2. Definition / Introduction
Historic Perspective
Aim
Indications
Contra-indications
Classification/Types
Principles and Techniques
Complications
Situation in our Sub-region
Conclusion

3. Biopsy is derived from a Greek word (By-op-see) = Bio –
meaning LIFE and Opsy – TO LOOK
This is the surgical removal of a tissue specimen in a
living body for the purpose of examination and
diagnoses.
It could also be therapeutic
Invaluable in the mgt of certain surgical lesions

4. Any organ in the body can be biopsied using a variety
of techniques.
Proper patient evaluation is paramount.
The need for biopsy in surgery can not be over-
emphasize

5. 1870, Ruge and Joham Vert in Berlin introduced surgical
biopsy as an essential tool for diagnosis.
1889, Emarch put forward an argument that
confirmations should be made before surgeries for
malignancies.
Williams halsted 1st introduced this principle in United
States.
1941, study of exfoliated cells from female genital tract by
Papanicolaou.

6. This was adapted to study cells from other body
systems
Along with this were innovations in various kinds of
tissue preparations and staining techniques

7. To establish tissue diagnosis
Grade tumors
To detect receptors
For screening purposes
Detecting enzymes and antigens

8. Monitoring, treatment, recurrence and prognosis
Research purposes
Microbiology
Medicolegal

9.  Any lesion that persists for more than 2 weeks
with no apparent etiologic basis
 Any inflammatory lesion that does not respond
to local treatment after 10 to 14 days.
 Persistent hyperkeratotic changes in surface
tissues.
 Any persistent tumescence, either visible or
palpable beneath relatively normal tissue.
 Evaluation and monitoring of tissue rejection
after transplantion –kidney and liver

10. Inflammatory changes of unknown cause that persist
for long periods
Lesion that interfere with local function
Bone lesions not specifically identified by clinical and
radiographic findings
Any lesion that has the characteristics of malignancy

11. Uncontrolled bleeding diasthasis
Anticoagulant therapy
Over-whelming sepsis
Severe impaired lung function
Uncoperative patient
Local infection near the site

12. CLOSED INDIRECT BIOPSY
- FNABC
- Core needle biopsy (tru-cut,Abram’s,vim
silverman,menghini)
- Punch biopsy
- Loop biopsy
- Endoscopic biopsy
CLOSED IMAGE GUIDED BIOPSY
- Stereotactic
- Ultrasound, CT, MRI

14. OPEN DIRECT BIOPSY
- Incisional
- Excisional
* marginal
* wide local
* radical

15. Aspiration biopsy is the use of a needle and syringe to
penetrate a lesion for aspiration if its contents.
Indications:
 To determine the presents of fluid within a lesion
 To ascertain the type of fluid within a lesion
 When exploration of an intraosseous lesion is
indicated

16. Outpatient procedure
Infiltrate the site with LA
22G needle attached to a 10ml syringe(syringe holder)
Place the needle in the mass
Apply suction while the needle is move back and
forth within the mass
Release the suction and withdraw needle once cellular
aspirate is seen

17. The cellular material is then expressed unto the
microscope slide
Air-dry or fixed with 95% ethanol

20. Skin cleansing + LA
Small skin incision
Lesion approach at an angle 450
Stabilize the lesion and introduce the needle via the
skin until it abuts against the lesion
Fully mechanical biopsy gun is then fired
Tissue fixed in formalin
Bleeding usually not a problem,apply pressure

21. Incision covered by an occlusive dressing
Sensitivity of 80 – 90%

22. An incisional biopsy is the surgical sampling of a
lesion(representative part).
If a lesion is large or has different characteristics in
various locations more than one area may need to be
sampled

23. Indications:
 Size limitations and ulcerated lesion
 Hazardous location of the lesion
 Great suspicion of malignancy
principle:
 Representative areas are biopsied in a wedge fashion.
 Margins should extend into normal tissue on the deep
surface.
 Necrotic tissue should be avoided.
 A narrow deep specimen is better than a broad shallow one.

24. An excisional biposy implies the complete removal of the
lesion.
Indications:
 lesions Less than 1cm
 The lesion on clinical exam appears benign.
 When complete excision with a margin of normal tissue
is possible without mutilation.

25. Technique:
 Skin incision shld be curvilinear and follow the langers lines
The entire lesion with 2 to 3mm of normal
appearing tissue surrounding the lesion is excised if
benign
 2 – 3cm if malignant.
 Lesions within 5cm of areolar margin ---- circumareolar
 Tissue forceps shld only be applied when the lesion has
been clearly defined

26. The lesion can be shelled out in cases of suspected
fibro adenomas
Secure hemostasis
Drains shld not be used
Wound closed in two layers

27. Gastroscopic or colonoscopic or through ERCP or
cystoscopic,arthroscopic

28. -Laparotomy
-Thoracotomy
-Craniotomy using dandy`s brain cannula

29.  Done whenever report is needed at the earliest
time. Here an unfixed fresh tissue is frozen (using
CO2) in a metal and sections are made and stained.
 PIT FALLS
-Technically difficult
-Difficult to get accurate result

30.  ADVANTAGES:
-Its quick and surgeons can decide the further steps to
follow

31.  USES:
-CA breast
-Follicular CA of thyroid when FNAC fails
-for accessing on-table clearance margin and depth.
-study of lymph nodes and their positivity for
malignancy.

32. This uses image intensifier to enhance the
accuracy of the site of the biopsy.
Radiological images of the site of the lesion, the
location the size and the shape the dept and other
characteristics are employed in order to increase
the accuracy of the procedure this involves
ultrasound CT-scan MRI and mammography.

35.  Exfoliative cytology is the histopathologic
examination of cells that have been obtained by
their physical removal, followed by their placement
on a glass slide, and then appropriately stained. The
term "Pap smear" is commonly used for exfoliative
cytology, but it only refers to the method of staining
and is in honor of the man who is credited with
developing the staining technique, Dr.
Papanicolaou.

36. It is important to develop a systematic approach in
evaluating a patient with a lesion in the body.
Pre-operative
Intra-operative
Post-operative

37. A detailed health history
A history of the specific lesion
A clinical examination
A radiographic examination
Laboratory investigations
Patient selection
Proper patient counseling
Obtain informed consent
Optimize patient e.g. stop anticoagulants

38. Proper pre-op localization of lesion especially of
impalpable lesions
Surgeon should be competent and preferably be the
one to perform the definitive surgery

39.  Congenital heart defects
 Coagulopathies
 Hypertension
 Poorly controlled diabetics
 Immunocompromised patients
 Renal compromise

40.  Erythroplasia- lesion is totally red or has a speckled red
appearance.
 Ulceration- lesion is ulcerated or presents as an ulcer.
 Duration- lesion has persisted for more than two weeks.
 Growth rate- lesion exhibits rapid growth
 Bleeding- lesion bleeds on gentle manipulation
 Induration- lesion and surrounding tissue is firm to the
touch
 Fixation- lesion feels attached to adjacent structures

41.  The anatomic location of the lesion/mass
 The physical character of the lesion/mass
 The size and shape of the lesion/mass
 Single vs. multiple lesions
 The surface of the lesion
 The color of the lesion
 The sharpness of the boundaries of the lesion
 The consistency of the lesion to palpation
 Presence of pulsation
 Lymph node examination

42. Anesthesia
- General, regional, or local
- block anesthesia is preferred to infiltration
- when block anesthesia is not possible, distant
infiltration may be used
- Do not inject directly into the lesion

43. POSITIONING
ANTIBIOTICS
ROUTINE CLEANING AND DRAPPING

44.  Incisions should be made with a scalpel.
 They should be converging
 Should extend beyond the suspected depth of the lesion
 They should parallel important structures
 Margins should include 2 to 3mm of normal appearing
tissue if the lesion is thought to be benign.
 5mm or more may be necessary with lesions that appear
malignant, vascular, pigmented, or have diffuse borders.
 Longitudinal in the extremities

45. . Ulcers;
- avoid central necrotic areas
- include adjoining normal tissue
. In deeply situated tissue take whole thickness and
normal tissue
. Handle tissues gently to preserve architecture

46. Avoid electrocautery for cutting if possible
Haemostasis
 Artery forceps, ligation, diathermy etc
Suction devices should be avoided
Drain when indicated, must be within the incision
Aim at primary closure of wound

47. Primary closure of the surgical site is necessary
In oral cavity mucosal undermining may be necessary
Elliptical incision on the hard palate or attached
gingiva may be left to heal by secondary intention.

48. Wound care
Analgesia
Antibiotics
Follow up

49. Direct handling of the lesion will expose it to crush injury
resulting in alteration the cellular architecture.
Specimen should be immediately placed in 10% formalin
solution and should be completely immersed
Boin’s solution for testicular biopsy and peripheral nerves
Chromate solution for chromafinomas
Gluteraldehyde for tissues for electron microscope

50. A biopsy data sheet should be completed and the
specimen immediately labeled. All pertinent history
and descriptions of the lesion must be conveyed.
 Biodata
 Unit and consultant in charge
 Nature of specimen and provisional diagnosis
 Date of specimen collection
 Previous histology results if any
 Clinical features and operative findings

51. This could be generalized or organ specific
Generalized :Infection;Hemorrhage;Pain; Tumor
upgrading; Ulceration; keloids; Hypertrophic
scar; Deformity
Specific organ compl.-PROSTATE:-
prostatitis,urinary retention,blood in
semen,bleeding rectum.LUNGS:-pneumothorax,
heamothorax,empyoma thorases,atelectases.

52. LIVER:-Intrahepertic hematoma,obstructive
jaundice,intra peritonal bleeding and bile leakage
BONE:-Osteoarthritis and joint stiffness etc
BREAST:-Seroma formation ,deformity or assymetry

53. They don’t corroborate your clinical impression
 Repeat the biopsy!!!
 Determine if the tissue was looked at by a Pathologist
 The results show malignancy

54. Inadequate facilities
Few number of experienced Pathologist
Patient associated factors e.g poverty, ignorance,
religious beliefs

55. As we are in the era of evidence-based medicine the
use of biopsy in surgery can never be over-emphasize.
A careful surgical harvest of a sample of tissue with
pertinent information so as to assist the pathologist in
making the correct diagnosis is paramount.

56. THANK YOU FOR
YOUR TIME