, K.M. 2010) .............................................................. 13
Gambar 15: sampel akhir (Sumber: Tobias, K.M. 2010). ................................... 14

iv
 I. PENDAHULUAN

1.1 Latar Belakang

Di Indonesia, penyakit pada organ hati banyak dijumpai terutama penyakit
hati menahun yang disebabkan oleh virus hepatitis (B,C,D). Virus ini dapat
menyebabkan berbagai perubahan pada struktur hati mulai dari yang ringan sampai
menjadi sirosis hati ataupun mengalami perubahan degenerasi malignan dalam
jangka waktu yang lama. Untuk melihat adanya perubahan pada struktur hati dan
derajat kerusakan pada hati dilakukan pemeriksaan biopsi hati.

Tindakan biopsi ini merupakan hal yang penting oleh karena dapat
digunakan untuk membantu menegakkan diagnosa yang lebih akurat, menentukan
staging dan grading dari perubahan struktur hati , menentukan terapi yang lebih
tepat dan untuk menentukan prognosis dari penyakit hati tersebut. Biopsi pada
organ hati ini sangat penting dilakukan terutama untuk penatalaksanaan hepatitis
kronik, juga dapat di gunakan untuk membantu menegakkan diagnosa
hemochromatosis, occult hepatitis B dan Non alcoholic steatosis Hepatitis.

Dalam bidang ilmu patologi anatomi, pemeriksaan histopatologi pada

jaringan hasil biopsi hati merupakan gold standard, oleh karena memeriksa secara
langsung struktur histopatologi jaringan dari hati. Melalui biopsi hati dapat dilihat
secara langsung perubahan-perubahan jaringan kolagen stroma antara lain fibrosis
dan nekrosis . Untuk mendapatkan diagnosa yang pasti pada penyakit hati, selain
tindakan biopsi, diperlukan juga pemeriksaan penunjang lainnya seperti
pemeriksaan laboratorium dan images analysis.

1
1.2 Rumusan Masalah
1. Bagaimana persiapan operasi biopsi hati pada hewan kecil?
2. Bagaimana anestesi untuk biopsi hati pada hewan kecil?
3. Bagaimana prosedur operasi biopsi hati pada hewan kecil?
4. Bagaimana hasil dan pasca operasi biopsi hati pada hewan kecil?

1.3 Tujuan
1. Mengetahui preoprasi biopsi hati pada hewan kecil.
2. Mengetahui anastesi untuk operasi biopsi hati pada hewan kecil.
3. Mengetahui prosedur operasi biopsi hati pada hewan kecil.
4. Mengetahui hasil dan pasca operasi biopsi hati pada hewan kecil.

1.4 Manfaat
1. Menambah ilmu mengenai teknik operasi biopsi hati pada hewan kecil.
2. Menambah pemahaman serta bacaan tentang Ilmu Bedah Khusus Veteriner.
3. Memberi teori mengenai teknik operasi biopsi hati pada hewan kecil.

2
 II. PEMBAHASAN

2.1 Definisi Biopsi Hati

Biopsi hati merupakan prosedur medis dimana sejumlah jaringan hati
diangkat melalui operasi agar bisa di analisis dalam laboratorium. Biopsi hati
biasanya dilakukan untuk mengevaluasi penyakit seperti sirosis, untuk mendeteksi
infeksi, inflamasi atau sel kanker. Biopsi hati memungkinkan agar organ hati di
inspeksi secara visual dan palpasi, menyediakan oportunitas ideal untuk
mendapatkan sampel biopsi dari lesi fokal untuk examinasi histologi, tes
sensitivitas antimikrobial dan kultur.
Indikasi untuk melakukan biopsi hati termasuk peningkatan aktivitas enzim
hati secara substansial atau persisten atau konsentrasi asam empedu serum,
hiperbilirubinemia hati, perubahan umum pada ekogenisitas ultrasonografi hati,
hepatomegali yang tidak dapat dijelaskan, atau adanya lesi fokal soliter atau
multipel dalam parenkim hati. Biopsi hati sangat penting ketika hasil pengujian
biokimia dan modalitas pencitraan canggih seperti ultrasonografi atau skintigrafi
tidak memadai untuk menegakkan diagnosis. Selain itu, informasi histologis dapat
digabungkan dengan diagnosis yang telah ditentukan untuk menyesuaikan protokol
pengobatan tertentu, mengevaluasi respons terhadap terapi, dan menentukan
prognosis. Indikasi spesifik untuk biopsi bedah termasuk mikrohepatia, abses hati
atau kista, atau lesi yang sulit dilokalisasi pada pemeriksaan ultrasonografi. Selain
itu, biopsi eksisi dari massa bertangkai atau soliter dapat memberikan peluang
pengobatan.
Biopsi hati juga direkomendasikan pada pasien dengan hepatomegali umum
yang tidak dapat dijelaskan atau ekogenisitas hati yang berubah pada USG. Sampel
hati dapat diperoleh secara perkutan atau dengan biopsi bedah terbuka atau
laparoskopi. Sampel yang diperoleh dengan biopsi bedah lebih besar dan lebih
mungkin memiliki kualitas diagnostik daripada yang diperoleh perkutan.
Pendekatan bedah juga mengurangi risiko kerusakan yang tidak disengaja ke
kantong empedu atau organ lain pada pasien dengan hati kecil.

3
2.2 Pre-operasi dan Anestesi
2.2.1 Preoperasi
Berikut merupakan tahapan preoperasi yang dapat dilakukan sebelum
melaksanakan pembedahan biopsi hati:

1. Alat dan Bahan

⁻ Alat :
Spuit 1 ml, scalpel, needle, needle holder, tampon, klem,
sarung tangan, lampu operasi, pinset anatomis, gunting
bedah, jarum, alat tambahan untuk monitoring (capnograf,
elektrokardiograf, monitor tekanan darah arteri, dan pulse
oximeter).
⁻ Bahan:
Anestesi (opiat kombinasi benzodiazepine atau
kombinasi ketamin dan diazepam) cairan infus dan
dukungan onkotik, analgesik serta benang absorbable
monofilament suture
2. Ruang Operasi
Ruang operasi yang akan digunakan untuk pembedahan
biopsi hati harus dalam kondisi yang bersih dengan penerangan yang
cukup, di dalam ruang operasi harus terdapat alas kaki khusus, meja
operasi yang bersih, dan diberi underpad. Sebelum operasi, ruang
operasi harus dibersihkan menggunakan desinfektan dan untuk meja
operasi didesinfeksi dengan alkohol 70%.
3. Hewan / Pasien
Sebelum melakukan pembedahan semua pasien harus
menjalani tes diagnostik pra-bedah (hitung darah lengkap, jumlah
trombosit, serum chemistry profile, tes koagulasi, urinalisis) untuk
menentukan perawatan perioperatif yang harus diberikan.
Contohnya, hewan dengan penyakit hati dapat mengalami muntah
yang mengakibatkan dehidrasi dan kelainan elektrolit. Kekurangan
kalium atau magnesium sebelum operasi dapat menyebabkan ileus,
aritmia, dan komplikasi lain selama atau setelah operasi, sehingga

4
penting untuk melakukan tes diagnostik sebelum anestesi. Hewan
dengan penyakit hati yang parah atau sepsis mungkin memiliki
waktu pembekuan yang lama, memerlukan pencocokan silang dan
transfusi sebelum operasi. Pada hewan yang diduga menderita
neoplasia harus menjalani stadium penyakit, termasuk radiografi
toraks dan ultrasonografi perut. Dengan ultrasonografi dapat
memberikan diagnosis pada beberapa pasien dan meniadakan
kebutuhan untuk pembedahan.
Jika memungkinkan, puasakan pasien selama 12 jam
sebelum operasi. Sebelum operasi, berikan cairan (hipoalbuminemia
cairan koloid seperti hetastarch atau plasma) dan analgesik. Induksi
dapat dilakukan dengan propofol intravena atau dengan isofluran
menggunakan mask induction. Klip pasien yang menjalani biopsi
hati ke tingkat midsternal, dan klip pasien yang menerima selang
makanan lebih jauh ke lateral di perut. Semua pasien harus memiliki
pipa endotrakeal berukuran tepat dengan manset yang mengembang.
Selama anestesi, infus fentanil dengan kecepatan terus menerus
dapat diberikan untuk mengurangi kebutuhan anestesi gas. Infus ini
dapat dilanjutkan pasca operasi untuk memberikan analgesia.
Idealnya, fungsi pernapasan dan jantung serta oksigenasi
harus dipantau selama anestesi dengan kapnografi,
elektrokardiograf, monitor tekanan darah arteri, dan oksimeter nadi.
Mempertahankan tekanan darah intraoperatif dengan cairan dan
dukungan onkotik sangat penting pada pasien dengan penyakit hati
karena penurunan perfusi hati dapat memiliki efek merusak pada
fungsi hati pasca operasi. Forced-air heating blankets dapat
digunakan untuk menghangatkan pasien selama prosedur.
Antibiotik profilaksis biasanya tidak diperlukan pada pasien
yang menjalani biopsi hati. Dokter hewan dapat mengambil sampel
kultur selama prosedur dan memasang selang makanan pada
beberapa pasien. Kauter harus tersedia intraoperatif untuk pasien
dengan koagulopati. Hitung spons dan bantalan laparotomi sebelum

5
 perut dibuka dan sekali lagi sebelum ditutup untuk mencegah benda
asing peritoneum iatrogenik. Hisap semua cairan dari rongga perut
sebelum penutupan.
4. Persiapan Operator
Biopsi hati merupakan prosedur yang aman jika dilakukan
oleh operator yang berpengalaman. Operator yang melakukan
operasi atau pembedahan biopsi hati perlu memiliki kriteria tertentu
yaitu memiliki kebersihan pribadi yang baik yaitu memiliki kondisi
sehat serta melakukan persiapan diri (mencuci tangan dengan sabun
antiseptik, memakai baju operasi, glove, masker, dan penutup
kepala). Operator harus mampu memprediksi hal-hal yang akan
terjadi atau dapat menggambarkan bahaya-bahaya yang mungkin
timbul pada waktu pelaksanaan operasi. Operator juga harus mampu
memperkirakan hasil operasi (prognosis) dan terampil dalam
melakukan pembedahan.

2.2.2 Anestesi
Berikan pasien hipoalbuminemia cairan koloid seperti hetastarch atau
plasma untuk memberikan dukungan tekanan onkotik. Pilih premedikasi dan dosis
dengan hati-hati karena metabolisme beberapa obat mungkin tertunda ketika
disfungsi hati hadir. Umumnya dokter hewan menggunakan opiat yang
dikombinasikan dengan benzodiazepin pada anjing dan kucing atau kombinasi
ketamin dan diazepam pada kucing. Jika acepromazine diberikan sebagai obat
penenang, dosis total tidak boleh melebihi 0,25 mg.

6
2.3 Prosedur Operasi
Pada hewan yang menjalani biopsi hati, sayatan garis tengah ventral harus
dimulai dari kaudal ke prosesus xiphoid untuk menghindari perforasi diafragma.
Ligasi dan amputasi lemak falsiform mungkin diperlukan untuk mengekspos hati
kecil. Jika seliotomi akan dilakukan, seluruh perut harus dieksplorasi untuk
kelainan. Untuk meningkatkan eksposur, bantalan laparotomi yang dibasahi dapat
ditempatkan di antara diafragma dan lobus hati. Salah satu sudut bantalan dapat
diikat ke gorden dengan hemostat agar tidak tertinggal di perut secara tidak sengaja.

Pada hewan dengan penyakit difus yang tidak memerlukan eksplorasi, hati
dapat dibiopsi melalui insisi lubang Keyhole ventral 2 sampai 4 cm. Hati dengan
penyakit difus dapat diambil sampelnya dengan forsep biopsi kulit kerang atau
teknik ligasi jahitan guillotine. Jahitan kotak mungkin diperlukan pada hewan
dengan lobus bulat. Ligasi jahitan biasanya dilakukan dengan bahan monofilamen
yang dapat diserap dengan cepat 3-0.

 Biopsy guillotine

Metode guillotine digunakan untuk mengambil sampel tepi hepar dari lobus
yang runcing atau bermata tajam.

1. Bentuk lingkaran dengan jahitan monofilamen yang dapat diserap 3-0,

buatlah suture loop 3 hingga 4 cm menggunakan satu kali ikatan sederhana
atau surgeon’s throw.
2. Lingkari ujung lobus hati dengan loop jahitan. Masukkan setidaknya 1 cm
jaringan di suture loop.
a. Jika ada celah alami di dekat ujung lobus, jatuhkan jahitan ke dalam
celah (Gambar 1).
b. Jika tepi hepar membulat, himpitkan tepi ujung lobus hepar pada kedua
sisi dengan forsep hemostatik untuk membuat celah (gbr. 2 dan 3).
Jatuhkan jahitan ke dalam celah.
c. Jika lobus hati tidak dapat dengan mudah terbuka, masukkan tang
jaringan Allis melalui suture loop. Pegang setidaknya 1 cm dari ujung
hati dengan forsep. Tarik perlahan lobus hati dan geser jahitan di sekitar
jaringan hati tepat di luar forsep.

7
 3. Kencangkan loop jahitan sampai menembus semua jaringan hati,
membiarkan pembuluh darah dan saluran tetap utuh (gbr. 4). Jangan
mengangkat jahitan saat mengencangkan atau menarik pengikat dan
merobek pembuluh darah. Satu ikatan sudah cukup untuk hemostasis.
4. Dengan gunting Metzenbaum atau pisau skalpel, transek jaringan di bagian
distal dari pengikat (gbr.5). Jika menggunakan pisau, letakkan jari di bawah
potongan hati yang akan diangkat, dan tekan bilah dengan lembut dan kuat
melalui jaringan ke arah jari (gbr. 5b). Jika menekan perlahan tapi kuat
dengan bagian datar dari ujung tombak, akan dengan mudah memotong
jaringan hati tetapi tidak akan merusak sarung tangan. Potong jahitan jahita n
pendek. Untuk menghindari iatrogenic artefak spesimen, Jangan menyentuh
sampel hati dengan forsep. Pendarahan yang berlebihan dapat dikontrol
dengan tekanan, ligasi, atau kauter.

Gambar 1: Jatuhkan loop jahitan di atas ujung hati ke dalam celah alami di
sepanjang margin (Sumber: Tobias, K.M. 2010).

Gambar 2: Jika margin dibulatkan, hancurkan tepi margin hati dengan hemostatik

(Sumber: Tobias, K.M. 2010).

8
 Gambar 3: Tarik hemostatik tertutup dengan lembut menjauh dari tepi untuk
membuat celah (Sumber: Tobias, K.M. 2010).

Gambar 4: Kencangkan loop jahitan di sekitar pangkal jaringan sampai itu

menghancurkan semua parenkim tertutup (Sumber: Tobias, K.M. 2010).

a b
. a. dengan gunting, gbr.b
. jaringan distal ke pengikat (gbr
Gambar 5: Transeksi
dengan pisau scalpel )

(sumber: Carrier, Amie., BS, Diana Burger.,BS, Karen M. Tobias, DVM, MS,
DACVS. 2006. How to perform a surgical hepatic biopsy.)

 Box suture liver biopsy (biopsi hati dengan jahitan kotak)

1. Dengan menggunakan bahan jahitan yang dapat diserap dengan jarum
swaged. Tusukan atau jahit jaringan hati yang berdekatan dengan lokasi
biopsi yang diinginkan. Masukkan jarum setebal penuh melalui lobus
hati tegak lurus ke tepi jaringan dan 1 sampai 1,5 cm dari tepi lobus.

9
 Gambar 6: Ambil tusukan jaringan hati melalui lobus hati tegak lurus dengan
margin (Sumber: Tobias, K.M. 2010).

2. Ikat satu atau dua lemparan. Kencangkan lemparan tegak lurus ke tepi
hati untuk menghancurkan jaringan yang dilingkari (gbr. 7). Potong
ujung jahitan.

Gambar 7: Ikat satu atau dua lemparan, kencangkan untuk memotong parenkim.
Potong ujung jahitan menjadi pendek (Sumber: Tobias, K.M. 2010).

3. Tempatkan tusukan penuh kedua di sisi berlawanan dari jaringan yang

akan dibiopsi. tusukan harus 1,5 sampai 2 cm sejajar dengan jahitan
pertama dan tegak lurus dengan margin hati. Ikat satu lemparan dan
himitkan jaringan yang dilingkari (gbr. 8). Biarkan ujung jahitan ini
panjang.

10
Gambar 8: Ambil tusukan kedua sejajar dengan yang pertama. Kencangkan
lemparan, biarkan kedua ujungnya Panjang (Sumber: Tobias, K.M. 2010).

4. Lewatkan salah satu ujung jahitan di bawah pedikel jaringan hati dan
melalui celah yang dibuat oleh pengikat pertama (gbr.9).

Gambar 9: Lewati jahitan melalui celah yang dibuat oleh dua pengikat dan di
sekitar pangkal jaringan (Sumber: Tobias, K.M. 2010).

5. Ikat ujung jahitan ini kembali ke jahitan yang tersisa untuk melingkari
dasar pedikel jaringan hati. Rekatkan jaringan yang dilingkari dengan
satu atau dua lemparan, hancurkan pangkal pedikel. Potong ujung
jahitan.
6. Buang jaringan hati di dalam daerah yang diligasi dengan gunting (gbr.
10)

Gambar 10: Ikat loop jahitan dan transek jaringan di luar ligature (Sumber:
Tobias, K.M. 2010).

 Skin punch liver biopsy

1. Tempatkan skin punch 6 mm tegak lurus dengan permukaan hati
2. Tekan ke bawah sambil memutar punch searah jarum jam dan
berlawanan arah jarum jam untuk memutarnya ke dalam jaringan hati.
Jangan menembus lebih dari setengah permukaan hati.

11
 3. Miringkan punch 45 derajat dan putar sambil maju sedikit untuk
memutuskan sisa jaringan yang menempel (gbr.11).

Gambar 11: Putar punch ke parenkim hati, lalu miringkan pukulan sedikit sambil
maju lebih jauh untuk memutuskan dasar jaringan (Sumber: Tobias, K.M. 2010).

4. Tarik punch pada suatu sudut untuk menahan sampel di dalam

instrumen (gbr.12). Jangan menangani sampel dengan forsep ibu jari.

Gambar 12: Lubang punch yang dihasilkan (Sumber: Tobias, K.M. 2010).

5. Jika tempat biopsi berdarah, masukkan sumbat bahan hemostatik

(misalnya, busa gelatin) ke dalam defek, atau berikan tekanan langsung
selama beberapa menit. Sebagai alternatif, tempatkan matras atau
jahitan cruciate dari bahan yang dapat diserap di seluruh lokasi. Ikat
dengan lembut agar bahan jahitan tidak merobek parenkim hati.
 Sayatan lubang kunci
1. Buat sayatan kulit 2 sampai 4 cm tepat di bagian kaudal prosesus
xiphoid (gbr.13)

12
 Gambar 13: Buat sayatan 2 sampai 4 cm melalui kulit, jaringan subkutan, dan
linea tepat di kaudal xiphoid (Sumber: Tobias, K.M. 2010).

2. Perluas sayatan melalui lemak dan linea subkutan

3. Masukkan jari secara perlahan melalui sayatan untuk memisahkan
lemak falsiformis.
4. Raih ke depan dengan jari telunjuk atau kelingking anda dan kaitkan
lekukan perut yang lebih rendah. Dengan tekanan digital ke bawah, tarik
perut ke kaudal lalu tarik jari.
5. Angkat satu sisi dinding perut dengan forsep ibu jari untuk mengekspos
hati. Jika hepar tidak terlihat, perpanjang insisi linea atau retraksi
dinding abdomen ke bawah.
6. Pegang bagian tepi hati yang besar dengan clamshell biopsy forceps
(gbr.14). Masukkan tang di atas tepi parenkim sehingga jaringan hati
mencapai sudut rahang

Gambar 14: Pegang tepi hati yang terbuka dengan tang clamshell biopsy forceps;
letakkan instrumen di tempat yang diinginkan dengan rahang terbuka. Masukkan
tang ke dalam parenkim sehingg jaringan hati mencapai sudut rahang, dan
menutup rahang tahan rahang selama 10 sampai 20 detik sebelum menarik forsep
menjauh dari hati (sumber: Tobias, K.M. 2010)

7. Tutup rahang dengan kuat dan tahan selama 10 hingga 20 detik.

13
8. Putar forsep sambil menarik ke belakang secara perlahan sampai
potongan jaringan hati terlepas (gbr.15).

Gambar 15: sampel akhir (Sumber: Tobias, K.M. 2010).

9. Jika jaringan terperangkap di dalam rahang instrumen, gunakan jarum

untuk menariknya keluar dengan lembut. Jangan menangani sampel
dengan forsep ibu jari.
10. Tutup selubung rektus luar dengan pola kontinu atau terputus-putus.
Tutup subkutan dan kulit secara rutin.

14
2.4 Hasil dan Pasca Operasi
Setelah prosedur, sayatan ditutup dengan jahitan terputus sederhana,
dan diberikan agen antiseptik untuk mencegah terjadi infeksi. Banamine
(Flunixin Meglumine; 1 mg / kg BB) diinjeksikan secara intramuskular 1 jam
setelah prosedur operasi untuk mengurangi ketidaknyamanan pascabedah.
Keseluruhan prosedur biasanya membutuhkan sekitar 20 menit dari waktu
injeksi xylazine hingga waktu penutupan sayatan kulit. Pendarahan pada tempat
dilakukannya sayatan, Tru-Cut, atau clamshell dapat dikontrol dengan berbagai
metode. Diantaranya dengan, busa gelatin yang adsorbable yang dimasukan ke
dalam sayatan operasi, kemudian di jahit dengan menggunakan bahan yang
dapat diserap yang dijahitkan disekitar luka operasi atau ditutup dengan omental
dan dijahit diatas luka terbuka bekas operasi tersebut. Atau, dapat dilakukan
penekanan pada daerah dilakukannya biopsi, atau dapat pula dilakukan
kauterisasi dengan menggunakan pengaturan rendah.

Komplikasi setelah biopsi hati jarang terjadi tetapi memungkinkan

terjadinya peritonitis empedu, perdarahan, dan sepsis. Risiko terjadi komplikas i
lebih besar pada pasien dengan koagulopati dan trombositopenia. Tingkat
komplikasi utama selama biopsi hati telah dilaporkan setinggi 22% dan 50% pada
anjing dan kucing yang trombositopenik. Banyak pasien dengan penyakit hati
dilemahkan dari hipoalbuminemia dan gangguan fungsi hati, meningkatkan risiko
komplikasi potensial dengan anestesi dan pembedahan seperti hipotensi dan
perubahan metabolisme obat anestesi dan analgesik (Carrier et al, 2006). Ada
beberapa potensi kecil yang menginduksi terjadinya hepatitis nekrotik, jika hewan
belum divaksinasi terhadap penyakit clostridial, jadi sebaiknya diberikan suntikan
penisilin atau antibiotik serupa pada saat pengambilan sampel.

15
 III. KESIMPULAN

3.1 Kesimpulan
Biopsi hati merupakan prosedur medis dimana sejumlah jaringan hati
diangkat melalui operasi agar bisa di analisis dalam laboratorium. Biopsi hati
biasanya dilakukan untuk mengevaluasi penyakit seperti sirosis, untuk mendeteksi
infeksi, inflamasi atau sel kanker. Sebelum melakukan pembedahan semua pasien
harus menjalani tes diagnostik pra-bedah (hitung darah lengkap, jumlah trombosit,
serum chemistry profile, tes koagulasi, urinalisis) untuk menentukan perawatan
perioperatif yang harus diberikan. Puasakan pasien selama 12 jam sebelum operasi.
Untuk anestesi umumnya dokter hewan menggunakan opiat yang dikombinasikan
dengan benzodiazepin pada anjing dan kucing atau kombinasi ketamin dan
diazepam pada kucing.

Pada hewan yang menjalani biopsi hati, sayatan dimulai dari garis tengah
ventral melalui kaudal ke prosesus xiphoid untuk menghindari perforasi diafragma.
Pada hewan dengan penyakit difus yang tidak memerlukan eksplorasi, hati dapat
dibiopsi melalui insisi lubang keyhole ventral 2 sampai 4 cm. Jahitan kotak
mungkin diperlukan pada hewan dengan lobus bulat. Ligasi jahitan biasanya
dilakukan dengan bahan monofilamen yang dapat diserap dengan cepat 3-0.
Komplikasi setelah biopsi hati jarang terjadi tetapi memungkinkan terjadinya
peritonitis empedu, perdarahan, dan sepsis.

3.2 Saran
Dari penulisan makalah ini, dapat diketahui bahwa Biopsi hati bukan tanpa
risiko dan biasanya dilakukan pada pasien yang lemah dengan berbagai derajat
penyakit hati yang mendasari. Disarankan untuk lebih memahami dan mempelajari
lebih mengenai teknik operasi ini agar dapat lebih waspada dalam melakukan
tindakan operasi biopsi hati pada hewan.

16
 DAFTAR PUSTAKA

Diana Burger, BS, Amie Carrier, BS, Karen M. Tobias, DVM, MS, DACVS. 2006.
How to perform a surgical hepatic biopsy. Department of Small Animal
Clinical Sciences.

Kemp, SD, KL Zimmerman, DL Panciera, WE Monroe, MS Leib, dan OI Lanz.

2015.Perbandingan Teknik Pengambilan Sampel Hati pada Anjing. J Vet
Intern Med 29:51-57.

Rothuizen, Jan. dan David C. Twedt. 2009.Teknik Biopsi Hati. Klinik Dokter
Hewan Anim Kecil hal. 469-480. Doi:10.1016/j.cvsm.2009.02.006.

Tobias, K.M. 2010. Manual of Small Animal Soft Tissue Surgery. Amerika Serikat:
Wiley-Blackwell.

17
How to perform a surgical hepatic biopsy
Latest News
May 1, 2006
Petco Love donates $1 million to assist Ukrainian pets
and their families

News wrap-up: This week's veterinary headlines, plus an

update from our Australian correspondent
In patients with known or suspected liver disease, obtaining a biopsy sample is often
Episode 84: We have great preventives. Why do we still
indicated. This article features guidance on when and how to perform a surgical have heartworm disease?
hepatic biopsy.
Meet the Fetch Faculty: Leilani Alvarez, DVM, DACVSMR
Part 2
In patients with known or suspected liver disease, obtaining a biopsy sample is often
View More Latest News
indicated. Liver samples may be obtained by a variety of techniques.1-4 Surgical
biopsy allows the whole liver to be visually inspected and palpated, providing an ideal
opportunity to obtain biopsy samples of focal lesions for histologic examination,
culture and antimicrobial sensitivity testing, and metal analysis. Surgical biopsy also
provides a larger tissue sample for a more complete histologic review and allows the
veterinarian to examine the biopsy site for adequate hemostasis.2 This article
features guidance on when and how to perform a surgical hepatic biopsy.

INDICATIONS

The indications for performing a liver biopsy include substantially or persistently

increased liver enzyme activities or serum bile acid concentrations, hepatic
hyperbilirubinemia, generalized changes in hepatic ultrasonographic echogenicity,
unexplained hepatomegaly, or the presence of solitary or multiple focal lesions within
the hepatic parenchyma.1 Liver biopsy is particularly important when the results of
biochemical testing and advanced imaging modalities such as ultrasonography or
scintigraphy are not adequate to establish a diagnosis. Additionally, histologic
information can be combined with an already determined diagnosis to tailor specific
treatment protocols, evaluate the response to therapy, and determine the prognosis.
Specific indications for a surgical biopsy include microhepatia, a hepatic abscess or
cyst, or a lesion that is difficult to localize on ultrasonographic examination.1 In
addition, excisional biopsy of a pedunculated or solitary mass may provide treatment
opportunities.

SELECTING AND COMPARING LIVER BIOPSY METHODS

Liver samples may be obtained percutaneously by blind or ultrasound-guided biopsy

or surgically by laparoscopy or celiotomy.1-4 Selecting the appropriate method is
determined by the size of the liver, the type and size of the lesion, and the patient's size
and overall health.1,2

Biopsy samples from unstable patients or from patients with severe coagulopathy are
best obtained by percutaneous means such as fine-needle aspiration or Tru-Cut
biopsy, particularly if diffuse disease is suspected.1 However, both of these methods
are significantly inferior to wedge biopsy, potentially affecting an accurate diagnosis.5-
8 Cytologic examination of samples obtained by fine-needle aspiration cannot provide
information about tissue architecture and may be nondiagnostic for lesions that
exfoliate poorly. The correlation between cytologic examination of fine-needle liver
aspirates and histologic examination of hepatic biopsy samples is poor; diagnostic
correlation of samples was 30% in dogs and 51% in cats in one study and 29% in
multiple species in another study.5,6 In fact, cytologic and histologic examinations
have a significantly lower correlation in hepatic tissue than all other tissues studied,
including cutaneous, subcutaneous, nasal, osseous, lymphatic, splenic,
gastrointestinal, cerebral, and ocular tissues.6

Sample size and quality are also variable when ultrasound-guided tissue core biopsy
samples are obtained. In one study, only 77% of intended liver biopsies retrieved
hepatic tissue, and 22% of the samples were less than 2 mm long and lacked
appropriate lobular architecture.7 Thirteen percent of the samples were completely
devoid of tissue, and another 10% contained skeletal muscle, blood, or small intestine.
Only 60% of samples obtained by Tru-Cut biopsy were of diagnostic quality.7

In another study, samples obtained with 18-ga spring-triggered biopsy needles using
ultrasound guidance or direct observation during laparotomy or immediately
postmortem had one-third to one-fourth of the median surface area of those obtained
with wedge biopsy.8 Because of this small sample size, a diagnosis based on needle
biopsy correlated with that of wedge biopsy in less than half the patients. Additionally,
the severity of pathology was graded as significantly less in needle biopsy samples for
most morphologic parameters, with the exception of inflammation, which was graded
more severe as compared with wedge samples. Smaller needle biopsy samples were
unable to achieve the necessary number of portal triads per sample to provide an
accurate diagnosis of portal triad diseases such as portal venous hypoplasia or portal
atresia and were subject to misinterpretation by evaluators.8 Laparoscopic biopsy
allows better visualization of the site compared with ultrasonography but may provide
less tissue volume compared with a surgical wedge biopsy.

PERIOPERATIVE CONSIDERATIONS

All patients should undergo presurgical diagnostic tests (complete blood count,
platelet count, serum chemistry profile, coagulation tests, urinalysis) to determine
which perioperative treatments should be administered. For example, animals with
liver disease may present with vomiting that could result in dehydration and electrolyte
abnormalities. Preoperative potassium or magnesium deficiencies may cause ileus,
arrhythmias, and other complications during or after surgery, so they are best
corrected before anesthesia. Animals with severe liver disease or sepsis may have
prolonged clotting times, requiring crossmatching and transfusion before surgery.2,3
Animals suspected of having neoplasia should undergo staging of their disease,
including thoracic radiography and abdominal ultrasonography. Aspirates obtained
during ultrasonography may provide a diagnosis in some patients, obviating the need
for surgery.

If possible, fast patients for 12 hours before surgery. Preoperatively, administer fluids
and analgesics. Give hypoalbuminemic patients colloidal fluids such as hetastarch or
plasma to provide oncotic pressure support. Choose premedicants and dosages with
care since metabolism of some drugs may be delayed when liver dysfunction is
present. We commonly use an opiate combined with a benzodiazepine in dogs and
cats or a combination of ketamine and diazepam in cats. If acepromazine is
administered as a sedative, the total dose should not exceed 0.25 mg. Induction can
be performed with intravenous propofol or by mask induction with isoflurane. Clip
patients undergoing liver biopsy to the midsternal level, and clip patients receiving
feeding tubes farther laterally on the abdomen. All patients should have an
appropriately sized endotracheal tube with an inflated cuff. During anesthesia,
continuous-rate infusions of fentanyl can be administered to reduce gas anesthetic
requirements.9,10 These infusions can be continued postoperatively to provide
analgesia.

Ideally, respiratory and cardiac function and oxygenation should be monitored during
anesthesia with a capnograph, electrocardiograph, arterial blood pressure monitor,
and pulse oximeter. Maintaining intraoperative blood pressure with fluids and oncotic
support is critical in patients with liver disease since reduced hepatic perfusion can
have deleterious effects on postoperative liver function. Forced-air heating blankets
(e.g. Bair Hugger—Arizant Healthcare) can be used to keep patients warm during the
procedure.

Prophylactic antibiotics are usually unnecessary in patients undergoing liver biopsy.

Be prepared to take culture samples during the procedure and to place feeding tubes
in some patients. Cautery should be available intraoperatively for patients with
coagulopathies. Count the sponges and laparotomy pads before the abdomen is
opened and again before it is closed to prevent iatrogenic peritoneal foreign bodies.
Suction all fluid from the abdominal cavity before closure.

Postoperative treatments, complications, and prognosis vary depending on the

underlying disease process and the patient's condition. Most animals continue to
receive fluid support and analgesics after surgery. In patients that are not vomiting,
small amounts of food and water can be offered within eight hours of the procedure.

OPEN SURGICAL BIOPSY TECHNIQUE

Make a ventral midline abdominal incision. The incision should extend cranially to the
level of the xiphoid to improve exposure of the liver, particularly if it is small. Liver
exposure can be improved by removing the falciform fat and by carefully incising the
triangular ligaments or by placing moistened laparotomy pads between the liver and
the diaphragm.2,3 Examine the entire liver visually and by gentle palpation for nodules,
cavitations, and other abnormalities.

Obtain samples at the junction of normal and diseased tissue to ensure that both
abnormal and normal hepatocellular structures are included.11 If the liver is diffusely
affected, obtain biopsy samples from the most accessible location, usually the liver
margin. In conditions in which lesions are distributed irregularly, obtain samples from
multiple lobes to increase the likelihood of obtaining a diagnostic sample. Although
affected liver margins typically suggest parenchymal disease, their greater distance
from hepatic blood supply may predispose them to fibrosis, obscuring the underlying
pathology. Misdiagnosis of hepatic fibrosis can be avoided by taking larger or multiple
samples.2,12

Figures 1,2

Peripheral or diffuse lesions

The guillotine method is used to sample the hepatic margin of pointed or sharp-edged
lobes. Form a loop with 3-0 absorbable monofilament suture, using a single throw.
Drop the suture loop over the point of the lobe, settling the suture into a natural fissure
or in notches made by Kelly forceps (Figure 1). Tighten the suture completely so that it
crushes all of the tissue within the loop, leaving the piece of tissue attached only by
vessels and ducts (Figure 2). While tightening, do not pull the suture outward or
upward, as this may sever the vessels and ducts and accidentally remove the ligature
with the sample. A second throw can be placed to form a knot but is not necessary for
hemostasis and can increase the risk of tearing the vessels. Transect tissue 2 to 3
mm distal to the suture from the lobe with Metzenbaum scissors or a scalpel blade. If
you use a blade, place a finger under the piece of liver to be removed, and press the
blade gently and firmly through the tissue toward the finger (Figures 3 & 4). If you
press slowly but firmly with the flat portion of the cutting edge, you will easily cut
through the liver tissue but will not damage your gloves. Trim the suture ligature short.
To avoid iatrogenic specimen artifacts, do not use tissue forceps to handle the tissue
sample.2,3 Excessive bleeding can be controlled with pressure, ligation, or cautery.2,4
Figures 3,4

For marginal lesions on rounded liver lobes, place two parallel, full-thickness guillotine
sutures perpendicular to the liver margin around the proposed site by using
absorbable suture with a swaged needle (Figures 5-8). Leave the ends of the second
suture knot long, and then pass one end of the suture around the base of the tissue
pedicle and tie it back to the other end (Figures 9 & 10). This will crush the tissues
across the base of the pedicle, resulting in hemostasis along all three sides of the
tissue sample. Tighten the sutures completely so that they cut through the tissues,
and remove the tissue within the suture box with scissors (Figures 11 & 12).

Figures 5,6,7,8

Central lesions

Samples from nonmarginal liver can be obtained with a skin biopsy punch, Tru-Cut
biopsy needle, or laparoscopic clamshell biopsy instrument.12 To avoid nicking the
large, dorsally located hepatic veins, take the sample, preferably, from the ventral
hepatic surface, and do not let it exceed half the thickness of the lobe.

Figures 9,10,11,12

When taking biopsy samples of the liver with clamshell forceps, place the instrument
against the site of interest with the jaws open. Insert the forceps into the parenchyma
to the level of the angle of the jaws, and close the jaws. After a few seconds of
crushing, twist the instrument until a free piece of tissue is removed. Pulling the
forceps straight out of the liver tends to cause more hemorrhage than twisting.12

Hemorrhage from punch, Tru-Cut, or clamshell biopsy sites can be controlled by a

variety of methods. Absorbable gelatin foam (Gelfoam—Pharmacia & Upjohn) can be
inserted into the defect, a mattress suture of 3-0 absorbable material can be placed
gently around the defect, or an omental flap can be sutured over the defect.
Alternatively, pressure can be applied to the site, or the site can be cauterized by using
a low setting.4,13 Thoroughly lavage the abdomen with a balanced electrolyte solution
in patients with bile leakage, excessive hemorrhage, or infected or necrotic lesions.2

COMPLICATIONS

Complications after liver biopsy are uncommon but may include bile peritonitis,
hemorrhage, and sepsis. The risk of complications is greater in patients with
coagulopathies and thrombocytopenia.14,15 Major complication rates during hepatic
biopsies have been reported to be as high as 22% and 50% in dogs and cats that are
thrombocytopenic.14 Many patients with liver disease are debilitated from
hypoalbuminemia and compromised liver function, increasing the risk of potential
complications with anesthesia and surgery such as hypotension and altered
metabolism of anesthetic and analgesic drugs.

Diana Burger, BS

Amie Carrier, BS

Karen M. Tobias, DVM, MS, DACVS

Department of Small Animal Clinical Sciences

College of Veterinary Medicine

The University of Tennessee

Knoxville, TN 37996-4544

REFERENCES

1. Day DG. Indications and techniques for liver biopsy. In: Textbook of veterinary
internal medicine. 5th ed. Philadelphia, Pa: WB Saunders Co, 2000;1294-1298.

2. Martin RA, Lanz OI, Tobias KM. Liver and biliary system. In: Small animal surgery.
3rd ed. Philadelphia, Pa: WB Saunders Co, 2003;713-717.

3. Fossum TW. Surgery of the liver. In: Small animal surgery. 2nd ed. St. Louis, Mo:
Mosby, 2002;450-457.

4. Harvey CE, Newton CD, Schwartz A. The liver and biliary tract, spleen, and pancreas.
In: Small animal surgery. Philadelphia, Pa: JB Lippincott Co, 1990;407-411.

5. Wang KY, Panciera DL, Al-Rukibat RK, et al. Accuracy of ultrasound-guided fine-
needle aspiration of the liver and cytologic findings in dogs and cats: 97 cases (1990-
2000). J Am Vet Med Assoc 2004;224:75-78.

6. Cohen M, Bohling MW, Wright JC, et al. Evaluation of sensitivity and specificity of
cytologic examination: 269 cases (1999-2000). J Am Vet Med Assoc 2003;222:964-
967.

7. de Rycke LMJH, van Bree HJJ, Simoens PJM. Ultrasound-guided tissue-core biopsy
of liver, spleen and kidney in normal dogs. Vet Radiol Ultrasound 1999;40:294-299.

8. Cole TL, Center SA, Flood SN, et al. Diagnostic comparison of needle and wedge
biopsy specimens of the liver in dogs and cats. J Am Vet Med Assoc 2002;220:1483-
1490.

9. Valverde A, Doherty TJ, Hernandez J, et al. Effect of lidocaine on the minimum

alveolar concentration of isoflurane in dogs. Vet Anaesth Analg 2004;31:264-271.

10. Hellyer PW, Mama KR, Shafford HL, et al. Effects of diazepam and flumazenil on
minimum alveolar concentrations for dogs anesthetized with isoflurane or a
combination of isoflurane and fentanyl. Am J Vet Res 2001;62:555-560.

11. Garner MM, Raymond JT, Toshkov I, et al. Hepatocellular carcinoma in black-tailed
prairie dogs (Cynomys ludivicianus): tumor morphology and immunohistochemistry
for hepadnavirus core and surface antigens. Vet Pathol 2004;41:353-361.

12. Richter KP. Laparoscopy in dogs and cats. Vet Clin North Am Small Anim Pract
2001;31:707-727.

13. Kim EH, Kopecky KK, Cummings OW, et al. Electrocautery of the tract after needle
biopsy of the liver to reduce blood loss. Invest Radiol 1993;28:228-230.
14. Bigge LA, Brown DJ, Penninck DG. Correlation between coagulation profile findings
and bleeding complications after ultrasound-guided biopsies: 434 cases (1993-1996).
J Am Anim Hosp Assoc 2001;37:228-233.

15. Weber JC, Navarra G, Jiao LR, et al. New technique for liver resection using heat
coagulative necrosis. Ann Surg 2002;236:560-563.

Related Content:
Surgery

The origins of Med Innovative 3D models What they didn't teach

Dimensions advancing veterinary you about laryngoscopes
medicine in veterinary school
J Vet Intern Med 2015;29:51–57

A Comparison of Liver Sampling Techniques in Dogs

S.D. Kemp, K.L. Zimmerman, D.L. Panciera, W.E. Monroe, M.S. Leib, and O.I. Lanz
Background: The liver sampling technique in dogs that consistently provides samples adequate for accurate
histopathologic interpretation is not known.
Hypothesis/Objectives: To compare histopathologic results of liver samples obtained by punch, cup, and 14 gauge
needle to large wedge samples collected at necropsy.
Animals: Seventy dogs undergoing necropsy.
Methods: Prospective study. Liver specimens were obtained from the left lateral liver lobe with an 8 mm punch, a
5 mm cup, and a 14 gauge needle. After sample acquisition, two larger tissue samples were collected near the center of the
left lateral lobe to be used as a histologic standard for comparison. Histopathologic features and numbers of portal triads
in each sample were recorded.
Results: The mean number of portal triads obtained by each sampling method were 2.9 in needle samples, 3.4 in cup
samples, 12 in punch samples, and 30.7 in the necropsy samples. The diagnoses in 66% of needle samples, 60% of cup
samples, and 69% of punch samples were in agreement with the necropsy samples, and these proportions were not signifi-
cantly different from each other. The corresponding kappa coefficients were 0.59 for needle biopsies, 0.52 for cup biopsies,
and 0.62 for punch biopsies.
Conclusion and Clinical Importance: The histopathologic interpretation of a liver sample in the dog is unlikely to vary
if the liver biopsy specimen contains at least 3–12 portal triads. However, in comparison large necropsy samples, the accu-
racy of all tested methods was relatively low.
Key words: Fibrosis; Hepatitis; Laparoscopy; Needle biopsy.

istopathology of the liver provides information
H about the cause, chronicity, and reversibility of
disease.1,2 However, reliable histopathologic results are
dependent upon a liver sample of adequate size and
quality.3,4 In humans, biopsy specimens containing
6–113,4 portal triads are recommended to ensure accu-
rate interpretation. Samples with few portal triads or
those that fracture into multiple pieces are considered
inadequate.3–5 In dogs the minimum number of portal
triads necessary for accurate histopathologic interpre-
tation is unknown.
The World Small Animal Veterinary Association
(WSAVA) Liver Standardization Group guidelines
suggest that needle biopsy is adequate and that surgical
liver biopsy is unnecessarily invasive.6 However, several
studies in dogs have questioned the accuracy of needle
biopsies.7–9 When histopathologic diagnoses obtained
with needle biopsies were compared to those obtained
in necropsy specimens in dogs, there was only 53%
agreement between samples.7 However, the size of the
biopsy instrument was not reported, nor was the qual-
ity of the samples. Another study demonstrated only a
From the Departments of Small Animal Clinical Sciences,
(Kemp, Panciera, Monroe, Leib, Lanz); and the Department of
Biomedical Sciences and Pathobiology, Virginia-Maryland
Regional College of Veterinary Medicine, Virginia Tech,
Blacksburg, VA (Zimmerman).
Data from this study was presented in part as an abstract at the
2013 ACVIM Forum, Seattle, WA.
Corresponding author: D.L. Panciera, Department of Small
Animal Clinical Sciences, Virginia-Maryland Regional College of
Veterinary Medicine, Virginia Tech, Blacksburg, VA 24061;
e-mail: panciera@vt.edu.
Submitted April 22, 2014; Revised September 22, 2014;
Accepted October 22, 2014.
Copyright © 2014 by the American College of Veterinary Internal
Medicine
DOI: 10.1111/jvim.12508
48% agreement in histopathologic diagnosis between
18 gauge needle biopsies and surgical samples taken
from the same animal.8 Finally, other studies have
demonstrated that punch and cup liver biopsies were
shown to routinely produce samples with greater than
6–8 portal triads,9 while 18 gauge and 16 gauge needle
biopsy specimens produced fewer than 6 portal
triads.8,9
Liver biopsy is an invasive procedure that is associ-
ated with risk. Hemorrhage from the biopsy site is
usually minimal but can be a potentially life threaten-
ing complication of any type of liver biopsy.9–12
Because different methods of liver biopsy have dissimi-
lar risks, morbidity, and cost, it is important to iden-
tify the biopsy technique that results in the most
accurate diagnosis with the least potential to harm the
patient.
Currently, the WSAVA Liver Standardization
Group recommends 14 gauge needle samples in most
dogs, with 16 gauge needles reserved for small
patients.6 The adequacy of samples obtained by this
method is unknown as previous studies have evaluated
smaller biopsy needles. Therefore, the primary goal of
this study was to compare postmortem liver samples
collected by 8 mm punch, 5 mm cup, and 14 gauge
needles and to identify the method that most consis-
tently produced samples that represent the histopathol-
ogy of the liver. We hypothesized that liver samples
obtained via punch, cup, and 14 gauge needle would
result in similar histopathologic diagnoses to those
found with large wedge samples of liver obtained at
necropsy.
Materials and Methods
This study was approved by the Institutional Animal Care
and Use Committee of Virginia Tech. This was a prospective
study of dogs presented to the necropsy service between May
52 Kemp et al
2011 and August 2012 at the Virginia-Maryland Regional
College of Veterinary Medicine, Veterinary Teaching Hospital
(VTH). All dogs were patients of the VTH that died or were
euthanized and written consent was obtained from all owners.
All samples were collected within 3 hours of death and by the
same investigator (SDK). For sample collection a midline
abdominal incision was made with a scalpel blade. After the
liver was visualized and exposed samples were collected from
the left lateral liver lobe in order to simulate sample collection
during percutaneous ultrasound-guided needle biopsy.6 All sam-
ple specimens were taken from near the center of the lobe,
within 5 cm of each other. Samples collected from each cadaver
included an 8 mm punch,a a 5 mm cup,b and a 14 gauge nee-
dlec sample. All techniques were performed in a manner that
simulated collection in living dog undergoing liver biopsy as
closely as possible. The punch sample was collected by advanc-
ing the cutting edge of a biopsy puncha at a 90° angle into the
surface of the liver parenchyma near the center of the left lat-
eral lobe. The cup sample was collected by advancing the open
jaws of the cup biopsy forcepsb at a 90° angle into the surface
of the liver parenchyma near the center of the left lateral lobe.
The needle sample was collected with a semiautomatic biopsy
needlec by advancing the needle into the center of the left
lateral liver lobe at a 90° angle to the surface.
Test samples using each technique were collected until a non-
fractured specimen that completely filled the sampling channel of
the instrument was obtained. The number of attempts required
to fill the sampling channel was not recorded. After test sample
acquisition, two deep tissue samples of approximately
2 cm 9 2 cm 9 1 cm were taken from the left lateral lobe. These
large samples (designated “necropsy” samples in this manuscript)
were used as the standard for morphologic diagnosis and com-
parison with each test sample. A histopathologic diagnosis was
determined using the necropsy samples based on the WSAVA
Liver Standardization Group’s classification of hepatic disorders.
If a focal liver lesion was noted (eg, mass or discoloration), the
procedures for obtaining test samples and necropsy samples were
repeated at the lesion site.
Tissue samples were placed in separate cassettes in the same
container and immediately fixed in neutral-buffered 10% forma-
lin at room temperature. After fixation, samples were arranged in
paraffin cassettes for embedding and processing. Five micron
thick sections were prepared and stained with hematoxylin and
eosin (H&E). Two-hundred eighty-four slides from 71 sample
sites were randomized and evaluated by a board certified veteri-
nary pathologist (KZ), who was unaware of their hospital case
identity, for standardized evaluation as described below.
Samples were assigned a score for 16 histologic features8:
hepatocellular atrophy, hepatocellular hypertrophy, biliary hyper-
plasia, ceroid lipofuscin pigment, hemosiderin pigment, canalicu-
lar cholestasis, congestion, extramedullary hematopoiesis,
vacuolar change, fibrosis, tissue inflammation, lobular collapse,
hepatocellular necrosis, neoplasia, thrombosis, and vascular
abnormalities. Scores were on a scale of 0–3 with 0 representing
no change and 3 representing severe change. Neoplasia was
assessed as present or absent.
Hepatocellular atrophy was identified by cords being closer
together, small hepatocytes, increased numbers of portal triads in
a given area, and a wrinkled capsule.13 Hepatocellular hypertro-
phy was defined by the presence of hepatocytes of increased size
and increased cytoplasmic basophilia.13 Biliary hyperplasia was
scored on the basis of increased number of small biliary duct
profiles located within the portal triad areas.13 Ceroid lipofuscin
was defined as a lightly golden-yellow, granular to globular,
hepatocellular cytoplasmic pigment.13 Hemosiderin was defined
as a brown crystalline pigment within both hepatocytes and
Kupffer cells.13 Canalicular cholestasis was scored based on the
identification of green bile plugs within the bile canaliculi.13
Congestion was diagnosed based on distention of hepatic sinu-
soids by erythrocytes.13 Extramedullary hematopoiesis was diag-
nosed when foci of hematopoietic precursors cells were identified
within the biopsy specimen.13 Vacuolar change was identified
based on the presence of swollen hepatocytes with cytoplasmic
vacuoles that were either distinct or indistinct, and, either single
or multiple, as well as those with finely reticulated cytosol.13
Fibrosis was diagnosed by a proliferation of fibroblasts and col-
lagen appreciable by hematoxylin and eosin stain.13 Tissue
inflammation was classified as acute hepatitis, chronic hepatitis,
reactive hepatitis, and cholangiohepatitis. Acute hepatitis was
characterized as a combination of inflammatory cells with neu-
trophils in majority, hepatocellular apoptosis and necrosis, with
or without regeneration.14 Chronic hepatitis was characterized by
a combination of hepatocellular apoptosis or necrosis with vari-
able lymphoplasmacytic infiltration with or without a neutrophil-
ic component, regeneration and fibrosis.14 Reactive hepatitis was
characterized by neutrophilic or mixed inflammation in portal
areas and the hepatic parenchyma without necrosis.14 Cholangio-
hepatitis was characterized by neutrophilic, lymphocytic, or
mixed inflammation involving portal region hepatocytes as well
as bile ducts.14 Hepatocellular apoptosis was characterized by
shrunken hepatocytes, with eosinophilic cytoplasm, and con-
densed nuclei surrounded by an empty halo.14 Lobular collapse
was diagnosed by loss of normal lobular architecture because of
loss of hepatocytes.13 Hepatocellular necrosis was diagnosed by
the presence of shrunken cells, with eosinophilic cytoplasm, and
fragmented or pyknotic nuclei.14 Neoplasia was diagnosed by
identification of atypical, dysplastic hepatic or metastatic cells in
the sample specimen.13 Thrombosis was identified by the presence
of thrombi within hepatic vasculature.13 Vascular abnormalities
were scored based on identification of small or absent portal
veins, arteriolar proliferation, with or without hepatocellular
atrophy.13 Cirrhosis was characterized by bridging fibrosis with
conversion of normal architecture into structurally abnormal
regenerative nodules, and the presence of portal-central vascular
anastomosis as a diffuse change.14 Regeneration was identified
when hyperplasia was present, particularly in a nodular pattern
accompanied by fibrosis. The criteria scores of the two necropsy
samples were averaged and served as the standard to which the
other samples were compared.
Based on the histologic criteria scores, a morphological diag-
nosis was assigned to each of the 4 specimens (three test methods
and necropsy sample) based on the WSAVA Liver Standardiza-
tion Group guidelines.15 Only histologic criteria scores ≥2 were
considered as part of the final morphologic diagnosis. The mor-
phologic diagnosis assigned to the necropsy samples was consid-
ered the definitive diagnosis. If the morphologic diagnoses from
the two necropsy samples from the same liver did not agree, all
specimens from that dog were censored from further analysis.
Finally, the number of portal triads present in each sample was
recorded. The basis for enumerating a portal triad was the identi-
fication of all three triad structures (hepatic artery, portal vein,
and bile duct).
Statistical Analysis
Agreement between definitive morphologic diagnosis and the
morphologic diagnosis of the test specimens were assessed by cal-
culating kappa coefficients. The sensitivity and specificity of each
sample type as compared to the necropsy samples was calculated.
In these calculations, the same predominant histopathologic
abnormality in the test sample and the necropsy sample was con-
sidered a true positive. Comparison between the sensitivity and
specificity for the 3 sampling methods was tested using the
Mantel-Haenszel Chi-square test. The proportions of concordant
 Liver Sampling Techniques in Dogs 53

sample results were compared with logistic generalized estimating
equations (GEE) analysis. The mean number of portal triads
between sample types was compared with a mixed model
ANOVA. The mean score for each of the 16 histologic features
was calculated for all samples of each test sample type and com-
pared using a linear GEE analysis to detect significant differences
in the histologic characteristics between test samples and nec-
ropsy samples. All analyses were performed using commercial
software.d Significance was determined at P < .05.
Results
Seventy dogs and 71 total sample sites (one dog had
a focal lesion) were included in this study. No cases
were censored because of disagreement between the
two necropsy samples. Morphologic diagnoses in the
necropsy samples were: no abnormality (18/71;
25.4%), vacuolar hepatopathy (18/71; 25.4%), neopla-
sia (8/71; 11.3%), primary fibrosis (6/71; 8.45%),
chronic hepatitis (5/71; 7.0%), congestion (5/71;
7.0%), cirrhosis (5/71; 7.0%), necrosis (3/71; 4.2%),
cholangiohepatitis (1/71; 1.4%), reactive hepatitis (1/
71; 1.4%), and cholestasis (1/71; 1.4%).
There were no significant differences (P = .29) in the
proportion of test samples that agreed with the nec-
ropsy sample between test sample types. Cohen’s
kappa coefficient for the needle, cup, and punch sam-
ples were 0.59, 0.52, and 0.62 respectively.
The mean number and 95% confidence intervals of
portal triads in each sampling method was 2.9 (2.6–3.2)
in needle samples, 3.4 (2.7–4.2) in cup samples, 12.0
(10.3–13.7) in punch samples, and 30.7 (27.0–34.5) in
the necropsy samples. Punch samples had significantly
more portal triads than either cup or needle samples
(P < .001) which were not statistically different from
each other (P = .98). The necropsy samples had signifi-
cantly more portal triads than all the test samples
(P < .001). The number of portal triads could not be
determined in 8 needle samples (diagnosis included neo-
plasia [4], cirrhosis [2], fibrosis [1], necrosis [1]), 11 cup
samples (diagnosis included neoplasia [5], cirrhosis [3],
necrosis [2], fibrosis [1]), 12 punch samples (diagnosis
included neoplasia [5], cirrhosis [4], acute hepatitis [1],
fibrosis [1], necrosis [1]), and 13 necropsy samples (diag-
nosis included neoplasia [5], cirrhosis [4], fibrosis [1],
necrosis [1], chronic hepatitis [1], and congestion [1]),
because of loss of normal hepatic architecture.
The sensitivities and 95% confidence intervals of the
test methods as compared to the necropsy samples
were similar, being 60% (46–73%), 55% (41–68%),
and 66% (52–78%) for needle, cup, and punch sam-
pling, respectively. The specificities were also similar
between methods and were higher than the sensitivi-
ties, being 83% (58–96%), 78% (52–93%), and 78%
(52–93%) for needle, cup, and punch sampling respec-
tively. When the sensitivity and specificity of each test
method was calculated for each diagnosis, the highest
sensitivities were found in dogs with vacuolar hepatop-
athy, normal hepatic histopathology, and neoplasia
(Table 1). Within each diagnosis category where sensi-
tivity and specificity were reported, there were no sig-
nificant differences in the sensitivities or specificities
between the test types. Results were not reported for
necrosis, cholangiohepatitis, reactive hepatitis, or cho-
lestasis because of the small number of cases in each
category. Diagnoses in the 8 livers with neoplasia
included histiocytic sarcoma (3), lymphoma (3), undif-
ferentiated round cell sarcoma (1), and spindle cell sar-
coma (1). The sensitivity for diagnosis of neoplasia
was 75% (95% CI: 0.45–1.0) for needle samples; 63%
(95% CI: 0.29–0.96) for cup samples; and 88% (95%
CI: 0.65–1.0) for punch samples. The specificity for
neoplasia was 100% in all three test types. Overall, the
sensitivity for the diagnosis of fibrosis was low, rang-
ing from 16 to 50% (Table 1).
The mean scores for each of the histologic features
were compared amongst the test sample types and sev-
eral significant differences from the necropsy samples
were identified (Table 2). The needle samples identified
significantly less hepatocellular atrophy, biliary hyper-
plasia, hemosiderin, and congestion compared to the
necropsy samples. The cup samples identified signifi-
cantly less biliary hyperplasia, hemosiderin, and con-
gestion when compared to the necropsy samples.
Finally, the punch samples showed significantly less
hepatocellular hypertrophy and hemosiderin than the
necropsy samples.
In the 6 cases with a predominant histopathologic
abnormality of fibrosis, the mean fibrosis score in the
necropsy samples was 2.5, which was significantly
higher than 1.5 in the punch (P = .014), 1.4 in the cup
samples (P = .014), and 0.5 in the needle samples
(P < .001). In the 5 cases of chronic hepatitis the mean

Table 1. Sensitivity, specificity, and 95% confidence intervals for each biopsy type stratified by morphologic
diagnosis in the necropsy samples.
Needle Laparoscopic Cup Punch
Gold Standard
Diagnosis Number Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity
Normal 18 0.83 (0.66–1.0) 0.75 (0.64–0.87) 0.78 (0.59–0.97) 0.68 (0.55–0.80) 0.78 (0.59–0.97) 0.81 (0.71–0.92)
Vacuolar 18 0.72 (0.51–0.92) 0.96 (0.03–0.91) 0.61 (0.39–0.84) 1 (1.0–1.0) 0.83 (0.66–1.0) 0.96 (0.91–1.0)
Neoplasia 8 0.75 (0.45–1.0) 1 (1.0–1.0) 0.63 (0.29–0.96) 1 (1.0–1.0) 0.88 (0.65–1.0) 1 (1.0–1.0)
Primary fibrosis 6 0.16 (0.0–0.64) 0.98 (0.92–1.0) 0.5 (0.12–0.87) 0.97 (0.89–1.0) 0.5 (0.12–0.87) 0.98 (0.92–1.0)
Chronic hepatitis 5 0.6 (0.17–1.0) 0.98 (0.96–1.0) 0.4 (0.0–0.83) 0.98 (0.96–1.0) 0.4 (0.0–0.83) 1 (1.0–1.0)
Congestion 5 0.4 (0.0–0.83) 0.98 (0.96–1.0) 0.2 (0.0–0.55) 0.98 (0.96–1.0) 0.4 (0.0–0.83) 0.97 (0.93–1.0)
Cirrhosis 5 0.6 (0.17–1.0) 1 (1.0–1.0) 0.8 (0.45–1.0) 1 (1.0–1.0) 0.8 (0.45–1.0) 1 (1.0–1.0)

Only morphologic diagnoses with ≥5 cases are shown.

54 Kemp et al

Abnormality
inflammation score in the necropsy samples was 2.6,

SD = 0.32

SD = 0.44

SD = 0.57

SD = 0.46
Vascular

0.078
which was significantly higher than 1.5 in the cup sam-

0.15

0.18

0.14
ples (P = .002), and 1.4 in the needle samples
(P < .001), but not significantly different from 2.1 in
the punch samples (P = .15).
Thrombosis

SD = 0.12

SD = 0.12
0.015

0.014
0

0
Discussion
0.28 SD = 0.59

Results of this study indicate that 14 gauge needle,

SD = 0.62

SD = 0.61

SD = 0.72
Necrosis

5 mm cup, and 8 mm punch samples of the liver have

0.34

0.33

0.41
a similar proportion of samples in agreement to larger
hepatic samples. However, the level of agreement
could be considered insufficient when a single sample
SD = 0.06

SD = 0.53

SD = 0.60

SD = 0.55
Collapse
Lobular

0.13

0.15

0.21

0.24
is taken by any tested technique. The disparity
Table 2. Mean scores and standard deviations for histologic features of each sample type.

between the test samples and the necropsy samples

seemingly occurs as a result of variable distribution of
Inflammation

SD = 0.64

SD = 0.68

SD = 0.79

SD = 0.80

morphologic features within a liver lobe which might

Tissue

0.32

0.37

0.39

0.41

be overcome by obtaining multiple samples, a larger

single sample, or perhaps biopsies from multiple lobes.
The paired necropsy samples from each dog had iden-
SD = 0.80

SD = 0.97

SD = 0.95

SD = 0.12
Fibrosis

tical histopathologic diagnoses, while the smaller sam-

0.43

0.60

0.49

0.64

ples obtained using the three test methods had less

consistent agreement with the large necropsy samples.
SD = 0.95

SD = 0.87

SD = 0.13

Because all the samples were obtained within 5 cm of

SD = 1.1
Vacuolar
Change

0.88

0.76

0.91

1.01

each other, the size of the specimen obtained by the

test methods was most likely the primary factor influ-
encing the histopathologic interpretation.
Extramedullary
Hematopoiesis

SD = 0.052
SD = 0.41

SD = 0.31

SD = 0.57

Smaller test samples had fewer portal triads. The

0.154

0.11

0.18

0.30

number of portal triads in the needle and cup samples

were not different, and both contained fewer than
what is recommended in humans, while the punch
(P = .0021)
Congestion

samples exceeded the minimum recommendations.3,4

SD = 0.50

SD = 0.54

SD = 0.67

SD = 0.73
(P < .001)
0.19

0.25

0.37

0.48

Despite this, the accuracy of the punch samples was

not greater than the other test methods. Therefore,
recommendations for sampling the human liver do not
Cholestasis

SD = 0.79

SD = 0.82

SD = 0.87

SD = 0.90

appear to be applicable to dogs.

(Bile)

0.37

0.43

0.49

0.57

The median and mean number of portal triads of 3

and 2.9, respectively, in needle samples in the present
Hemosiderin

study was lower than previous reports where 18 gauge

(P = .0033)
SD = 0.95

SD = 0.87

SD = 0.82

SD = 0.92
(P = .024)
(P = .02)

needle biopsies had a median of 4 portal triads8 and

0.71

0.75

0.79

0.95

16 gauge needle samples had a mean of 6–7.9 portal

triads.9 This discrepancy may be attributable to the
Lipofuscin

SD = 0.95

SD = 0.92

SD = 0.75

SD = 0.76

strict criteria used for counting portal triads in this

Ceroid

0.87

0.92

0.96
1.0

study, where all 3 structures comprising the portal

triad had to be clearly identified. Other studies that
did not describe their methodology in detail may have
Hyperplasia

SD = 0.67

SD = 0.90

SD = 0.97
(P < .001)

(P < .001)
SD=0.73
Biliary

included portal areas without all three components of

0.27

0.32

0.45

0.58

the triad visible. Despite the punch samples containing

significantly more triads than the other test methods,
Hepatocellular

the overall histopathological agreement with necropsy

Hypertrophy

SD = 0.45

SD = 0.66

SD = 0.45

SD = 0.66
(P = .017)

(P = .039)

samples was not different. Therefore, when the number

0.18

0.34

0.17

0.29

of portal triads in samples ranges from 3 to 12, the

Significant differences are shaded.

final histopathologic interpretation is unlikely to vary.

However, because of the relatively poor agreement
Hepatocellular

SD = 0.43

SD = 0.49

SD = 0.52

SD = 0.45
Atrophy

with the necropsy samples, it is reasonable to assume

0.13

0.16

0.19

0.19

that biopsies larger than those obtained in this study

might enhance the likelihood of a correct diagnosis.
Because techniques used to obtain larger biopsies
Sample Type

might result in increased risk for hemorrhage, multiple

Necropsy
(N = 71)

Laparo-
scopic
Needle

biopsies from different locations of a lobe might be the

Punch
cup

best method to safely acquire adequate tissue.

 Liver Sampling Techniques in Dogs
Portal triads could not be reported in 13 (18%) of
the necropsy samples because of severe distortion in
the hepatic architecture. This raises concern for the use
of portal triad numbers as the only measure of biopsy
specimen quality, as these samples were large but did
not contain recognizable triad structures. However, the
diagnoses in the majority of these cases were neoplasia
or cirrhosis and it is likely that in such severe disease
large samples with many portal triads may not be nec-
essary for diagnosis.
In this group, the sensitivity of needle samples were
similar to a previous report that compared 18 gauge
needle and surgical biopsies.8 While the sensitivity for
detection of hepatic neoplasia was similar to that of
another study (80%) using a smaller needle biopsy, the
specificity was 100% in all sample methods tested in
the present study.8 Because the majority of neoplasms
in our population were systemic, it is unclear if similar
results would be found in dogs with focal, metastatic,
or multifocal neoplasia.16
In cases where fibrosis was the histopathologic diag-
nosis, all three sampling methods had a significantly
lower mean fibrosis score than the necropsy samples. In
these cases the punch and cup samples had a concordant
diagnosis in 3 samples, and only 1 of the 6 livers with
fibrosis had it identified on needle biopsy. These findings
suggest that large tissue samples may be necessary to
accurately describe the degree of fibrosis when severe
disease is present. This is in contrast with previous stud-
ies where needle biopsy specimens showed higher histo-
logic scores for fibrosis.8 However, the results of the
present study mirror those of several human studies in
which fibrosis scores declined with smaller biopsy
size.5,17 The discordance in the fibrosis scoring is likely
caused by variation in severity of fibrosis throughout or
between lobes, which has been documented in humans.
In a report of patients with primary biliary fibrosis,
whole section scanning of the liver at the time of trans-
plantation revealed that only 20% of these livers had
fibrosis throughout the entire organ.18
All test methods were insensitive for diagnosis of
chronic hepatitis, unlike a previous study that reported
needle biopsies had higher scores for inflammation
when compared to wedge biopsies obtained at sur-
gery.8 In the present study, there were no significant
differences in the histologic scores for inflammation
between the sampling methods. However, when the
five cases of chronic hepatitis were analyzed separately,
inflammation scores for both the cup and needle sam-
ples were significantly lower than those of the necropsy
samples. The punch and cup samples both had concor-
dant diagnoses in 2 cases and the needle samples had
concordant diagnoses in 3 cases. Although the number
of cases in the present study was limited, the results
suggest that histopathology of a single sample may un-
derrepresent the severity of disease when chronic
inflammation is present. This finding is similar to a
report in humans which demonstrated that shorter
needle biopsies produced samples with lower inflam-
matory scores in patients with hepatitis C virus infec-
tion.4 However, it is not known if the lower histologic
55
scores for inflammation reported in the small test sam-
ples in the present study would result in a different
clinical diagnosis in dogs.
The high number of discordant samples amongst all
test methods may be attributable to nonuniform
lesions throughout the liver lobe, even in diffuse hepat-
opathies. For example, marked variation in copper
concentration was found when needle biopsy speci-
mens were compared to wedge samples in dogs.19 Con-
clusions of the small number of studies that have
evaluated the diagnostic accuracy of liver biopsy tech-
niques in dogs have been hampered by limitations in
our understanding of canine liver disease. Studies eval-
uating liver biopsy in humans typically focus on
patients with a specific disease such as hepatitis C virus
or nonalcoholic steatohepatitis, and are aimed to
define the best biopsy method for that specific disease,
whether for diagnostic or prognostic purposes.5,20
Because of limited knowledge of the etiology and clini-
cal markers of specific liver diseases in dogs, any
biopsy technique must be able to identify any of the
histologic features that might be present.
One limitation of this study is reliance on a single
pathologist for interpretation of all of the liver samples.
However, use of a single pathologist likely resulted in
more consistent results between cases, compared with
multiple observers.21 The expertise of the pathologist in
evaluating the liver is another important consideration
in humans and likely is important in veterinary medi-
cine as well.22 Dogs enrolled in the study were not
selected because of known hepatic disease, thus were
not representative of the population in which liver
biopsies would be obtained in clinical practice. The
influence that a higher prevalence of hepatic disease
would have had on the results of this study remains
unclear. It is important to note that in a study of liver
biopsy in population of patients where biopsy was
deemed appropriate for clinical reasons, 28% had no
hepatic disease, similar to the 26% in the present
study.8 Sample collection was performed using methods
that mimicked their antemortem use, but differed from
percutaneous and laparoscopic biopsy as the samples
were obtained through a large abdominal incision and
repeated sampling was attempted until a sufficient sam-
ple was retrieved. The number of attempts required to
obtain a sample that filled the biopsy instrument was
not recorded, but the size of antemortem biopsies varies
within a given method and fragmented samples compli-
cate histopathologic interpretation.9 In addition, sam-
ple acquisition can be affected by the underlying liver
disease. For example, in the authors’ experience, needle
or cup sampling of a severely fibrotic liver often results
in smaller biopsies and frequently multiple attempts are
necessary to obtain an adequate sample. Biopsies
obtained in a clinical setting might be of lower quality
and be limited by the potential for complications of
repeated sampling. Thus, it is possible that the accuracy
of nonsurgical biopsies in clinical cases may be lower
than reported here.
Because the WSAVA Liver Standardization Group
recommends two biopsies for histopathologic
56
evaluation, the present study might have been strength-
ened by evaluating more than one sample using each
test method. However, our study was not designed to
determine the minimum number of samples necessary to
ensure accurate histopathologic diagnosis, rather it was
to investigate the ability of commonly used sampling
methods to accurately reflect the histopathologic diag-
nosis. Sample quality in the present study was con-
trolled by using only samples that fully filled the
instrument’s chamber and were not fragmented, result-
ing in uniform comparisons between sampling methods
and avoiding the influence of variation in biopsy size
which has been shown to affect biopsy interpretation in
humans with hepatitis.4 Because no sampling method
had a strong agreement with the gold standard, it seems
clear that multiple samples should be obtained in the
hope that it would improve accuracy. It is likely that the
number of samples necessary for an accurate histopath-
ologic interpretation would vary depending on the dis-
ease and biopsy quality. Histochemical staining was
limited to H&E in the present study, which may have
led to underestimation of fibrosis, limited assessment of
architectural changes in some diseases, and prevented
identification of some intracellular contents and pig-
ments. However, the same stains and analytic criteria
were applied to each sample, so the detrimental effects
of using a single stain would be limited. Future studies
should address these important issues.
Our study design limited the surgical samples to one
technique that allowed for sampling from the center of
the lobe. Other methods of surgical liver biopsy have
been described in the dog,9 and it is possible that an
alternate method of sampling such as obtaining a lar-
ger wedge from the edge of a liver lobe might improve
accuracy.
The results of this study demonstrate substantial
limitations in the accuracy of a single liver sample by
any of the tested techniques. Obtaining multiple sam-
ples from the liver might be of greater importance than
the method of biopsy.
Footnotes
a canine and feline liver 2. Hepatocellular death, hepatitis and cir-
8 mm Biopsy Punch, Miltex, Inc., Plainsboro, NJ
b rhosis. In: Rothuizen J, Bunch SE, Charles JA, Cullen JM,
Eragon 5 mm biopsy forceps, Richard Wolf Medical Instru-
ments Corporation, Vernon Hills, IL
c Winkle TV, Washabau RJ, eds. WSAVA Standards for
SurgiVet VET-Core Biopsy needle 14 ga, 9 cm, Smiths Medical
PM, Inc. Waukesha, WI
d Liver Diseases. Philadelphia, PA: Saunders Elsevier; 2006:
SAS/STAT software version 9.2. (Cary, NC)
Acknowledgments
The authors thank Dr Stephen R. Werre for statisti-
cal assistance. The study was funded by the Virginia
Veterinary Memorial Fund.
Conflict of Interest Declaration: The authors disclose
no conflict of interest.
Kemp et al
Off-label Antimicrobial Declaration: The authors
declare no off-label use of antimicrobials.
References
1. Rockey DC, Caldwell SH, Goodman ZD, et al. Liver
biopsy. Hepatology 2009;49:1017–1044.
2. Rothuizen J, Twedt DC. Liver biopsy techniques. Vet Clin
North Am Small Anim Pract 2009;39:469–480.
3. Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J
Med 2001;344:495–500.
4. Colloredo G, Guido M, Sonzogni A, et al. Impact of liver
biopsy size on histological evaluation of chronic viral hepatitis:
The smaller the sample, the milder the disease. J Hepatol
2003;39:239–244.
5. Bedossa P, Dargere D, Paradis V. Sampling variability of
liver fibrosis in chronic hepatitis C. Hepatology 2003;38:1449–1457.
6. Rothuizen J, Desmet VJ, Vanden Ingh TSAGM, et al.
Sampling and handling of liver tissue. In: Rothuizen J, Bunch
SE, Charles JA, Cullen JM, Desmet VJ, Szatmari V, Twedt DC,
van den Ingh TSGAM, Winkle TV, Washabau RJ, eds. WSAVA
Standards for Clinical and Histological Diagnosis of Canine and
Feline Liver Diseases. Philadelphia, PA: Saunders Elsevier;
2006:5–14.
7. Brobst DF, Schall WD. Needle biopsy of the canine liver
and correlation of laboratory data with histopathologic observa-
tions. J Am Vet Med Assoc 1972;161:382–388.
8. Cole TL, Center SA, Flood SN, et al. Diagnostic compari-
son of needle and wedge biopsy specimens of the liver in dogs
and cats. J Am Vet Med Assoc 2002;220:1483–1490.
9. Vasanjee SC, Bubenik LJ, Hosgood G, et al. Evaluation of
hemorrhage, sample size, and collateral damage for five hepatic
biopsy methods in dogs. Vet Surg 2006;35:86–93.
10. Hardy R. Hepatic biopsy. In: Kirk RW, ed. Current Vet-
erinary Therapy VIII. Small Animal Practice. Philadelphia, PA:
Saunders; 1983:813–817.
11. Tsochatzis E, Deutsch M, Zaphyropoulou R, et al. Acute
ischemic injury due to a giant intrahepatic hematoma: A compli-
cation of percutaneous liver biopsy. Eur J Intern Med
2007;18:339–341.
12. Yu MC, Jeng LB, Lee WC, et al. Giant intrahepatic
hematoma after liver biopsy in a liver transplant recipient. Trans-
plant Proc 2000;32:2217–2218.
13. Cullen J. Liver, biliary system and exocrine pancreas. In:
Zachary JF, McGavin D, eds. Pathologic Basis of Veterinary
Disease, 4th ed. St. Louis, MO: Elsevier Mosby; 2007:
393–461.
14. Van den Ingh TSGAM, Winkle TV, Cullen JM, et al.
Morphological classification of parenchymal disorders of the
Desmet VJ, Szatmari V, Twedt DC, van den Ingh TSGAM,
Clinical and Histological Diagnosis of Canine and Feline
85–101.
15. Rothuizen J, Bunch SE, Charles JA, et al. eds. WSAVA
Standards for Clinical and Histological Diagnosis of Canine
and Feline Liver Diseases. Philadelphia, PA: Saunders Elsevier;
2006.
16. Maharaj B, Maharaj RJ, Leary WP, et al. Sampling vari-
ability and its influence on the diagnostic yield of percutaneous
needle biopsy of the liver. Lancet 1986;1:523–525.
17. Poynard T. Prospective analysis of discordant results
between biochemical markers and biopsy in patients with chronic
hepatitis C. Clin Chem 2004;50:1344–1355.
 Liver Sampling Techniques in Dogs
18. Garrido MC, Hubscher SG. Accuracy of staging in pri-
mary biliary cirrhosis. J Clin Pathol 1996;49:556–559.
19. Johnston AN, Center SA, McDonough SP, et al. Influence
of biopsy specimen size, tissue fixation, and assay variation on
copper, iron, and zinc concentrations in canine livers. Am J Vet
Res 2009;70:1502–1511.
20. Ratziu V, Charlotte F, Heurtier A, et al. Sampling vari-
ability of liver biopsy in nonalcoholic fatty liver disease. Gastro-
enterology 2005;128:1898–1906.
57
21. Theodossi A, Skene AM, Portmann B, et al. Observer vari-
ation in assessment of liver biopsies including analysis by kappa
statistics. Gastroenterology 1980;79:232–241.
22. Bateman AC. Patterns of histological change in liver dis-
ease: My approach to ‘medical’ liver biopsy reporting. Histopa-
thology 2007;51:585–596.
Liver Biopsy Te ch niq ues
Jan Rothuizen, DVM, PhDa,*, David C.Twedt, DVM, PhDb

KEYWORDS
 Liver biopsy  True cut needle  Menghini needle
 Laparoscopy  Wedge biopsy  Fine needle aspiration
 Gall bladder punction  Coagulation

Liver biopsy is an important step in the evaluation of a patient with hepatic disease and
is required to formulate a diagnosis, direct therapy, and provide an accurate prog-
nosis. However, a liver biopsy evaluates only a small percentage of the liver and
may not represent the entire liver. Consequently, the results should always be
combined with the clinical information, laboratory data, and imaging procedures to
formulate a diagnosis.1 There are advantages and disadvantages of each method of
obtaining a liver biopsy. This article presents the indications, technique, and diag-
nostic accuracy of the various biopsy methods, including fine-needle liver aspiration,
needle biopsy, laparoscopic-assisted biopsy, and surgical biopsy. Descriptions of
many of the surgical techniques are beyond the scope of this article; specific details
are available in most surgical texts.
The diagnosis of most liver diseases requires a histopathologic examination of liver
tissue. Histology is especially important for parenchymal liver diseases such as hepa-
titis occurring in dogs and inflammatory biliary tract disease common to the cat. Of the
circulatory diseases of the liver, portal vein hypoplasia (microvascular dysplasia) can
only be diagnosed by a combination of histopathology and imaging (eg, ultrasonog-
raphy) techniques. Diffuse liver diseases may be sampled randomly, but focal lesions
require careful selective sampling using ultrasound-guided needle biopsy, laparo-
scopic guidance, or surgically. Large focal lesions should be sampled in the periphery
of the lesion because a neoplastic mass may have a necrotic center and the malignant
characteristics are best observed in the periphery of the mass.
Neoplasia and diffuse vacuolar disorders (eg, lipidosis, steroid hepatopathy) of the
liver can often be diagnosed by cytologic examination obtained using fine-needle
aspiration. However, cytology does not show the architectural changes of the liver
that can be seen with histopathology. For example, differentiation of liver cell
adenomas and carcinomas often cannot be distinguished without evaluating the histo-
pathology. Needle biopsies also have limitations due to their small sample size; for

a
Department of Clinical Sciences of Companion Animals, University Utrecht, Yalelaan 108, P.O.
Box 80.154, 3508 TD Utrecht, The Netherlands
b
Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences,
Colorado State University, Fort Collins, CO 80523, USA
* Corresponding author.
E-mail address: j.rothuizen@uu.nl (J. Rothuizen).

Vet Clin Small Anim 39 (2009) 469–480

doi:10.1016/j.cvsm.2009.02.006 vetsmall.theclinics.com
0195-5616/09/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
470 Rothuizen & Twedt

example, with macronodular cirrhosis, needle aspirates may only sample a hyper-
plastic nodule and inflammatory and fibrotic areas may be missed.
In every case, all available information must be considered before reaching the final
diagnosis, and this implies selecting the proper techniques for obtaining tissue
samples (representative and big enough), adhering to the important requirements of
tissue handling, and providing the pathologist with all available essential clinical infor-
mation. The clinician should then consider the information from the history, physical
examination, clinical pathology, and ultrasonography or other imaging procedures
with the histologic results of the liver biopsy before making the diagnosis.

GENERAL CONSIDERATIONS

The risk/benefit ratio of performing a liver biopsy must be weighed for every case.
Although the chance of serious complications is low for a specific case or procedure,
there is always the potential for complications to occur. Operator experience also has
a significant influence on the complication rate. However, most diseases of the liver
are best defined and treated following a liver biopsy with histologic examination.
It is important that the patient fasts for approximately 12 hours to ensure that the
stomach is small. Fasting aids the ultrasonographic examination and is required
before sedation or anesthesia. The stomach covers the caudal visceral surface of
the liver and a distended stomach may prevent the biopsy needle reaching the liver.
Anesthesia is required for surgery and laparoscopy, and possibly for some dogs
and all cats undergoing a needle biopsy. Needle biopsies can be obtained in cooper-
ative dogs using local anesthesia of the skin and abdominal wall. Fine-needle aspira-
tion is usually performed using minimal or no sedation and without local anesthesia.

Coagulation Testing
As the liver produces all the clotting factors except Factor VIII, bleeding from a liver
biopsy is reported to be the most frequent complication. With every liver biopsy there
is always a small amount of blood loss, which can be seen by ultrasonography or
during laparoscopy or surgery. The average amount of blood loss from a liver biopsy
is reported to be around 2 mL in normal dogs. 2,3 Fine-needle aspirates are generally
considered safe and there are few reports of serious bleeding following a needle aspi-
rate.4 If the coagulation tests are normal, bleeding becomes less of a concern.5 The
reserve capacity of the liver in producing clotting factors is so huge that, for most liver
diseases, factor production is rarely decreased to the point whereby it becomes
a limiting factor. Abnormalities in coagulation tests may also not preclude a liver
biopsy but may increase the likelihood of bleeding. The results of routine coagulation
tests have shown the degree of bleeding from a biopsy does not correlate with the pa-
tient’s clotting times.6 However, a liver biopsy should be avoided if there is clinical
evidence of bleeding or marked abnormalities in the coagulation tests. Thrombocyto-
penia (<80,000 platelets) or prolongation of the coagulation times increases the risk of
bleeding following a liver biopsy. The presence of marked abnormalities in coagulation
in a patient with liver disease becomes prognostic and suggests significant hepatic
dysfunction.7
Ideally, before a liver biopsy the coagulation status should be assessed by evalu-
ating the intrinsic pathway (activated partial thromboplastin time [APTT]), the extrinsic
pathway prothrombin time (PT), fibrinogen content, and platelet count. A buccal
mucosal bleeding time (BMBT) is also recommended especially in breeds associated
with von Willebrand’s disease. Patients with von Willebrand’s disease usually have
normal coagulation tests and platelet numbers but have significantly decreased
 Liver Biopsy Techniques 471

platelet function, which increases the BMBT. Disease of the liver can also lead to an
increased consumption of fibrinogen and other clotting factors with a significant effect
on coagulation.8 This situation occurs in diffuse diseases of the liver associated with
pronounced hepatocyte necrosis/apoptosis leading to subclinical diffuse intravas-
cular coagulation (DIC). Associated diseases are active forms of hepatitis and malig-
nant lymphoma in the liver. In such cases, fine-needle aspiration of the liver is still
possible, allowing identification or exclusion of malignant lymphoma. A fibrinogen
concentration less than 50% of the lower reference level can be used as an absolute
contraindication for taking a liver biopsy. The activation of factors II, VII, IX, and X
depends on the availability of vitamin K1. In prolonged and complete obstruction of
the bile flow, the intestinal absorption of fat-soluble vitamins K1 may be severely
impaired due to the lack of bile acids entering the intestine. In these cases, it is useful
to administer vitamin K1 (1–5 mg/kg subcutaneously daily for several days) and then
re-evaluating the effect on the clotting times before biopsy. Some investigators
recommend administering vitamin K1 to all patients if the clotting times are at all
abnormal. However, unless there is vitamin K deficiency, there will likely be little
improvement. With abnormalities in PT, APTT, or BMBT fresh frozen plasma should
be administered 2 hours before the procedure and the patient should be monitored
closely following the biopsy. Suspected bleeding following biopsy should be evalu-
ated with abdominocentesis or ultrasonography, and is evident within 0.5 to 1 hour
after the procedure. Life-threatening bleeding following biopsy is treated with fresh
frozen plasma, fresh whole blood, or, rarely and as a last resort, surgery to stop the
source of the bleeding. Bleeding, with a dropping hematocrit level, is usually evident
within the first 5 hours following the biopsy.6

Ultrasound Examination
It is important to evaluate the structure of the liver, biliary tract, and portal vein in prep-
aration for a liver biopsy. This evaluation is usually done with ultrasonography, but may
also be performed by laparoscopy or surgical inspection. Systematic evaluation
should be performed to determine: (1) the size of the liver; (2) the presence of focal
lesions; (3) the liver architecture and structure; (4) the diameter of the lumen and the
thickness of the wall of the extrahepatic and intrahepatic bile ducts and the gall-
bladder; (5) vascular changes, especially of the portal vein but also the presence of
arteriovenous fistulas; (6) the presence of free abdominal fluid; and (7) echo Doppler
evaluation of the portal blood flow velocity and direction. These evaluations provide
important information for the clinician and the pathologist. Histologic findings become
optimally meaningful when combined with the relevant clinical, clinicopathologic, and
imaging findings.

Risk Factors
Precautions with respect to the coagulation process are not the only factors associ-
ated with complications of a liver biopsy. The experience of the operator must also
be considered. With an experienced operator most techniques are safe and have
a low complication rate. A third complication associated with a needle biopsy is the
induction of vagotonic shock immediately following the procedure.9 Rapid-firing auto-
matic biopsy needles increase the risk for this complication. The automatic spring-
loaded biopsy guns have been reported to produce such a strong impulse to the liver
that it causes a lethal shock reaction in cats but this has not been observed in dogs.
The larger bile ducts and the gallbladder have a dense autonomic innervation and
trauma induced by penetration with a wide core biopsy needle may also induce an
autonomic reaction with bradycardia and deep shock within 30 minutes of the
472 Rothuizen & Twedt

procedure, which may be especially relevant if dilated bile ducts of an extrahepatic

bile duct obstruction (EHBDO) have been hit. Other biopsy techniques are recommen-
ded if an obstruction associated with duct dilation is present. The authors have also
observed biopsy-induced shock following liver biopsy when large liver cell carcinomas
are sampled. A small percentage of these cases may develop severe shock requiring
intensive care treatment, but this is not a reason for avoiding the procedure. The owner
should be informed in advance of a potential higher risk. In these situations, it may be
better to avoid ultrasound-directed needle biopsy.

What Constitutes a Good Liver Biopsy

An ideal liver biopsy should be of proper size and taken from a location that represents
the primary liver pathology. In diffuse liver disease, the biopsy will likely represent the
entire liver but focal or regional disease becomes more problematic. Ultrasound exam-
ination or visual inspection is important to determine the presence of focal disease.
Ideally, at least 2 and preferably 3 biopsies should be obtained from separate liver
lobes.1 If one area seems normal and other areas seem abnormal, representative
samples from each area should be taken. Occasionally the normal looking areas
may actually be abnormal. Because of the smaller sample size obtained from needle
biopsies, there is greater potential for the needle sample not to represent the entire
liver. It is stated that 1 good core needle biopsy represents only a 50,000th of the entire
liver.10 The authors believe that 18G needle biopsies are generally too small, fragment
easily, and do not contain enough portal areas to be of diagnostic value. Good samples
can be obtained with 14G needle diameter for dogs and 16G for small dogs and cats.
Laparoscopic wedge and surgical wedge biopsies generally provide larger samples
but the procedure is more invasive. Samples from laparoscopic biopsy forceps are
usually approximately 5 mm in diameter. Surgical wedge samples should be at least
1 cm, preferably 2 cm deep. Subcapsular tissue contains more fibrous tissue and
may have nonspecific inflammatory changes that could be misleadingly interpreted
as representing the entire liver. With the larger wedge samples, this may be less of
a concern and the pathologist should interpret subcapsular change with caution.
Appropriate tissue handling and histologic interpretation is critical for a correct diag-
nosis. Box 1 provides guidelines for tissue handling of liver samples. An accurate
interpretation of the biopsy requires the presence of a sufficient number of portal
and central areas because different diseases are associated with different sublobular
zones. Many pathologists believe that 6 portal areas are necessary to make an
adequate diagnosis of inflammatory liver disease.11,12 The quality of a clinical diag-
nosis of liver disease depends largely on the histologic description. There is often
confusion about which criteria are essential to diagnose a certain disease, and indi-
vidual pathologists may have different interpretations or even different diagnoses on
the same sample. The World Small Animal Veterinary Association (WSAVA) has initi-
ated standards for unification of diagnostic criteria and nomenclature of liver diseases.
A team of leading specialists, clinicians and pathologists, have reviewed most known
liver diseases of companion animals and have described clear-cut and well-illustrated
criteria in the publication, WSAVA Standards for Clinical and Histologic Diagnosis of
Canine and Feline Liver Diseases in 2006.13 The clinician should expect a detailed
description according to these international guidelines from their pathologist.
In addition to tissue for histopathology, samples may also be procured for culture or
quantitation of copper or other metals. Ideally, approximately 20 to 40 mg of liver (wet
weight) is required for copper quantitation using atomic absorption spectrophotom-
etry methods. This amount equates to a sample of approximately 2.5 mm diameter
or one full 14G (2-cm long) needle biopsy sample. Smaller samples may decrease
 Liver Biopsy Techniques 473

Box 1
Guidelines for proper handling of liver tissue

1. Verify the quality of the tissue; it should be unfragmented and at least 1 cm, preferably 2 cm
in length. Samples obtained surgically should be cut into thin slices <5 mm thick. The center
of thicker pieces will not be fixated adequately in formalin or another fixative.
2. The tissue should be put into the fixative within 5 minutes; 10% neutral buffered formalin is
used routinely.
3. The fixation time should not be too long; after long formalin fixation
immunohistochemistry becomes impossible with many antibodies.
4. Think in advance about the specific requirements. It may be necessary to perform electron
microscopy, specific stains for metabolic diseases, and so forth. In case of doubt, the
pathologist should be contacted about the best way to preserve the tissue.
5. For quantitative measurement of metals in liver such as copper, avoid saline if using neutron
activation analysis for measurement of small amounts in biopsy samples because the analysis
is affected by the presence of sodium. Tissue should be sampled in a metal-free plastic
container and freeze-dried; thereafter closed containers can be stored at room temperature.
6. Fill the container completely with fixative so that the sample is not stirred and broken
during transportation.

the accuracy of the metal analysis. Laparoscopic cup biopsy forceps provide 45 mg of
liver tissue, a 14G Tru-Cut–type biopsy needle provides 15 to 20 mg, whereas an 18G
needle biopsy provides only 3 to 5 mg of liver tissue. Liver tissue taken for culture
should be approximately 5 mg in size and placed in appropriate transport broth or
medium that preserves aerobic and anaerobic bacteria.

FINE-NEEDLE ASPIRATION

Fine-needle aspiration (FNA) with cytologic examination is commonly performed in

small animals with liver disease because it is cheap and easy to do. FNA can be per-
formed at low risk to the patient and usually without the need for sedation or local
anesthesia.4,14 It is best suited for diffuse hepatic disease. If focal lesions are present
ultrasound direction becomes necessary. Bleeding complications from FNA of the
liver are uncommon and there is rarely a need to perform coagulation tests unless
overt hemorrhage is identified before the aspiration. However, there are limitations
to FNA and examination of the liver cytology. These include failure to correctly identify
the primary disease due to the small sample size and the cytology does not reflect the
morphology of the parenchymal architecture. Several studies have compared liver
aspirates and their cytologic interpretation with the histopathologic diagnosis from
a biopsy. In a large study of 97 cases involving dogs and cats, only 30% of the canine
cases and 51% of the feline cases had overall agreement between the histopathologic
diagnosis and the cytologic diagnosis.15 In this study, the diagnosis of vacuolar hep-
atopathy was the category with the highest percentage of agreement, whereas inflam-
matory disease was correctly diagnosed only 25% of the time when dogs and cats
were grouped together. Other similar studies also point out the low correlation of
cytology with histopathology. Although FNA is frequently used by clinicians to support
the diagnosis of hepatic lipidosis in cats, there is a report of 4 cats incorrectly diag-
nosed as having hepatic lipidosis instead of lymphoma.16 A multistep approach to
cytologic evaluation of nonvacuolar diseases may provide useful standardization for
cytologic evaluation and improve the diagnostic accuracy.17
474 Rothuizen & Twedt

The location of the entry site for most FNAs is determined using ultrasound to direct
the needle to focal lesions or to certain areas in the liver. Alternatively a blind method,
in which a random sample of the liver is obtained, may be adequate if a palpable large
liver is present and diffuse disease such as malignant lymphoma or diffuse vacuolar
hepatopathies (lipidosis) of the liver is suspected. If a large palpable liver is present
and if using a blind technique, the usual entry point is caudal to the costal arch. The
liver can also be approached on the right side at the 10th intercostal space at the level
of the rib-cartilage junction. For either approach there is no need for local or general
anesthesia in dogs or cats if using thin needle sampling. Most FNAs are performed
using a 20G to 22G needle. A 3-inch disposable injection needle is usually sufficient,
but longer needles may be required for deep-lying lesions. The tissue is aspirated in an
identical procedure to that used for peripheral structures such as lymph nodes. The
needle attached to a 5 or 12 mL syringe is advanced under ultrasound guidance
into the liver. At the site of aspiration the needle is quickly advanced and withdrawn
0.5 to 1 cm several times. Cells within the needle are then blown on the microscope
slide with the syringe. Others prefer to apply negative pressure on the syringe plunger
while aspirating the liver. Pressure on the plunger is released and the needle with-
drawn. This technique collects more cells but also results in more blood contamina-
tion, which must be considered in the cytologic interpretation. Liver aspirates are
placed on a glass microscope slide, air-dried and routine cytologic staining used. It
is also possible to use specific staining methods such as copper stains (rubeanic
acid or rhodanine stain) for intracellular copper granules, Sudan stain for lipids, and
periodic acid-Schiff stain for the presence of glycogen.

NEEDLE BIOPSY

Several different needles and biopsy techniques are used to obtain liver tissue for
examination, each with advantages and disadvantages. The Menghini technique
involves tissue aspiration (using saline) with a syringe attached to a large bore hollow
needle. The tip of the needle is convex and is sharp around the circumference. Most
needles have a blocking device in the shaft to prevent liver tissue going into the
syringe. The Menghini or blind technique is not suitable for ultrasound guidance and
is almost always performed using the needle tip as a probe to palpate the appropriate
location.1 When the site is determined, suction is applied to the syringe and the needle
is quickly thrust into the liver and then rapidly retrieved. A core of liver is then sucked
into the needle. The samples are larger than those obtained with Tru-Cut needles
because the entire lumen is filled with tissue and the length of the sample can be pre-
determined. The Menghini technique is not suitable for cats.
The Tru-Cut–type needle is generally performed using ultrasound guidance, but
may also be done under visual control during laparoscopy or surgery. This technique
is the most widely used. The Tru-Cut–type needle has an outer cannula and an inner
notched shaft in which a tissue specimen is retained. The notched portion has a 2-cm
long indentation which is first advanced into the liver, so that the tissue can fall in the
indentation. Then, the outer cutting cannula slides over the inner notched shaft so that
the tissue is sliced off. The entire instrument is finally withdrawn and the tissue slice
retrieved. Tru-Cut needles have a sharp tip and should therefore only be used under
visual control such as ultrasound guidance or during surgery. There are 3 types of
Tru-Cut needles: manual, semi-automatic, and those used in a biopsy gun device.18
Manual devices are cheap but they are the most difficult to handle and their use is
not advised other than during surgery under direct visual control. Semi-automatic nee-
dles are the most expensive but easy to use. These needles are recommended for
 Liver Biopsy Techniques 475

cats. Biopsy gun devices require a larger financial investment, but the Tru-Cut needles
used with them are inexpensive. The gun-driven needles are recommended for
centers where biopsies (not only of the liver but also of kidneys and other structures)
are routinely taken under ultrasound guidance.19 An advantage of Tru-Cut guns is that
they operate so quickly that a firm, fibrotic liver or a liver with concurrent ascites tissue
is more easily sampled. In these situations, the liver may be hard to puncture using
conventional needles. As a rule, most semi-automatic and gun-driven Tru-Cut needles
advance 2 cm into the liver so it is important to note the amount of liver tissue available
in front of the needle before advancement so that no structures other than the liver are
hit with the needle.

LAPAROSCOPIC LIVER BIOPSY

Diagnostic laparoscopy is a technique used to view and biopsy the organs in the
abdominal cavity.20 The technique involves distention of the abdominal cavity with
gas followed by placement of a rigid telescope through a portal (cannula) in the
abdominal wall to examine the contents of the peritoneal cavity. Biopsy forceps or
other instruments are then passed into the abdomen through adjacent portals to
perform various procedures. Laparoscopy requires general anesthesia but the limited
degree of invasiveness, diagnostic accuracy, large biopsy sample size, and rapid
patient recovery make laparoscopy a valuable technique for obtaining liver tissue.
The excellent view of the liver with magnification is an advantage but limitations
include the expense of the equipment, adequate operator training, and increased
time over needle biopsy techniques. Laparoscopy is frequently used to obtain biop-
sies of the liver, pancreas, kidney, spleen, lymph node, and intestine. Laparoscopy
may also reveal small (0.5 cm or less) metastatic lesions, peritoneal metastases, or
other organ involvement not easily observed by other techniques. One of the ancillary
diagnostic techniques using laparoscopic guidance also includes gallbladder aspira-
tion (choleocystocentesis).
Laparoscopy is a step between needle liver biopsy and surgical laparotomy for
obtaining tissue for histopathology. Because most liver diseases are nonsurgical,
laparoscopy is often the preferred technique over laparotomy. The advantages of
laparoscopy over conventional surgical laparotomy include improved patient recovery
because of smaller surgical sites, lower postoperative morbidity, and decreased infec-
tion rate, postoperative pain, and hospitalization time. Other less obvious benefits of
laparoscopy are related to fewer stress-mediated factors than are reported to occur
with surgery.
Discussion of basic laparoscopic equipment and a detailed description of the tech-
niques for laparoscopy are beyond the scope of this article and the reader should
consult specific texts or articles on laparoscopy. For most diagnostic laparoscopic
procedures a 5-mm diameter 0 field of view telescope is recommended. The 0 desig-
nation means that the telescope views the visual field directly in front of the telescope
in a 180 circumference. Angled viewing scopes such as the 30 telescope enable the
operator to see into areas with a small field of view. However, angled telescopes make
the orientation more difficult for the inexperienced operator. Five-millimeter diameter
forceps with oval biopsy cups are most often used for liver biopsy.21
The patient should be fasted for at least 12 hours. Under general anesthesia
2 cannula portals are placed through the abdominal wall, one for the telescope
and the other for the biopsy forceps. There are 2 basic entry sites for liver biopsy.
The first uses dorsal recumbency in which the telescope is placed on the midline
behind the umbilicus. This position provides a view of the entire surface of the liver,
476 Rothuizen & Twedt

however the falciform ligament is often a nuisance and the pancreas is more difficult
to identify. The second entry site requires placement of the animal in left lateral
recumbency with the telescope portal in the right mid-abdominal wall. This lateral
approach is preferred by the authors because the falciform ligament is not in the
way, the right limb of the pancreas is easily seen, and the extrahepatic biliary system
can be easily followed to where it enters the duodenum. Using this approach the left
lateral lobe of the liver is difficult to examine completely.
The liver, extrahepatic biliary system, and other abdominal structures are examined
and can be palpated using a specialized palpation probe. The palpation probe is used
to move or elevate lobes of the liver for complete inspection and to aid in selecting
representative areas of the liver to be sampled. Using the oval biopsy cups either
an edge of the liver or the surface of the liver is sampled. To take a biopsy of the
surface of the liver, the forceps are directed at approximately 90 angle to the liver,
opened and pushed into the liver, and then closed. Sample size will vary with the
operator’s technique and depth of penetration. With either sampling technique the
forceps are closed tightly for 15 to 30 seconds and then gently tugged away from
the liver. The biopsy site is then examined for bleeding which usually subsides quickly.
Because of the magnification of the telescope, 1 to 2 milliliters of blood may seem
excessive. Abnormal hemorrhage rarely occurs but if present can be controlled by
several methods. Some prefer using monopolar electrocautery while compressing
the liver tissue with the biopsy forceps. Electrocautery is reported to affect only the
periphery of the biopsy sample.2 A second technique is to place absorbable gelatin
coagulation material in the biopsy site. It is also possible to apply compression over
the bleeding area with forceps or the palpation probe.
Intrahepatic lesions observed using ultrasound may be more difficult to identify.
Deeper samples of the liver can be obtained using laparoscopic direction of a biopsy
needle. Needles are passed directly through the abdominal wall and can be guided to
the area to be sampled without the need for a cannula. Laparoscopic-guided chole-
cystocentesis can also be performed if inflammatory or infectious biliary tract disease
is suspected. A 22G long needle is used to collect bile for culture and cytology. The
needle is directed through the abdominal wall behind the diaphragm into the
gallbladder and the contents aspirated. It is important to remove as much bile as
possible to empty the gallbladder and prevent leakage when the needle is removed.
As previously stated it is important to biopsy areas that seem normal as well as
those that seem abnormal. Some investigators suggest that biopsies taken at the
edge of the liver often do not reflect deeper lesions and that the histopathology at
the subcapsular edge of the liver is usually more reactive.22 Others suggest that the
samples collected by laparoscopic cup biopsy are so large that this should not be
considered a major concern.
The complication rate of laparoscopy is low. In an unpublished review of a series of
cases involving diagnostic laparoscopy, the complication rate was less than 2%.
Serious complications include anesthetic- or cardiovascular-related death, bleeding,
or air embolism. Minor complications are generally operative and are associated
with inexperience or failure to understand the limitations and potential complications.

SURGICAL LIVER BIOPSY

Liver biopsy alone is rarely an indication for a laparotomy. However, there are indica-
tions for surgical procedures such as investigation of an extrahepatic biliary obstruc-
tion or for correction of a vascular anomaly. In these cases, a liver biopsy is always
indicated. Liver biopsies are also often obtained in conjunction with other surgical
 Liver Biopsy Techniques 477

procedures. A biopsy should be performed if the liver looks abnormal or abnormal liver
enzyme levels are discovered before surgery. It is recommended that a surgical liver
biopsy be taken early during the laparotomy because hepatocellular changes can
result from prolonged anesthesia, vascular changes, and manipulation of the
bowel.2,23
There are several techniques for obtaining liver tissue during a laparotomy. The
most commonly used method is the suture fracture technique. With this method,
samples are generally obtained from the tip of a liver lobe. A 5- to 6-mm skin biopsy
punch has also been described to sample focal superficial lesions. Once the core
sample is obtained with the punch, gelatin coagulation material is placed in the biopsy
site. Readers should refer to surgical texts for details of surgical methods of liver
biopsy.
The advantage of surgery is the exposure, ability to manipulate the tissues, and
ability to monitor the biopsy site for bleeding. A review comparing two 18G needle
Tru-Cut biopsy samples with a larger wedge biopsy found poor histologic correlation,
pointing out the advantage of larger surgical or laparoscopic biopsies.20 The extrahe-
patic biliary system can also be completely investigated with surgery and bile is easily
sampled through directed aspiration. The disadvantage of surgical biopsy is the need
for general anesthesia, the large abdominal incision, and the postoperative recovery

Fig. 1. Laparoscopic liver biopsy. Liver biopsies are taken with 5-mm oval biopsy forceps.
(A) View of a liver biopsy taken from the edge of a liver lobe; (B) view showing the liver
following the biopsy; (C) view showing a liver biopsy taken from the surface of the liver;
and (D) view showing the liver following the biopsy.
478 Rothuizen & Twedt

Fig. 2. Local anesthesia given for Menghini needle liver biopsy. The incision is made through
the skin and abdominal wall just 1 to 2 cm caudal to the xyphoid in the midline. The position
of the last rib is indicated.

time. The sample size of a biopsy obtained through surgery is the largest of any of the
methods described, providing more than adequate tissue for histopathology, copper
analysis, and culture. Bleeding can also be controlled easily using focal pressure,
suturing methods, or electrocoagulation.

GALLBLADDER PUNCTURE

Although this is not strictly a liver-sampling procedure, sampling of bile in all cases in
which inflammatory/infectious biliary disease is suspected, is an essential diagnostic
step.24,25 Puncture of the gallbladder can be performed safely using the ultrasound-
guided thin needle technique. There is no need to approach the gallbladder transhe-
patically; any approach is safe. Thin needle sampling does not lead to vagal reactions
and shock. Puncture of the gallbladder should be avoided in cases of extrahepatic bile
duct obstruction because of the risk of inducing rupture or bile leakage. Sampling of
bile for cytology and culture is especially important in cats, in which cholangitis is
a major hepatobiliary disorder.

Fig. 3. Typical liver tissue samples obtained with different biopsy devices. Top: a Tru-Cut
needle, which is usually driven by a biopsy gun. Half of the diameter of the inner needle
is available to collect the biopsy. Bottom: Menghini needle tip with the tissue sample aspi-
rated. The entire lumen of the needle is available to collect tissue; the sample is caught by
aspiration with saline while advancing the needle into the liver. Middle: a Vim-Silverman
needle, no longer in use.
 Liver Biopsy Techniques 479

SUMMARY

A liver biopsy is generally safe and provides useful information about the liver.
However, the importance of the information to be obtained from a biopsy must be
weighed against the risk to the patient. A liver biopsy provides important information
on the status of the liver. Only after the clinical information, liver biopsy, and histopa-
thology are obtained can a diagnosis and prognosis be made. With proper training and
adequate operator experience liver biopsy is an important diagnostic tool (Figs. 1–3).

REFERENCES

1. Rothuizen J. Diseases of the liver and biliary tract. In: Dunn J, editor. Textbook of
small animal medicine. London: Saunders; 1999. p. 448–97.
2. Rawlings CA, Howerth EW. Obtaining quality biopsies of the liver and kidney.
J Am Anim Hosp Assoc 2004;40:352–8.
3. Vasanjee SC, Bubenik LJ, Hosgood G, et al. Evaluation of hemorrhage, sample
size, and collateral damage for five hepatic biopsy methods in dogs. Vet Surg
2006;35(1):86–93.
4. Weiss DJ, Moritz A. Liver cytology. Vet Clin North Am Small Anim Pract 2002;
32(6):1267–91.
5. Hitt ME, Hanna P, Singh A. Percutaneous transabdominal hepatic needle biopsies
in dogs. Am J Vet Res 1992;53:785–7.
6. Bigge LA, Brown DJ, Penninck DG. Correlation between coagulation profile find-
ings and bleeding complications after ultrasound-guided biopsies: 434 cases
(1993–1996). J Am Anim Hosp Assoc 2001;37(3):228–33.
7. Badylak SF, Dodds WJ, Van Vleet JF. Plasma coagulation factor abnormalities in
dogs with naturally occurring hepatic disease. Am J Vet Res 1983;44(12):
2336–40.
8. Badylak SF, Van Vleet JF. Alterations of prothrombin time and activated partial
thromboplastin time in dogs with hepatic disease. Am J Vet Res 1981;42(12):
2053–6.
9. Smith S. Ultrasound guided biopsy. Semin Vet Med Surg 1989;4:95–104.
10. Geller SA. Liver biopsy for the nonpathologist. In: Gitnick G, editor. Principles and
practice of gastroenterology and hepatology. 2nd edition. Norwalk (CT): Appleton &
Lange; 1994. p. 1023–36.
11. Desmet V, Fevery J. Liver biopsy. In: Hayes PC, editor, Investigations in Hepa-
tology. Baillière’s Clinical Gastroenterology, vol 9, nr 4. London: Baillière Tindall;
1995. p. 811-28.
12. Crawford AR, Xi-Zhang L, Crawford JM. The normal adult human liver biopsy:
a quantitative reference standard. Hepatology 1998;28(2):323–31.
13. Rothuizen J, Bunch SE, Cullen JM, et al. WSAVA standards for clinical and histo-
logical diagnosis of canine and feline liver diseases. Edinburgh: Saunders; 2006.
14. Kerwin SC. Hepatic aspiration and biopsy techniques. Vet Clin North Am Small
Anim Pract 1995;25:275–91.
15. Wang KY, Panciera DL, Al Rukivat RK, et al. Accuracy of ultrasound-guided fine-
needle aspiration of the liver and cytologic findings in dogs and cats: 97 cases
(1990–2000). J Am Vet Med Assoc 2004;224:75–8.
16. Willard M. Fine-needle aspirate cytology suggesting hepatic lipidosis in four cats
with infiltrative hepatic disease. J Feline Med Surg 1999;1(4):215–20.
17. Stockhaus C, Van Den Ingh T, Rothuizen J, et al. A multistep approach in the cyto-
logic evaluation of liver biopsy samples of dogs with hepatic diseases. Vet Pathol
2004;41:461–70.
480 Rothuizen & Twedt

18. de Rycke LM, van Bree HJ, Simoens PJ. Ultrasound-guided tissue-core biopsy of
liver, spleen and kidney in normal dogs. Vet Radiol Ultrasound 1999;40(3):294–9.
19. Hoppe FE, Hager DA, Poulos PW, et al. A comparison of manual and automatic
ultrasound-guided biopsy techniques. Vet Radiol 1986;27:99–101.
20. Monnet E, Twedt DC. Laparoscopy. Vet Clin North Am Small Anim Pract 2003;33:
1147–63.
21. Twedt DC. Laparoscopy of the liver and pancreas. In: Tams TR, editor. Small
animal endoscopy. 2nd edition. St. Louis (MO): CV Mosby Co; 1999. p. 44–60.
22. Patrelli M, Scheuer PA. Variation in subcapsular liver structure and its significance
in the interpretation of wedge biopsies. J Clin Pathol 1967;20:743–8.
23. Fossum TW, Hedlund CS. Surgery of the liver. In: Fossum TW, editor. Small animal
surgery. St. Louis (MO): Mosby; 1997. p. 367–99.
24. Cole TC, Center SA, Flood SN, et al. Diagnostic comparison of needle and wedge
biopsy specimens of the liver in dogs and cats. J Am Anim Hosp Assoc 2002;
220:1483–90.
25. Savary-Bataille KC, Bunch SE, Spaulding KA, et al. Percutaneous ultrasound-
guided cholecystocentesis in healthy cats. J Vet Intern Med 2003;17(3):298–303.
Chapter 16
Liver BIOPSY

Indications for liver biopsy include hepatic masses or nodules, hepatic hyper-
bilirubinemia, or persistent increase in liver enzyme, serum bile acid, or
plasma ammonia concentration. Liver biopsies are also recommended in
patients with unexplained generalized hepatomegaly or altered hepatic echo-
genicity on ultrasound. Liver samples can be obtained percutaneously or by
open or laparoscopic surgical biopsy. Samples obtained by surgical biopsy
are larger and more likely to be of diagnostic quality than those obtained per-
cutaneously. Surgical approaches also reduce the risk of inadvertent damage
to the gallbladder or other organs in patients with small livers.

Preoperative management

Preoperative diagnostics and treatment depend on the underlying disease

process. Coagulation panels and buccal mucosal bleeding times should be
performed in patients with thrombocytopenia, significant hypoalbuminemia,
biliary obstruction, severe liver disease, or sepsis. If prolonged clotting times
are detected, the patient should receive fresh frozen plasma or fresh whole
blood before surgery. Vitamin K1, which is necessary for production of
clotting factors II, VII, IX, and X, should be administered in patients with
biliary obstruction (1–5 mg/kg SC with a small needle). Animals should be
clipped to midthorax, since the abdominal incision often extends to the
xiphoid cartilage.

Surgery

In animals undergoing liver biopsy, ventral midline incisions should start

caudal to the xiphoid process to avoid perforation of the diaphragm. Liga-
tion and amputation of falciform fat may be necessary to expose small livers.
If a celiotomy is to be performed, the entire abdomen should be explored
for abnormalities. To improve exposure, a moistened laparotomy pad can
be placed between the diaphragm and liver lobes. One corner of the pad can
be secured to the drape with a hemostat so that it can’t be accidently left in
the abdomen. In animals with diffuse disease that do not require explora-
tion, the liver can be biopsied through a 2- to 4-cm ventral keyhole incision.
Livers with diffuse disease can be sampled with a clamshell biopsy forceps
or a guillotine suture ligation technique. A box stitch may be needed in
animals with rounded lobes. Suture ligations are usually performed with 3-0
rapidly absorbable monofilament material. Samples from central lesions can
be obtained with clamshell biopsy forceps or a skin punch. A 6-mm punch

125
Surgery of the Digestive System biopsy instrument is preferred in animals with microvascular disease, since
the 4-mm instruments are less likely to provide an adequate number of
portal triads for evaluation. Because hepatic veins are located closer to the
caudodorsal (visceral) surface of the liver, punch biopsies are taken from the
convex, diaphragmatic surface. Punch biopsy depth should not exceed 50%
of the liver lobe thickness.
If focal lesions are present, the junction between normal and abnormal
tissue should be included in the biopsy sample. Multiple lobes are usually
biopsied when congenital microvascular anomalies are suspected (e.g., micro-
vascular dysplasia secondary to congenital portal hypoplasia).

Surgical technique: guillotine biopsy

1. Using 3-0 rapidly absorbable monofilament material, fashion a 3- to 4-
cm suture loop that has a simple or surgeon’s throw.
2. Encircle the tip of a liver lobe with the suture loop. Include at least 1 cm
of tissue in the suture loop.
a. If a natural fissure is present near the tip of the lobe, drop the suture
into the fissure (fig. 16-1).
b. If the liver margin is rounded, crush the edge of the liver lobe tip on
both sides with a hemostatic forceps to make fissures (figs. 16-2 and
16-3). Drop the suture into the fissures.
c. If the liver lobe cannot be easily exposed, insert an Allis tissue
forceps through the suture loop. Grasp at least 1 cm of the tip of the
liver with the forceps. Gently retract the liver lobe and slide the
suture around the liver tissue just beyond the forceps.
3. Tighten the suture loop until it crushes through all the liver tissue,
leaving the vessels and ducts intact (fig. 16-4). Do not lift up on the
suture when tightening or you will pull the ligature off and tear the
vessels. A single throw is sufficient for hemostasis.

Figure 16-1 Drop the suture loop over

the liver tip into natural fissures along
the margins.

126
 Liver Biopsy

Figure 16-2 If the margin is rounded,

crush the edge of the liver margin with
hemostats.

Figure 16-3 Pull the closed hemostat

gently away from the edge to make a
fissure.

Figure 16-4 Tighten the suture loop

around the base of the tissue until
it crushes through all the enclosed
parenchyma.

127
 Liver Biopsy

Figure 16-5 Transect the tissue distal

to the ligature.

Figure 16-6 Take a bite through the

liver perpendicular to the margin.

4. With scissors or a blade, transect the tissue distal to the ligature (fig.
16-5). Do not grasp the liver sample with forceps.

Surgical technique: box suture liver biopsy

1. With 3-0 absorbable suture material on a taper needle, take a bite
through the liver tissue adjacent to the desired biopsy site. Pass the needle
full thickness through the liver lobe perpendicular to the tissue margin
and 1 to 1.5 cm from the edge of the lobe (fig. 16-6).

128
 Liver Biopsy

Figure 16-7 Tie one or two throws,

tightening to cut through the
parenchyma. Cut the suture ends short.

Figure 16-8 Take a second bite parallel

to the first. Tighten the throw, leaving
both ends long.

2. Tie one or two throws. Tighten the throws perpendicular to the hepatic
margin to crush through the encircled tissue (fig. 16-7). Cut the suture
ends.
3. Place a second full-thickness bite on the opposite side of the tissue to
be biopsied. The bite should be 1.5 to 2 cm parallel to the first suture
and perpendicular to the liver margin. Tie a single throw and crush the
encircled tissue (fig. 16-8). Leave the ends of this suture long.
4. Pass one end of the suture under the pedicle of liver tissue and through
the fissure created by the first ligature (fig. 16-9).
5. Tie this suture end back to the remaining suture to encircle the base of
the hepatic tissue pedicle. Ligate the encircled tissue with one to two
throws, crushing the pedicle base. Cut the ends of the suture.
6. Remove the hepatic tissue within the ligated region with scissors (fig.
16-10).

129
 Liver Biopsy

Figure 16-9 Pass the suture through

the fissures created by the two ligatures
and around the base of the tissue.

Figure 16-10 Tie the suture loop and

transect the tissue beyond the ligature.

Surgical technique: skin punch liver biopsy

1. Position a 6-mm skin punch perpendicular to the surface of the liver.
2. Press downward while rotating the punch clockwise and counterclock-
wise to twist it into the liver tissue. Do not penetrate more than halfway
through the liver surface.
3. Tilt the punch 45 degrees and rotate while advancing slightly to sever
any remaining tissue attachments (fig. 16-11).
4. Withdraw the punch at an angle to retain the sample within the instru-
ment (fig. 16-12). Do not handle the sample with thumb forceps.
5. If the biopsy site is bleeding, insert a plug of hemostatic material (e.g.,
gelatin foam) into the defect, or apply direct pressure for several minutes.
Alternatively, place a mattress or cruciate suture of absorbable material
across the site. Tie gently so that the suture material does not tear the
liver parenchyma.

130
 Liver Biopsy

Figure 16-11 Rotate the punch into

the hepatic parenchyma, then tilt the
punch slightly while advancing further
to sever the tissue base.

Figure 16-12 Resultant punch hole.

Surgical technique: keyhole incision

1. Make a 2- to 4-cm skin incision just caudal to the xiphoid process (fig.
16-13).
2. Extend the incision through the subcutaneous fat and linea.
3. Insert a finger gently through the incision to separate the falciform fat.
4. Reach forward with your index finger or pinkie and hook the lesser
curvature of the stomach. With downward digital pressure, pull the
stomach caudally and then withdraw your finger.
5. Lift one side of the abdominal wall with thumb forceps to expose the
liver. If the liver is not visible, extend the linea incision or retract the
abdominal wall cranially.

131
 Liver Biopsy

Figure 16-13 Make a 2- to 4-cm

incision through the skin, subcutaneous
tissues, and linea just caudal to the
xiphoid.

Figure 16-14 Grasp the exposed liver

margin with clamshell biopsy forceps;
hold the jaws closed for 10 to 20
seconds before pulling the forceps away
from the liver.

6. Grasp a large bite of the edge of the liver with clamshell biopsy forceps
(fig. 16-14). Insert the forceps over the parenchymal edge so that the
liver tissue reaches the angle of the jaws.
7. Close the jaws firmly and hold them apposed for 10 to 20 seconds.
8. Twist the forceps while pulling back gently until the piece of liver tissue
is freed (fig. 16-15).
9. If the tissue is trapped within the jaws of the instrument, use a needle
to gently tease it out. Do not handle the sample with thumb forceps.
10. Close the external rectus sheath with a continuous or interrupted
pattern. Close the subcutis and skin routinely.

132
 Liver Biopsy

Figure 16-15 Final sample.

POSTOPERATIVe cONSIDERATIONS

Since complications of surgical liver biopsy are rare,

postoperative care is primarily focused on treatment of
the underlying condition. If hemorrhage is a concern,
hematocrit should be measured immediately after
surgery and then several hours later to evaluate the
animal for progressive anemia. Punch biopsies cause
significantly more hemorrhage than guillotine or
clamshell techniques.

Bibliography
Burger D et al: How to perform a surgical hepatic biopsy.
Vet Med 2006;101:306– 312.
Cole TL et al: Diagnostic comparison of needle and wedge
biopsy specimens of the liver in dogs and cats. J Am Vet
Med Assoc 2002;220:1483–1490.
Roth L: Comparison of liver cytology and biopsy diagnoses
in dogs and cats: 56 cases. Vet Clin Pathol 2001;30:35–
38.
Vasanjee SC et al: Evaluation of hemorrhage, sample size,
and collateral damage for five hepatic biopsy methods in
dogs. Vet Surg 2006;35:86–93.

133
Bedah Sistem Digesti I
“Biopsi Hati”
KELOMPOK A1 :

Reynara Wildan Pratama 1809511111

Adithya Fauzan 1909511001
Lily Sin Ina Indayani 1909511002
Ni Luh Putu Suarniti 1909511003
Siti Putrindah Mentari 1909511004
Rahma Anissa Prayoko 1909511005
 TERMINOLOGI
Biopsi
prosedur untuk mengangkat sepotong jaringan, sehingga dapat diperiksa di
bawah mikroskop untuk mencari tanda-tanda kerusakan atau penyakit.

Biopsi Hati
prosedur untuk mengangkat sepotong kecil jaringan hati, sehingga dapat
diperiksa di bawah mikroskop untuk mencari tanda-tanda kerusakan atau
penyakit.
 INDIKASI

● Harus dilakukan Test ALT

dan HCV
● Dilakuan MRI dan USG untuk
melihat keabnormalitas hati
atau bisa juga di gunakan
Fibroscan
 Anestesi
● Opiat yang dikombinasikan dengan
benzodiazepin pada anjing dan kucing atau
● Kombinasi ketamin dan diazepam pada
kucing.
● Acepromazine diberikan sebagai obat
penenang.
 Pre-Operasi

01 Alat dan Bahan 02 Ruang Operasi

Ruangan bersih dengan penerangan yang
- Alat Operasi cukup, terdapat alas kaki khusus, meja
- Anestesi, Cairan infus, Analgesik, operasi yang bersih, dan diberi underpad.
Benang absorbable Sebelum operasi, ruang operasi
dibersihkan menggunakan desinfektan dan
untuk meja operasi didesinfeksi dengan
alkohol 70%.

03 Hewan/Pasien 04 Operator
Memiliki kebersihan pribadi yang baik yaitu
- Tes diagnostik pra-bedah untuk menentukan
memiliki kondisi sehat serta melakukan
perawatan perioperatif yang harus diberikan.
persiapan diri (mencuci tangan dengan
- Puasakan selama 12 jam sebelum operasi.
sabun antiseptik, memakai baju operasi,
- Berikan cairan (hipoalbuminemia diberikan
glove, masker, dan penutup kepala).
cairan koloid seperti hetastarch atau plasma)
dan analgesik.
 Prosedur Operasi
➔ Biopsi guillotine

● Bentuk lingkaran dengan jahitan monofilamen yang dapat diserap, buatlah suture loop 3
hingga 4 cm menggunakan satu kali ikatan sederhana atau surgeon’s throw.

● Lingkari ujung lobus hati dengan suture loop. Masukkan setidaknya 1 cm jaringan di loop
jahitan

Jatuhkan jahitan di atas titik lobus, Jika margin membulat, himpitkan Tarik hemostatik tertutup dengan
pasang jahitan ke dalam celah alami tepi margin hati denganforsep lembut menjauh dari tepi untuk
hemostatik membuat celah
➔ Biopsi guillotine

● Kencangkan loop jahitan sampai ● transek jaringan di bagian distal dari

menembus semua jaringan hati, pengikat (gbr a. dengan gunting, gbr.b
membiarkan pembuluh darah dan dengan pisau scalpel )
saluran tetap utuh
 ➔ Box suture liver biopsy

Ikat satu atau dua lemparan, Ambil tusukan kedua sejajar dengan
Ambil tusukan jaringan hati melalui lobus
kencangkan untuk memotong yang pertama. Kencangkan, biarkan
hati tegak lurus dengan margin
parenkim. Potong ujung jahitan kedua ujungnya Panjang
menjadi pendek

Lalu lewati salah satu ujung jahitan melalui

Buang jaringan hati di dalam daerah yang
celah yang dibuat oleh dua pengikat dan di
diligasi dengan gunting
sekitar pangkal jaringan. ikat kembali ke ujung
yang lain
 ➔ Skin punch liver biopsy

Tempatkan skin punch 6 mm tegak

Putar punch ke parenkim hati, lalu miringkan punch
lurus dengan permukaan hati sedikit sambil maju lebih jauh untuk memutuskan
dasar jaringan

Tekan ke bawah sambil

memutar punch searah jarum
jam dan berlawanan arah jarum
jam untuk memutarnya ke
dalam jaringan hati

Tarik punch
➔ Keyhole incision

Buat sayatan 2 sampai 4 cm

melalui kulit, jaringan subkutan, Pegang tepi hati dengan
sampel akhir
dan linea tepat di kaudal xiphoid tang clamshell biopsy
forceps
Pasca Operasi
1. Injeksi Banamine (Flunixin Meglumine; 1 mg / kg BB) IM
setelah OP
2. Jika terjadi pendarahan di tempat sayatan, Tru-Cut/
clamshell:
a. Dikontrol dengan busa gelatin adsorbable
b. Ditutup dengan omental dan dijahit diatas luka terbuka
bekas operasi
c. Dilakukan penekanan pada daerah dilakukannya
biopsi
d. Dilakukan kauterisasi dengan menggunakan
pengaturan rendah
TERIMA
KASIH