University of Edinburgh



ABSTRACTObjectives: Biopsy quality is an essential factor for successful diagnosis of canine liver disease. Several minimally invasive methods to obtain diagnostic liver biopsies have been described. The aim of this study was to compare weight and volume of the samples, surgical time required, possible complications and histological quality between liver biopsies obtained laparoscopically with a pre-tied ligating loop (PLL) and cup biopsy forceps (CBF). Materials and Methods: Fifteen client owned dogs underwent laparoscopic liver biopsies for diagnosis of liver disease. Biopsies were obtained from the same liver lobe using a PLL and CBF. The resulting biopsies were evaluated for; weight, volume, histological value and the surgical time required and compared. Any surgical complications were recorded.ResultsSamples obtained with the PLL were significantly heavier and larger in volume than those obtained with CBF. Samples obtained with the PLL contained significantly more portal tracts and less crush and fragmentation artefact than the ones obtained with CBF. The duration required to obtain a liver biopsy with the PLL was approximately double of that of the CBF. Clinical significanceThe use of a PLL is a good alternative technique to the CBF when performing laparoscopic liver biopsies in dogs. KEYWORDS: Soft Tissue-General, Laparoscopy, Pre-tied ligating loop, Liver biopsy, Hepatic biopsy. INTRODUCTIONLiver biopsy is integral in the diagnosis, treatment and assessment of prognosis of hepatic disease PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb2NrZXk8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA (Rockey et al. 2009, Rothuizen and Twedt 2009). However, each available liver biopsy method presents with specific limitations and risks. The main methods available are fine needle aspiration, ultrasound guided core needle biopsies, laparoscopy, and open abdominal surgery.Fine needle aspiration and core needle biopsy are the less invasive and inexpensive options available. Fine needle aspiration can be diagnostic in some neoplastic processes and vacuolar disorders, however, cytology does not allow appreciation of structural changes in the liver PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb3RodWl6ZW48L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFy

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ADDIN EN.CITE.DATA (Rothuizen and Twedt 2009). Furthermore, agreement between histopathological diagnosis obtained with needle biopsy and cytological diagnosis was only found in 30.3% of canine cases and 51.2% of feline cases in one study PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYW5nPC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA (Wang et al. 2004).Ultrasound guided core needle biopsies are minimally invasive and are usually performed without the need of general anaesthesia or specialised equipment other than the needle. A study comparing needle biopsies with surgical wedge biopsies identified agreement in morphological diagnosis in 56-67% of the paired samples. This study concluded that needle biopsy specimens of the liver of dogs and cats must be interpreted with caution ADDIN EN.CITE <EndNote><Cite><Author>Cole</Author><Year>2002</Year><RecNum>56</RecNum><DisplayText>(Cole et al. 2002)</DisplayText><record><rec-number>56</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1463483697">56</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cole, T. L.</author><author>Center, S. A.</author><author>Flood, S. N.</author><author>Rowland, P. H.</author><author>Valentine, B. A.</author><author>Warner, K. L.</author><author>Erb, H. N.</author></authors></contributors><titles><title>Diagnostic comparison of needle and wedge biopsy specimens of the liver in dogs and cats</title><secondary-title>J Am Vet Med Assoc</secondary-title></titles><periodical><full-title>J Am Vet Med Assoc</full-title><abbr-1>Journal of the American Veterinary Medical Association</abbr-1></periodical><pages>1483-90</pages><volume>220</volume><number>10</number><keywords><keyword>Animals</keyword><keyword>Biopsy</keyword><keyword>Biopsy, Needle</keyword><keyword>Cat Diseases</keyword><keyword>Cats</keyword><keyword>Dog Diseases</keyword><keyword>Dogs</keyword><keyword>Female</keyword><keyword>Laparotomy</keyword><keyword>Liver</keyword><keyword>Liver Diseases</keyword><keyword>Male</keyword><keyword>Prospective Studies</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>2002</year><pub-dates><date>May</date></pub-dates></dates><isbn>0003-1488</isbn><accession-num>12018374</accession-num><urls><related-urls><url>;(Cole et al. 2002). Transjugular liver biopsy is a technique commonly used in human patients but only one cadaveric study has been published in dogs with a high complications rates reported ADDIN EN.CITE <EndNote><Cite><Author>Levien</Author><Year>2014</Year><RecNum>5</RecNum><DisplayText>(Levien et al. 2014)</DisplayText><record><rec-number>5</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1463433178">5</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Levien, A. S.</author><author>Weisse, C.</author><author>Donovan, T. A.</author><author>Berent, A. C.</author></authors></contributors><titles><title>Assessment of the efficacy and potential complications of transjugular liver biopsy in canine cadavers</title><secondary-title>J Vet Intern Med</secondary-title><alt-title>Journal of veterinary internal medicine / American College of Veterinary Internal Medicine</alt-title></titles><periodical><full-title>J Vet Intern Med</full-title><abbr-1>Journal of veterinary internal medicine / American College of Veterinary Internal Medicine</abbr-1></periodical><alt-periodical><full-title>J Vet Intern Med</full-title><abbr-1>Journal of veterinary internal medicine / American College of Veterinary Internal Medicine</abbr-1></alt-periodical><pages>338-45</pages><volume>28</volume><number>2</number><edition>2014/04/26</edition><keywords><keyword>Animals</keyword><keyword>Biopsy/adverse effects/methods/*veterinary</keyword><keyword>Biopsy, Needle/methods/veterinary</keyword><keyword>Dogs</keyword><keyword>Female</keyword><keyword>*Jugular Veins</keyword><keyword>Liver/injuries/*pathology</keyword><keyword>Male</keyword></keywords><dates><year>2014</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><isbn>0891-6640</isbn><accession-num>24765677</accession-num><urls></urls><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Levien et al. 2014).Laparoscopy is a minimally invasive method which allows direct visualisation of the liver whilst obtaining biopsies and resulting in less postoperative pain PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EZXZpdHQ8L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA (Devitt et al. 2005) and a faster return to normal activity ADDIN EN.CITE <EndNote><Cite><Author>Culp</Author><Year>2009</Year><RecNum>331</RecNum><DisplayText>(Culp et al. 2009)</DisplayText><record><rec-number>331</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1464363653">331</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Culp, W. T.</author><author>Mayhew, P. D.</author><author>Brown, D. C.</author></authors></contributors><auth-address>Department of Clinical Studies-Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, USA. william.culp@colostate.edu</auth-address><titles><title>The effect of laparoscopic versus open ovariectomy on postsurgical activity in small dogs</title><secondary-title>Vet Surg</secondary-title><alt-title>Veterinary surgery : VS</alt-title></titles><periodical><full-title>Vet Surg</full-title><abbr-1>Veterinary surgery : VS</abbr-1></periodical><alt-periodical><full-title>Vet Surg</full-title><abbr-1>Veterinary surgery : VS</abbr-1></alt-periodical><pages>811-7</pages><volume>38</volume><number>7</number><keywords><keyword>Animals</keyword><keyword>Body Size</keyword><keyword>*Dogs</keyword><keyword>Female</keyword><keyword>Laparoscopy/*veterinary</keyword><keyword>Motor Activity/*physiology</keyword><keyword>Ovariectomy/methods/*veterinary</keyword><keyword>*Postoperative Period</keyword></keywords><dates><year>2009</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1532-950X (Electronic)&#xD;0161-3499 (Linking)</isbn><accession-num>19781023</accession-num><urls><related-urls><url>;(Culp et al. 2009) in comparison to an open approach. The traditional sampling instrument used in laparoscopic liver biopsies are the cup biopsy forceps (CBF), which provide a sample of a maximum volume depending on the size of the forceps. The size of the collected sample is important and recommendations in the human literature state that it should contain a representative amount of parenchyma including more than 11 portal tracts ADDIN EN.CITE <EndNote><Cite><Author>Rockey</Author><Year>2009</Year><RecNum>64</RecNum><DisplayText>(Rockey et al. 2009)</DisplayText><record><rec-number>64</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1463653682">64</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rockey, D. C.</author><author>Caldwell, S. H.</author><author>Goodman, Z. D.</author><author>Nelson, R. C.</author><author>Smith, A. D.</author><author>American Association for the Study of Liver, Diseases</author></authors></contributors><auth-address>Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX 75390-8887, USA. don.rockey@utsouthwestern.edu</auth-address><titles><title>Liver biopsy</title><secondary-title>Hepatology</secondary-title><alt-title>Hepatology</alt-title></titles><periodical><full-title>Hepatology</full-title><abbr-1>Hepatology</abbr-1></periodical><alt-periodical><full-title>Hepatology</full-title><abbr-1>Hepatology</abbr-1></alt-periodical><pages>1017-44</pages><volume>49</volume><number>3</number><keywords><keyword>*Biopsy/adverse effects/contraindications/methods</keyword><keyword>Humans</keyword><keyword>Liver/*pathology/radiography</keyword><keyword>Liver Diseases/*diagnosis/pathology/physiopathology</keyword><keyword>Liver Function Tests</keyword></keywords><dates><year>2009</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1527-3350 (Electronic)&#xD;0270-9139 (Linking)</isbn><accession-num>19243014</accession-num><urls><related-urls><url>;(Rockey et al. 2009). Furthermore, a study in human patients showed a correlation between fragment size and number of portal tracts and found that advanced fibrosis was linked to the representation of less than 11 portal tracts PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db3JhbDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl

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ADDIN EN.CITE.DATA (Coral et al. 2016).Biopsy quality is an essential factor for successful diagnosis of liver biopsies. In the veterinary literature, two previous studies looking at the quality of canine hepatic biopsies reported only 8-13 portal tracts in one study ADDIN EN.CITE <EndNote><Cite><Author>Petre</Author><Year>2012</Year><RecNum>9</RecNum><DisplayText>(Petre et al. 2012)</DisplayText><record><rec-number>9</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1463433178">9</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Petre, S. L.</author><author>McClaran, J. K.</author><author>Bergman, P. J.</author><author>Monette, S.</author></authors></contributors><auth-address>Animal Medical Center, 510 E 62nd St, New York, NY 10065, USA. sarah.p.daniel@</auth-address><titles><title>Safety and efficacy of laparoscopic hepatic biopsy in dogs: 80 cases (2004-2009)</title><secondary-title>J Am Vet Med Assoc</secondary-title><alt-title>Journal of the American Veterinary Medical Association</alt-title></titles><periodical><full-title>J Am Vet Med Assoc</full-title><abbr-1>Journal of the American Veterinary Medical Association</abbr-1></periodical><alt-periodical><full-title>J Am Vet Med Assoc</full-title><abbr-1>Journal of the American Veterinary Medical Association</abbr-1></alt-periodical><pages>181-5</pages><volume>240</volume><number>2</number><edition>2012/01/06</edition><keywords><keyword>Animals</keyword><keyword>Biopsy/instrumentation/methods/veterinary</keyword><keyword>Blood Transfusion/veterinary</keyword><keyword>Dog Diseases/*diagnosis</keyword><keyword>Dogs</keyword><keyword>Female</keyword><keyword>Hemorrhage/etiology/veterinary</keyword><keyword>Laparoscopy/adverse effects/*veterinary</keyword><keyword>Liver Diseases/diagnosis/pathology/*veterinary</keyword><keyword>Male</keyword><keyword>Retrospective Studies</keyword></keywords><dates><year>2012</year><pub-dates><date>Jan 15</date></pub-dates></dates><isbn>0003-1488</isbn><accession-num>22217026</accession-num><urls></urls><electronic-resource-num>10.2460/javma.240.2.181</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Petre et al. 2012) and a mean of 3.4 portal tracts in another PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZW1wPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA (Kemp et al. 2015b). The size of the sample has also shown to affect the concentration of metal detected and being statistically significantly lower in the core needle biopsy method in comparison to wedge biopsy specimens in canine livers due to the smaller size of core needle biopsies ADDIN EN.CITE <EndNote><Cite><Author>Johnston</Author><Year>2009</Year><RecNum>14</RecNum><DisplayText>(Johnston et al. 2009)</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1463433178">14</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Johnston, A. N.</author><author>Center, S. A.</author><author>McDonough, S. P.</author><author>Warner, K. L.</author></authors></contributors><auth-address>Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA.</auth-address><titles><title>Influence of biopsy specimen size, tissue fixation, and assay variation on copper, iron, and zinc concentrations in canine livers</title><secondary-title>Am J Vet Res</secondary-title><alt-title>American journal of veterinary research</alt-title></titles><periodical><full-title>Am J Vet Res</full-title><abbr-1>American journal of veterinary research</abbr-1></periodical><alt-periodical><full-title>Am J Vet Res</full-title><abbr-1>American journal of veterinary research</abbr-1></alt-periodical><pages>1502-11</pages><volume>70</volume><number>12</number><edition>2009/12/03</edition><keywords><keyword>Animals</keyword><keyword>Biopsy/*veterinary</keyword><keyword>Copper/*analysis</keyword><keyword>*Dogs</keyword><keyword>Hepatitis, Chronic</keyword><keyword>Iron/*analysis</keyword><keyword>Liver/*chemistry/metabolism/pathology</keyword><keyword>Specimen Handling/veterinary</keyword><keyword>Tissue Fixation/veterinary</keyword><keyword>Zinc/*analysis</keyword></keywords><dates><year>2009</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0002-9645 (Print)&#xD;0002-9645</isbn><accession-num>19951122</accession-num><urls></urls><electronic-resource-num>10.2460/ajvr.70.12.1502</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Johnston et al. 2009). Therefore, there are limitations with all the techniques available and there is scope for better techniques.A pre-tied ligating loop (PLL) has been previously used to perform liver lobectomies and liver biopsies in open surgery with low perioperative complications PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DdWRkeTwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+PFJl

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ADDIN EN.CITE.DATA (Cuddy et al. 2013, Goodman and Casale 2014). This technique allows collection of a biopsy sample of variable size depending on the amount of tissue incorporated in the loop. PLLs are available for use in laparoscopy and have been previously used for laparoscopic ovariectomy in horses ADDIN EN.CITE <EndNote><Cite><Author>Boure</Author><Year>1997</Year><RecNum>628</RecNum><DisplayText>(Boure et al. 1997)</DisplayText><record><rec-number>628</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1492536815">628</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Boure, L.</author><author>Marcoux, M.</author><author>Laverty, S.</author></authors></contributors><auth-address>Departement de Sciences Cliniques, Faculte de Medecine Veterinaire, Universite de Montreal, Saint-Hyacinthe, Quebec, Canada.</auth-address><titles><title>Paralumbar fossa laparoscopic ovariectomy in horses with use of Endoloop ligatures</title><secondary-title>Vet Surg</secondary-title><alt-title>Veterinary surgery : VS</alt-title></titles><periodical><full-title>Vet Surg</full-title><abbr-1>Veterinary surgery : VS</abbr-1></periodical><alt-periodical><full-title>Vet Surg</full-title><abbr-1>Veterinary surgery : VS</abbr-1></alt-periodical><pages>478-83</pages><volume>26</volume><number>6</number><keywords><keyword>Animals</keyword><keyword>Equipment Design</keyword><keyword>Female</keyword><keyword>Horses/*surgery</keyword><keyword>Laparoscopy/standards/*veterinary</keyword><keyword>Ligation/methods/veterinary</keyword><keyword>Ovariectomy/instrumentation/methods/*veterinary</keyword><keyword>Ovary/surgery</keyword></keywords><dates><year>1997</year><pub-dates><date>Nov-Dec</date></pub-dates></dates><isbn>0161-3499 (Print)&#xD;0161-3499 (Linking)</isbn><accession-num>9387212</accession-num><urls><related-urls><url>;(Boure et al. 1997) and sheep ADDIN EN.CITE <EndNote><Cite><Author>Barros</Author><Year>2015</Year><RecNum>633</RecNum><DisplayText>(Barros et al. 2015)</DisplayText><record><rec-number>633</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1492599402">633</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Barros, Felipe Farias Pereira da C?mara</author><author>Teixeira, Pedro Paulo Maia</author><author>Silva, Marco Augusto Machado</author><author>Coelho, Cassia Maria Molinaro</author><author>Lopes, Maristela de Cassia Seudo</author><author>Kawanami, Aline Eyko</author><author>Chung, Denise Granato</author><author>Coutinho, Leandro Nassar</author><author>Ribeiro, Rachel Bittencourt</author><author>Padilha, Luciana Cristina</author><author>Vicente, Wilter Ricardo Russiano</author></authors></contributors><titles><title>Single-port laparoscopic ovariectomy using a pre-tied loop ligature in Santa Ines ewes</title><secondary-title>Ciência Rural</secondary-title></titles><periodical><full-title>Ciência Rural</full-title></periodical><pages>2033-2038</pages><volume>45</volume><dates><year>2015</year></dates><isbn>0103-8478</isbn><urls><related-urls><url>;(Barros et al. 2015), orchiectomy in abdominal cryptorchidism in dogs ADDIN EN.CITE <EndNote><Cite><Author>Oviedo Pe?ata</Author><Year>2013</Year><RecNum>358</RecNum><DisplayText>(Oviedo Pe?ata and Hernandez Lopez 2013)</DisplayText><record><rec-number>358</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1485969338">358</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Oviedo Pe?ata, Carlos Andres</author><author>Hernandez Lopez, Carlos Andres.</author></authors></contributors><titles><title>Laparoscopy versus parapreputial laparotomy for the treatment of abdominal cryptorchidism in dogs.</title><secondary-title>CES Medicina Veterinaria y Zootecnia</secondary-title></titles><periodical><full-title>CES Medicina Veterinaria y Zootecnia</full-title></periodical><pages>9</pages><volume>8</volume><number>2</number><section>83</section><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>(Oviedo Pe?ata and Hernandez Lopez 2013) and horses ADDIN EN.CITE <EndNote><Cite><Author>Fischer</Author><Year>1998</Year><RecNum>632</RecNum><DisplayText>(Fischer and Vachon 1998)</DisplayText><record><rec-number>632</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1492598009">632</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Fischer, A. T.</author><author>Vachon, A. M.</author></authors></contributors><auth-address>Chino Valley Equine Hospital, California 91710, USA.</auth-address><titles><title>Laparoscopic intra-abdominal ligation and removal of cryptorchid testes in horses</title><secondary-title>Equine Vet J</secondary-title><alt-title>Equine veterinary journal</alt-title></titles><periodical><full-title>Equine Vet J</full-title><abbr-1>Equine veterinary journal</abbr-1></periodical><alt-periodical><full-title>Equine Vet J</full-title><abbr-1>Equine veterinary journal</abbr-1></alt-periodical><pages>105-8</pages><volume>30</volume><number>2</number><keywords><keyword>Animals</keyword><keyword>Cryptorchidism/surgery/*veterinary</keyword><keyword>Electrosurgery/veterinary</keyword><keyword>Horses/*surgery</keyword><keyword>Laparoscopy/methods/*veterinary</keyword><keyword>Ligation/methods/veterinary</keyword><keyword>Male</keyword><keyword>Orchiectomy/methods/*veterinary</keyword><keyword>Retrospective Studies</keyword></keywords><dates><year>1998</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0425-1644 (Print)&#xD;0425-1644 (Linking)</isbn><accession-num>9535065</accession-num><urls><related-urls><url>;(Fischer and Vachon 1998) and also for thoracoscopic and thoracoscopic-assisted lung lobectomy in dogs PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GYXVudDwvQXV0aG9yPjxZZWFyPjE5OTg8L1llYXI+PFJl

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ADDIN EN.CITE.DATA (Relave et al. 2008). However, the use of a PLL to obtain laparoscopic liver biopsies has never been reported in dogs.In the authors’ experience, the sample obtained with CBF can contain less than 11 portal tracts and show marked crush and fragmentation artefact, making histological diagnosis challenging. Furthermore, the amount of tissue obtained in one cup is often insufficient for copper analysis and extra biopsies need to be obtained for this purpose. We hypothesise that the PLL is a method as safe as the CBF to obtain laparoscopic liver biopsies in dogs with similar complication rates than previously reported. In addition, we hypothesise the volume and weight of the samples collected with the PLL will be statistically significantly larger and of better histological quality (i.e. higher number of portal tracts and reduced frequency of sampling artefacts), than biopsies obtained with CBF from the same liver lobeThe aim of this study was to compare the surgical time, weight and volume of the biopsies, possible complications and histological quality of the samples obtained between laparoscopic PLL and CBF.MATERIALS AND METHODSAnimals and inclusion criteriaBased on a power of 0.80 and an alpha error of 0.05 to detect an estimated difference of 25% in tissue sample volume, the target sample size was a minimum of 14 cases. Seventeen dogs with suspected diffuse hepatopathy were originally recruited in the study; however, two dogs were excluded because a large solitary liver mass was identified on laparoscopy and the procedure was converted to an open coeliotomy and liver lobectomy. Finally, fifteen privately owned dogs undergoing laparoscopic liver biopsies for suspected diffuse liver disease between January 2016 and December 2016 were enrolled in the study. Informed consent was obtained from the owners and the project was accepted by the Veterinary Ethical Research Committee (VERC 68/15). Seven of the 15 cases underwent gallbladder bile aspiration as an additional procedure at the time of surgery.Previous investigationsAll cases underwent diagnostic tests prior to the procedure including haematology, serum biochemistry, coagulation panel, endocrine disease screening tests, abdominal ultrasound and fine needle aspiration. All dogs had a platelet count, prothrombin time (PT) and partial thromboplastin time (PTT) performed within two weeks prior to the procedure.Anaesthetic protocolDogs were premedicated according to the anaesthetist preference. Induction was performed with either propofol (Propoflo Plus, Zoetis) or alfaxolone (Alfaxan, Jurox) to effect. General anaesthesia was maintained with isoflurane (IsoFlo, Abbott) or sevoflurane (SevoFlo, Abbott) in oxygen. Intra-operative analgesia was selected according to the preferences of the attending anaesthetist. Perioperative intravenous antibiotics were administered at induction or after obtaining a biopsy for bacterial culture using cefuroxime (Zinacef, GlaxoSmithKline) (20 mg/kg).Surgical techniqueDogs were placed in dorsal recumbency and the ventral abdominal hair was clipped from the xiphoid to the pubis. The area was aseptically prepared and draped as for a ventral midline coeliotomy. In all cases, the surgical procedure was performed by the main author as the primary surgeon. Surgical assistance was provided by either a board-certified surgeon (n=3), another surgical resident (n=10) or an undergraduate veterinary student (n=2).A modified Hasson technique (Humphrey and Najmaldin 1994) was used to introduce a 6-mm trocar-cannula (Storz) assembly 1-1.5cm caudal to the umbilicus. If ascites was present, a Poole suction tip was introduced through the incision and the peritoneal fluid was suctioned prior to insufflation. The abdomen was insufflated to 8 to 12 mm Hg with carbon dioxide by means of a pressure regulating mechanical insufflator (Storz). A 5 mm 0 or 30 telescope (Storz) was introduced. A second 6 mm blunt trocar-cannula assembly was placed under direct visualisation through an incision, also performed with an 11 scalpel blade, in the left or right cranial abdominal quadrant. A third, 11 mm blunt trocar-cannula assembly was placed on the contralateral side under direct visualisation through an incision performed with an 11 scalpel blade. The abdomen and liver were explored with the aid of a blunt probe and any abnormalities were recorded. Selection of the liver lobes from which biopsies were collected was based upon; the presence of local or diffuse macroscopic abnormalities, the available access and the potential risks associated with the localisation of the lesion within the liver. A cup biopsy sample and a wedge biopsy, performed with the PLL, were obtained from the same liver lobe as detailed below. The order in which the biopsies were obtained was randomised using a toss of a coin online programme ().After the biopsies were obtained, the biopsy sites were immediately observed for haemorrhage. Haemorrhage associated with each procedure was recorded as none, mild, moderate or severe. Mild haemorrhage was defined as not needing any intervention, moderate haemorrhage was recorded when a collagen haemostatic agent (Lyostypt, B. Braun Medical Ltd) or a second PLL was needed and severe haemorrhage was recorded when the procedure was converted to an open coeliotomy or when blood products were administered as a result of haemorrhage.The abdomen was actively deflated prior to closure. All wounds were closed in three layers using monofilament absorbable suture material (PDS, Ethicon). The skin was sutured with an intradermal pattern using monofilament absorbable suture (Monocryl, Ethicon).The total surgery time was recorded, as well as specific times for: time to establish the two 6 mm ports, time to establish the 11 mm port, time for observation of the abdomen, time to obtain the gallbladder bile aspirate (n=7), time to harvest biopsies using CBF, time to harvest a wedge biopsy with the PLL, time to observe for haemorrhage, time for closure of the two 6 mm wounds and time for closure of the 11 mm wound.Cup biopsy technique (CBF) Five mm CBF (Storz) were used to obtain biopsies from different liver lobes. The number of biopsies depended on the estimated tissue required for diagnosis. The biopsy forceps were introduced into the liver with the jaws in the open position. The liver lobe was lifted ventrally, away from the other abdominal organs with the bottom jaw. The forceps were advanced towards the liver and closed to grasp the biopsy. The forceps were held in this locked position for approximately 15 seconds (Twedt and Monnet, 2003) before the laparoscopic cannula was advanced over the forceps until contacting the liver. At this point, the forceps were withdrawn, pulling the tissue sample from the liver. This technique prevented tearing of the liver tissue adjacent to the biopsy site.All the biopsies obtained were weighed and measured in three dimensions (length, width and height) in a sterile manner by the main author (NF) with the same scales and ruler. One of the samples from the same liver lobe as the PLL sample was always submitted for histological analysis. Any remaining cup biopsies were submitted for bacterial culture or added for mineral analysis depending on the analytical requirements of the case.Pre-tied Ligating Loop wedge biopsy technique (PLL)A 3-0 polydiaxonone pre-tied suture loop (Endoloop, Ethicon) was introduced through the lateral 6mm cannula. A pair of endoscopic Babcock (Storz) forceps were introduced from the contralateral side (11mm cannula) and passed through the pre-tied loop (Figure 1). The liver lobe was grasped and lifted ventrally with the endoscopic Babcock forceps. The pre-tied loop was passed around the end of the liver lobe and the suture was pulled tight whilst advancing the plastic applicator to create a wedge biopsy using the suture fraction or ‘guillotine’ technique. The suture end was then cut with endoscopic scissors through the same cannula by which it was introduced and then the scissors were used to cut the liver parenchyma approximately 5 mm distal to the suture to allow a decent cuff of tissue to prevent suture slipping. The biopsy was followed with the camera to ensure it could be safely retrieved through the 11mm cannula.All the biopsies obtained were weighed and measured in the same way as described for the CBF biopsies. The wedge obtained with the PLL was divided with a scalpel blade in two portions macroscopically similar in size and the two portions were weighed and measured again. One of the portions was submitted for histological analysis and the other for mineral analysis.Histological preparation for analysisThe samples for histopathology were fixed in 10% neutral buffered formalin for at least 24 hours. All samples were trimmed in the same manner (i.e. longitudinally to a slice thickness of 2-3mm), and then processed for histology and haematoxylin and eosin staining using standard protocols. The sections were then assessed for total cut area of tissue available, number of portal tracts, degree of crush and fragmentation artefacts, subjective diagnostic value and histological diagnosis. The score used for both crushing and fragmentation artefacts had four values, ranging from 0-absent to 3-severe (Figure 2).Postoperative period and follow-upPostoperative analgesia was provided with intravenous methadone (Comfortan, Eurovet Animal Health) boluses (0.1-0.2 mg/kg) every 4 hours for the first 8h and intravenous buprenorphine (Buprecare, Animalcare) boluses (20 ?g/kg) q 8 hours until discharge.All dogs were hospitalised for a minimum of 12 hours and the hospitalisation time was recorded. Dogs discharged from the hospital were prescribed a five to seven-day course of oral tramadol (Bristol Laboratories Ltd) (2-3 mg/kg, p.o., q 8-12h). Dogs requiring a change in the analgesia plan were recorded. An Elizabethan collar was placed at time of recovery from anaesthesia, and all dogs were discharged with it.Dogs that survived to hospital discharge were examined 10-14 days postoperatively. The wounds were examined and a questionnaire was completed by the consulting veterinarian (ECVS resident) (appendix 1). The questionnaire used was a modification from the questionnaire used for surveillance of surgical site infections (SSI) in people, provided by the Centre of Disease Control and Prevention (CDC) (). Further follow-up was performed four to six weeks after the procedure by routine rechecks or by telephone contact of the owners or referring plications during the follow-up period were recorded and classified as minor or major. Complications treated with medical management or dressings were considered minor and complications requiring a second intervention were considered major. Survival time after surgery was also recorded for dogs that died or were euthanized in the study period.Statistical analysisDescriptive statistics were calculated for all recorded variables (categorical and continuous). Statistical differences of continuous variables between groups were assessed with a paired t-test for normally distributed variables and a 1-sample Wilcoxon Signed Rank test for ordinal variables. The significance threshold was set at p<0.05. All the data was collated and described in Excel (2006, Microsoft, US), and statistical analysis were conducted in Minitab Express statistical software (version 1.5.0, Minitab).RESULTSAnimalsThe mean body weight of the dogs in the study was 21.5 (±11.3SD) Kg, and the breeds included Mixed-breed dogs (n=4), Tibetan terriers (n=2), Labradors (n=2), and one of each Shih Tzu, Border Collie, German Shepherd, West Highland White Terrier, Bichon Frisé, Dalmatian and Staffordshire Bull Terrier. There were six males and nine female dogs and the mean age was 6.7 (±3.2) years.Five (33.3%) of 15 dogs had a low platelet number (<200 x 109/l) with a mean platelet count of 142.0 (±33.7) x 109/l. Two different analysers were used to measure prothrombin time (PT) and activated partial thromboplastin time (aPTT). Only one dog showed a mildly increased PT at 16.9 s (ref. 5-12 s) and this dog received an intraoperative fresh frozen plasma transfusion.Laparoscopy The mean time to obtain 2-3 biopsies with CBF was 8.3 (±3.7) minutes, whereas the mean time to obtain a biopsy with a PLL was 22.4 (±13.3) minutes. The time to obtain one biopsy with a PLL was significantly longer than the time to obtain 2-3 biopsies with the CBF (Table 1). The mean total surgery time was 78 (±24.1) minutes. Placement and closure of the first and second ports (6 mm) took a mean time of 11.3 (±5.8) and 11.6 (±3.56) minutes respectively and placement and closure of the third port (10mm) took a mean time of 2.8 (±1.6) and 5.2 (±1.57) minutes respectively. A mean time of 5.4 (±2.3) minutes was used for initial observation of the abdomen and a mean time of 4.33 (±4.81) minutes was used to observe for haemorrhage once the biopsies were obtained. Finally, gallbladder bile aspiration was performed in a mean time of 14.1 (±10) minutes (n=7). There were no major intraoperative or postoperative complications, and biopsies were successfully obtained with the PLL and the CBF in all cases. The biopsies submitted for histopathology were obtained from the left lateral liver lobe (n=6), left medial lobe (n=5), right medial lobe (n=2), right lateral (n=1) and quadrate lobe (n=1). Three cases required a second PLL; in one case the ligature was cut with scissors inadvertently whilst obtaining the biopsy and a second loop was used to control the haemorrhage and in the two other cases the first loop was tightened before placing it around the liver lobe and could not be re-used.Only one of 15 dogs presented with ascites and the minimum amount of fluid needed was aspirated to allow adequate visualisation. Mild haemorrhage was recorded in all biopsies obtained with CBF. No haemorrhage was recorded in 14 of 15 biopsies obtained with the PLL, and moderate haemorrhage was recorded in the case in which the PLL was cut inadvertently. No cases required conversion to open approach. The weight and volume of the biopsies obtained with the PLL were on average more than three times higher than those obtained with CBF, irrespectively if considered total sample or sample submitted for histology (p<0.001, Table 1). A total of 13 of 15 dogs survived to hospital discharge. The mean hospitalisation time for the dogs that survived was 1.2 (±0.4) days. Only one dog required rescue analgesia two days after surgery and the frequency of administration of tramadol was increased to three times daily and subcutaneous maropitant (Cerenia, Pfizer) (1mg/kg) was administered in case the clinical signs were secondary to nausea rather than pain.Biopsy evaluationThe PLL method resulted in a greater area available for histological analysis compared to the CBF (median 108 vs 26 mm2, p=0.0004, Table 1) with a greater number of portal tracts obtained (median 69 vs 19, p <0.001, Table 1). Four of 15 (26.7%) of the samples obtained with the CBF contained ≤11 portal tracts and all the samples obtained with the PLL contained >11 portal tracts. In addition, there was reduced crush and fragmentation artefact with PLL samples compared to CBF (p<0.038, Table 1).All the samples, independent of the method used, were diagnostic. The diagnoses included chronic hepatitis with fibrosis (n=6), chronic hepatitis (n=2), steroid hepatopathy (n=2), subacute hepatitis (n=1), fibrosis and biliary hyperplasia (n=1), chronic cholestasis and biliary hyperplasia (n=1), hepatocellular swelling (n=1) and normal liver (n=1).Complications and follow-upEight dogs were presented to the scheduled recheck appointment 10-14 days after surgery. Three of the eight dogs had minor wound complications. Two cases showed dehiscence of the 6 mm side wound and one case showed dehiscence of the wounds on both sides (11 mm and 6 mm wounds). None of the dogs that developed wound complications wore the Elizabethan collar given to the owner at discharge. Bacterial culture was performed in two of the three cases which developed wound complications. One yielded a mixed growth of E. coli and Pasteurella sp and no growth was reported in the second one. Both cases received oral co-amoxiclav (15-20 mg/kg, q 12h) for 10 days. All three cases were also managed with wound dressings.Of the five remaining dogs, which were not presented to the scheduled recheck appointment, no wound complication was reported by the owners on follow-up by telephone contact or on routine recheck appointment with the Internal Medicine Service.In total, four dogs (26.6%) were euthanased during the study period due to disease progression. Follow-up time for the rest of the dogs was 26-254 days.DISCUSSIONThe results of the present study confirm that using a PLL is a feasible and safe method to obtain laparoscopic liver biopsies. In addition, the hepatic sample obtained is significantly larger and contains significantly more portal tracts and less artefacts than those obtained with CBF from the same liver lobe.The size of the sample obtained by traditional open coeliotomy is the largest of any of the methods described in the literature, providing more than adequate tissue for histopathology, copper analysis and culture ADDIN EN.CITE <EndNote><Cite><Author>Rothuizen</Author><Year>2009</Year><RecNum>376</RecNum><DisplayText>(Rothuizen and Twedt 2009)</DisplayText><record><rec-number>376</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1486395135">376</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rothuizen, J.</author><author>Twedt, D. C.</author></authors></contributors><auth-address>Department of Clinical Sciences of Companion Animals, University Utrecht, Yalelaan 108, P.O. Box 80.154, Utrecht 3508 TD, The Netherlands. j.rothuizen@uu.nl</auth-address><titles><title>Liver biopsy techniques</title><secondary-title>Vet Clin North Am Small Anim Pract</secondary-title><alt-title>The Veterinary clinics of North America. Small animal practice</alt-title></titles><periodical><full-title>Vet Clin North Am Small Anim Pract</full-title><abbr-1>The Veterinary clinics of North America. Small animal practice</abbr-1></periodical><alt-periodical><full-title>Vet Clin North Am Small Anim Pract</full-title><abbr-1>The Veterinary clinics of North America. Small animal practice</abbr-1></alt-periodical><pages>469-80</pages><volume>39</volume><number>3</number><edition>2009/06/16</edition><keywords><keyword>Animals</keyword><keyword>Biopsy/methods/*veterinary</keyword><keyword>Cat Diseases/*pathology</keyword><keyword>Cats</keyword><keyword>Dog Diseases/*pathology</keyword><keyword>Dogs</keyword><keyword>Laparoscopy/veterinary</keyword><keyword>Liver/*pathology</keyword><keyword>Liver Diseases/pathology/*veterinary</keyword><keyword>Risk Factors</keyword><keyword>Specimen Handling/veterinary</keyword></keywords><dates><year>2009</year><pub-dates><date>May</date></pub-dates></dates><isbn>0195-5616</isbn><accession-num>19524789</accession-num><urls></urls><electronic-resource-num>10.1016/j.cvsm.2009.02.006</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Rothuizen and Twedt 2009). The sample obtained with the PLL via laparoscopy shows similar characteristics to biopsies obtained in open surgery with the guillotine technique with a sample significantly larger than that obtained with CBF and enough tissue to perform histopathology, bacterial culture and copper analysis for comprehensive evaluation of liver disease. Conversely, the total amount of tissue obtained with CBF in this study would have not been enough to perform all the tests required (i.e. quantitative copper analysis). However, for ethical reasons, a smaller number of hepatic biopsies were obtained with CBF as the aim was not to remove more liver tissue than required between the two methods. The PLL technique for laparoscopic hepatic biopsies has been described previously in a surgical textbook and in a review on diagnostic laparoscopic techniques in cats PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb2JlcnRzb248L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFy

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ADDIN EN.CITE.DATA (Robertson et al. 2014a, Robertson et al. 2014b). In both, its use is recommended for animals with increased risk of haemorrhage such as advance hepatic failure, focal or highly vascular lesions and coagulopathies. None of the dogs in the current study had a clinically significant coagulopathy and comparing the degree of haemorrhage between the two methods in dogs with and without coagulopathy in detail was beyond the scope of the study. However, less haemorrhage was noted when using the PLL in comparison to the CBF.In this study, both techniques were used in dogs of a wide range of body sizes and different histological diagnoses. The PLL was easier to use in dogs with fibrosis as the tissues were more resilient to handling. On the contrary, the technique was slightly more challenging in dogs with a friable liver or those with rounded liver edges.A recent study concluded that the likelihood of obtaining a sample that represents the predominant histological diagnosis is increased when multiple liver lobes were biopsied. ADDIN EN.CITE <EndNote><Cite><Author>Kemp</Author><Year>2015</Year><RecNum>363</RecNum><DisplayText>(Kemp et al. 2015a)</DisplayText><record><rec-number>363</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1486395135">363</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kemp, S. D.</author><author>Zimmerman, K. L.</author><author>Panciera, D. L.</author><author>Monroe, W. E.</author><author>Leib, M. S.</author></authors></contributors><auth-address>Department of Small Animal Clinical Sciences, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Tech, Blacksburg, VA.</auth-address><titles><title>Histopathologic variation between liver lobes in dogs</title><secondary-title>J Vet Intern Med</secondary-title><alt-title>Journal of veterinary internal medicine / American College of Veterinary Internal Medicine</alt-title></titles><periodical><full-title>J Vet Intern Med</full-title><abbr-1>Journal of veterinary internal medicine / American College of Veterinary Internal Medicine</abbr-1></periodical><alt-periodical><full-title>J Vet Intern Med</full-title><abbr-1>Journal of veterinary internal medicine / American College of Veterinary Internal Medicine</abbr-1></alt-periodical><pages>58-62</pages><volume>29</volume><number>1</number><edition>2015/01/13</edition><keywords><keyword>Animals</keyword><keyword>Dog Diseases/*pathology</keyword><keyword>Dogs</keyword><keyword>Liver/*anatomy &amp; histology</keyword><keyword>Liver Diseases/diagnosis/pathology/*veterinary</keyword><keyword>Fibrosis</keyword><keyword>Hepatitis</keyword><keyword>Liver biopsy</keyword></keywords><dates><year>2015</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0891-6640</isbn><accession-num>25581717</accession-num><urls></urls><electronic-resource-num>10.1111/jvim.12520</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Kemp et al. 2015a). They reported that when one liver lobe was sampled, the sample would reflect the prevalent histologic diagnosis in 92% of the cases, whereas when two liver lobes were sampled, the percentage increased to 98%. The previous study was published after all the data collection had completed for the current study with only one liver lobe sampled with the two different techniques. Therefore, we have not included this circumstance in our experimental design.Despite all samples being considered of diagnostic value, 33% of the biopsies obtained with the cup forceps contained less than eleven portal tracts as recommended in the human literature ADDIN EN.CITE <EndNote><Cite><Author>Rockey</Author><Year>2009</Year><RecNum>64</RecNum><DisplayText>(Rockey et al. 2009)</DisplayText><record><rec-number>64</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1463653682">64</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rockey, D. C.</author><author>Caldwell, S. H.</author><author>Goodman, Z. D.</author><author>Nelson, R. C.</author><author>Smith, A. D.</author><author>American Association for the Study of Liver, Diseases</author></authors></contributors><auth-address>Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX 75390-8887, USA. don.rockey@utsouthwestern.edu</auth-address><titles><title>Liver biopsy</title><secondary-title>Hepatology</secondary-title><alt-title>Hepatology</alt-title></titles><periodical><full-title>Hepatology</full-title><abbr-1>Hepatology</abbr-1></periodical><alt-periodical><full-title>Hepatology</full-title><abbr-1>Hepatology</abbr-1></alt-periodical><pages>1017-44</pages><volume>49</volume><number>3</number><keywords><keyword>*Biopsy/adverse effects/contraindications/methods</keyword><keyword>Humans</keyword><keyword>Liver/*pathology/radiography</keyword><keyword>Liver Diseases/*diagnosis/pathology/physiopathology</keyword><keyword>Liver Function Tests</keyword></keywords><dates><year>2009</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1527-3350 (Electronic)&#xD;0270-9139 (Linking)</isbn><accession-num>19243014</accession-num><urls><related-urls><url>;(Rockey et al. 2009). Conversely, all the biopsies obtained with the PLL had more than 18 portal tracts and showed a significantly less crush and fragmentation artefact making the PLL method a superior method to the CBF in terms of histologic sample quality. Furthermore, the PLL method provided a total sample 3.23 times heavier and 4.33 times larger in volume than those obtained with CBF. Both weight and volume were measured as different hepatopathies may affect weight and volume independently and they may not increase or decrease together in a proportional fashion. PLL sampling consistently required more surgical time than cup forceps biopsy. The PLL technique requires more advanced laparoscopic skills when compared to the CBF and the learning curve is probably steeper. All the procedures were performed by a resident in training as the primary surgeon who had previous experience using CBF but had minimal experience with the PLL. This study is likely to represent part of the learning curve for this procedure and this surgeon. All these reasons may explain the longer duration required to obtain the necessary biopsies. Additionally, the PLL method required a third port being placed for triangulation which also added a mean time of 2.8 minutes to the total surgical time.An assistant was required in all the procedures included in this study. When an assistant is used, the primary surgeon and the assistant should be able to coordinate their movements and therefore, the assistant should also have previous laparoscopic experience. Following the study, the procedure has been performed without a trained assistant, with them only stabilising the camera whilst the surgeon was positioned at the caudal aspect of the dog between the hind limbs rather than on the side of the dog.In the case in which the PLL was cut inadvertently, a collagen sponge was used first to stop the haemorrhage. However, this was not enough to control the haemorrhage and a second PLL was placed around the liver parenchyma which immediately controlled the haemorrhage. This could provide an additional use of the PLL in controlling haemorrhage in laparoscopic surgery.None of the cases in this study required conversion to an open approach during surgery due to uncontrolled haemorrhage or laceration of abdominal viscera. In a previous retrospective study including 80 cases undergoing laparoscopic liver biopsies, the spleen was lacerated in one (1,3%) of the cases and necessitated conversion to an open approach ADDIN EN.CITE <EndNote><Cite><Author>Petre</Author><Year>2012</Year><RecNum>9</RecNum><DisplayText>(Petre et al. 2012)</DisplayText><record><rec-number>9</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1463433178">9</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Petre, S. L.</author><author>McClaran, J. K.</author><author>Bergman, P. J.</author><author>Monette, S.</author></authors></contributors><auth-address>Animal Medical Center, 510 E 62nd St, New York, NY 10065, USA. sarah.p.daniel@</auth-address><titles><title>Safety and efficacy of laparoscopic hepatic biopsy in dogs: 80 cases (2004-2009)</title><secondary-title>J Am Vet Med Assoc</secondary-title><alt-title>Journal of the American Veterinary Medical Association</alt-title></titles><periodical><full-title>J Am Vet Med Assoc</full-title><abbr-1>Journal of the American Veterinary Medical Association</abbr-1></periodical><alt-periodical><full-title>J Am Vet Med Assoc</full-title><abbr-1>Journal of the American Veterinary Medical Association</abbr-1></alt-periodical><pages>181-5</pages><volume>240</volume><number>2</number><edition>2012/01/06</edition><keywords><keyword>Animals</keyword><keyword>Biopsy/instrumentation/methods/veterinary</keyword><keyword>Blood Transfusion/veterinary</keyword><keyword>Dog Diseases/*diagnosis</keyword><keyword>Dogs</keyword><keyword>Female</keyword><keyword>Hemorrhage/etiology/veterinary</keyword><keyword>Laparoscopy/adverse effects/*veterinary</keyword><keyword>Liver Diseases/diagnosis/pathology/*veterinary</keyword><keyword>Male</keyword><keyword>Retrospective Studies</keyword></keywords><dates><year>2012</year><pub-dates><date>Jan 15</date></pub-dates></dates><isbn>0003-1488</isbn><accession-num>22217026</accession-num><urls></urls><electronic-resource-num>10.2460/javma.240.2.181</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Petre et al. 2012). 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ADDIN EN.CITE.DATA (Schafer et al. 2001).A total of 13 of 15 (86.6%) survived to hospital discharge. The two dogs that died or were euthanased during the study period had a histologic diagnosis of chronic hepatitis with cirrhosis. Cirrhosis is a poor prognosis indicator in canine liver disease associated to a median survival time of 1.3 months ADDIN EN.CITE <EndNote><Cite><Author>Favier</Author><Year>2013</Year><RecNum>384</RecNum><DisplayText>(Favier et al. 2013)</DisplayText><record><rec-number>384</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1488133936">384</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Favier, Robert P.</author><author>Poldervaart, Joost H.</author><author>van den Ingh, Ted S. G. A. M.</author><author>Penning, Louis C.</author><author>Rothuizen, Jan</author></authors></contributors><titles><title>A retrospective study of oral prednisolone treatment in canine chronic hepatitis</title><secondary-title>Veterinary Quarterly</secondary-title></titles><periodical><full-title>Veterinary Quarterly</full-title></periodical><pages>113-120</pages><volume>33</volume><number>3</number><dates><year>2013</year><pub-dates><date>2013/09/01</date></pub-dates></dates><publisher>Taylor &amp; Francis</publisher><isbn>0165-2176</isbn><urls><related-urls><url>;(Favier et al. 2013).Only four cases developed postoperative complications. One dog needed rescue analgesia 24 hours after discharge and three dogs had wound related complications. Tramadol is considered an unpredictable analgesic and oral tramadol alone provided an inadequate level of analgesia in a significant number of dogs undergoing an orthopaedic procedure PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYXZpbGE8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA (Davila et al. 2013). Postoperative wound complications was reported in 16% in a study on dogs undergoing laparoscopic ovariectomy ADDIN EN.CITE <EndNote><Cite><Author>Pope</Author><Year>2014</Year><RecNum>270</RecNum><DisplayText>(Pope and Knowles 2014)</DisplayText><record><rec-number>270</rec-number><foreign-keys><key app="EN" db-id="vz050ffr1psxdaefxw5xtd0irdrvza2app9s" timestamp="1464362307">270</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pope, J. F.</author><author>Knowles, T. G.</author></authors></contributors><titles><title>Retrospective analysis of the learning curve associated with laparoscopic ovariectomy in dogs and associated perioperative complication rates</title><secondary-title>Vet Surg</secondary-title></titles><periodical><full-title>Vet Surg</full-title><abbr-1>Veterinary surgery : VS</abbr-1></periodical><pages>668-77</pages><volume>43</volume><number>6</number><keywords><keyword>Animals</keyword><keyword>Clinical Competence</keyword><keyword>Dog Diseases</keyword><keyword>Dogs</keyword><keyword>Education, Veterinary</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Intraoperative Complications</keyword><keyword>Learning Curve</keyword><keyword>Ovariectomy</keyword><keyword>Postoperative Complications</keyword><keyword>Retrospective Studies</keyword></keywords><dates><year>2014</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1532-950X</isbn><accession-num>24962374</accession-num><urls><related-urls><url>;(Pope and Knowles 2014). In that study, they could not find a statistically significant difference in wound complications between the wound of 6 mm ports and 11 mm ports. In the present study, three (20%) cases developed wound related complications which is a similar to previously reported and only one of the three showed a wound complication in the 10 mm wound.The goal of this study was to describe the use of a PLL to perform laparoscopic liver biopsies and compare it to the traditional cup biopsy forceps. The limitations of the present study include the limited number of cases, the use of single liver lobe for histological diagnosis and the experience of the primary surgeon. The number of cases that developed complications was too low to allow meaningful comparison with previous studies. The mean total surgery time was 78 minutes and this included cases in which gallbladder bile aspiration was performed. Given the steep learning curve for performing laparoscopy, it is possible that the mean surgery time would have been shorter if the procedures were performed by a more experienced surgeon.ConclusionThe PLL is a successful and safe method to obtain laparoscopic liver biopsies. The resulting samples were on average >3 times as heavy and larger in volume compared to samples obtained with cup biopsy forceps. Although both methods resulted in biopsies of diagnostic value, the samples obtained with the PLL showed superior quality in terms of number of portal tracts, crushing and fragmentation artefacts.We propose that obtaining laparoscopic hepatic biopsies with a PLL method can be considered a good alternative method to the cup biopsy forceps method in dogs.Conflict of interestNo conflicts of interest have been declared.References ADDIN EN.REFLIST Barros, F. F. P. d. C., Teixeira, P. P. M., Silva, M. A. M., Coelho, C. M. M., Lopes, M. d. C. S., Kawanami, A. E., Chung, D. G., Coutinho, L. N., Ribeiro, R. B., Padilha, L. C. and Vicente, W. R. R. (2015) Single-port laparoscopic ovariectomy using a pre-tied loop ligature in Santa Ines ewes. Ciência Rural, 45, pp. 2033-2038.Boure, L., Marcoux, M. and Laverty, S. (1997) Paralumbar fossa laparoscopic ovariectomy in horses with use of Endoloop ligatures. Vet Surg, 26(6), pp. 478-83.Cole, T. L., Center, S. A., Flood, S. N., Rowland, P. H., Valentine, B. A., Warner, K. L. and Erb, H. N. (2002) Diagnostic comparison of needle and wedge biopsy specimens of the liver in dogs and cats. J Am Vet Med Assoc, 220(10), pp. 1483-90.Coral, G. P., Antunes, A. D., Serafini, A. P., Araujo, F. B. and Mattos, A. A. (2016) Liver Biopsy: Importance of Specimen Size in the Diagnosis and Staging of Chronic Viral Hepatitis. Rev Inst Med Trop Sao Paulo, 58, pp. 10.Cuddy, L. C., Risselada, M. and Ellison, G. W. (2013) Clinical evaluation of a pre-tied ligating loop for liver biopsy and liver lobectomy. J Small Anim Pract, 54(2), pp. 61-6.Culp, W. T., Mayhew, P. D. and Brown, D. C. (2009) The effect of laparoscopic versus open ovariectomy on postsurgical activity in small dogs. Vet Surg, 38(7), pp. 811-7.Davila, D., Keeshen, T. P., Evans, R. B. and Conzemius, M. G. (2013) Comparison of the analgesic efficacy of perioperative firocoxib and tramadol administration in dogs undergoing tibial plateau leveling osteotomy. J Am Vet Med Assoc, 243(2), pp. 225-31.Devitt, C. M., Cox, R. E. and Hailey, J. J. (2005) Duration, complications, stress, and pain of open ovariohysterectomy versus a simple method of laparoscopic-assisted ovariohysterectomy in dogs. J Am Vet Med Assoc, 227(6), pp. 921-7.Faunt, K. K., Jones, B. D., Turk, J. R., Cohn, L. A. and Dodam, J. R. (1998) Evaluation of biopsy specimens obtained during thoracoscopy from lungs of clinically normal dogs. Am J Vet Res, 59(11), pp. 1499-502.Favier, R. P., Poldervaart, J. H., van den Ingh, T. S. G. A. M., Penning, L. C. and Rothuizen, J. (2013) A retrospective study of oral prednisolone treatment in canine chronic hepatitis. Veterinary Quarterly, 33(3), pp. 113-120.Fischer, A. T. and Vachon, A. M. (1998) Laparoscopic intra-abdominal ligation and removal of cryptorchid testes in horses. Equine Vet J, 30(2), pp. 105-8.Goodman, A. R. and Casale, S. A. (2014) Short-term outcome following partial or complete liver lobectomy with a commercially prepared self-ligating loop in companion animals: 29 cases (2009-2012). J Am Vet Med Assoc, 244(6), pp. 693-8.Johnston, A. N., Center, S. A., McDonough, S. P. and Warner, K. L. (2009) Influence of biopsy specimen size, tissue fixation, and assay variation on copper, iron, and zinc concentrations in canine livers. Am J Vet Res, 70(12), pp. 1502-11.Kemp, S. D., Zimmerman, K. L., Panciera, D. L., Monroe, W. E. and Leib, M. S. (2015a) Histopathologic variation between liver lobes in dogs. J Vet Intern Med, 29(1), pp. 58-62.Kemp, S. D., Zimmerman, K. L., Panciera, D. L., Monroe, W. 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(2009) Liver biopsy techniques. Vet Clin North Am Small Anim Pract, 39(3), pp. 469-80.Schafer, M., Lauper, M. and Krahenbuhl, L. (2001) Trocar and Veress needle injuries during laparoscopy. Surg Endosc, 15(3), pp. 275-80.Wang, K. Y., Panciera, D. L., Al-Rukibat, R. K. and Radi, Z. A. (2004) 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, 224(1), pp. 75-8.**Figure 1. Laparoscopic Babcock forceps holding the liver lobe through the pre-tied ligating loop ready to position the loop around the hepatic tissue (left). Cuff of liver tissue and visible ends of the PLL (white asterisk) and biopsy sites from the CBF (white arrows) (right).1mm0.5mm1mm0.5mmFigure 2. Examples showing the different grades (0-3) of crush and fragmentation artefact in the population of the study. 0 = none, 1 = mild, 2 = moderate, 3 = severe). Please note that grade 3 fragmentation was absent in this dataset. Stain: Haematoxylin and eosin. Bar: 1mm for fragmentation, 500um for crush.Cup biopsy forceps (CBF)Pre-tied ligating loop (PLL)Statistical test and significanceT bx (min)Mdn=7 (IQR = 4)Mdn=18 (IQR = 17)1-s W, WS= 115, p =0.0020Total W (mg)M=184 (±56.9SD)M=595.8 (±313.2)P-t (>0), t=5.37, p<0.001 W Histo (mg)M=62.87 (±15.57)M=340.00 (±144,98)P-t (>0), t=7.33, p<0.0001Total V (cm3)M=0.29 (±0.10) M=1.30 (±0.60)P-t (>0), t=6.82, p<0.0001V Histo (cm3)M=0.09 (±0.03)M=0.73 (±0.41)P-t (>0), t=6.03, p<0.0001A Histo (mm2)Mdn=26.30 (IQR=18.70)Mdn=107.91 (IQR=137.40)1-s W(>0), WS=120, p=0.0004PT (number)Mdn=19 (IQR=24)Mdn=69 (IQR=75)1-s W(>0), WS=119, p=0.0004C artefact (0-3)Mdn=1 (IQR=2)Mdn=0 (IQR=1)1-s W(<0), WS=13.50, p=0.0249F artefact (0-3)Mdn=1 (IQR=1)Mdn=0 (IQR=1)1-s W(<0), WS=7.00, p=0.0378Table 1. Summary of the differences between the CBF and the PLL techniques. 1. Time to obtain the biopsies (minutes). 2. Total weight of the biopsy obtained at surgery. 3. Weight of the sample submitted for histology. 4. Total volume of the biopsy obtained at surgery. 5. Volume of the sample submitted for histology. 6. Total area of tissue available for histology. 7. Number of portal tracts. 8. Crush artefact (0-3). 9. Fragmentation artefact (0-3). ?, mean (±SD). §, median (IQR). t, paired t-test. 1-s W, 1-sample Wilcoxon test. Statistical significance <0.05. ................
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