It is not uncommon during an exploratory laparotomy to remove a small fragment of the liver for histologic study. Biopsy of the liver could be indicated in patients who are found to have a nodule of malignant potential or unexpected liver disease.
Two deep 2-0 absorbable sutures (a and b) are placed about 2 cm apart at the liver border (FIGURE 1) using an atraumatic type of needle. The suture is passed through the edge of the liver and back through again to include about one-half the original distance (FIGURE 1A). This prevents the suture from slipping off the biopsy margin with resulting bleeding. These sutures are tied with a surgeon’s knot, which will not slip between the tying of the first and second parts (FIGURE 1A). The suture should be tied as snugly as possible without cutting into the liver, for the tension under which these knots are tied is the important factor in the procedure. Such sutures control the blood supply to the intervening liver substance.
The two sutures are placed not more than 2 cm apart, deep in the liver substance; yet as they are tied, at least 2 cm of liver is included at the free margin to increase the size of the biopsy by making it triangular in shape. An additional mattress suture (c) may be taken at the tip of the triangular wound (FIGURE 3). After the biopsy is removed with a scalpel (FIGURE 3), the wound is closed by tying together the sutures (a and b) or by placing an additional (2-0 absorbable) mattress suture (d) beyond the limits of the original sutures (FIGURES 4 and 5). The area of biopsy is covered with some type of anticoagulant matrix and omentum.
More commonly today, liver biopsy can be performed using the assistance of a commercially available biopsy device. Use of such a device reduces the operative time, minimizes bleeding from the cut edge of liver, and may permit easier biopsy of deeper parenchymal lesions under ultrasound guidance. A needle-type biopsy device such as a Tru-Cut (R) biopsy needle is loaded and aligned along the target lesion either under direct visualization or ultrasound guidance (FIGURE 6). The biopsy device is triggered and then gently removed from the liver, and electrocautery of the biopsy track prevents oozing from the surface (FIGURE 7). The tissue biopsy then is removed from the device and inspected to ensure adequate sampling, with repeat biopsy performed if necessary.