**4. Laparoscopic Liver Biopsy (LLB)**

PLB under image guidance essentially eliminates the risk of pneumothorax, or injury to the gallbladder or other viscera because the needle track is directly visualize of organ. Pain is the commonest complication, and up to 75% of patients suffer some discomfort after LB [21]. However, complications after PLB require careful observation. Piccinino et al. [22] reported that 61% of such complications appeared in the first 2 hours after the biopsy, 82% in the first 10 hours, and 96% in the first 24 hours. Strict observation is therefore required for the first 24 hours after PLB. Several large studies have shown rates of major complication after PLB ranging from 0.09% to 2.3%, severe complications in 0.57%, and mortality ranging from 0.03% to 0.11% [23-25]. Hardman et al. [4] reported one patient with graft vs. host disease and hypertension who died after PLB. This patient had multi-organ system failure at the time of biopsy and died within 24 hours of the biopsy. Furthermore, the complications of PLB seem to be related to the type of technique employed. In fact, the complications associ‐ ated with US-guided PLB are significantly lower than those associated with blind PLB: 0.5% vs. 2.2% for severe complications [26], 2% vs. 4% [27] and 1.8% vs. 7.7% [28] for total compli‐ cations. PLB under US guidance is recommended as a reasonable and cost-efficient proce‐ dure [1, 26, 28]. However, EI-Shabrawi et al. [5] have reported that blind PLB performed by the Menghini aspiration technique is safe even in infants and small children without mortal‐ ity or major complications such as bile leakage, pneumothorax, and bleeding requiring blood transfusion. Szymczak et al. [6] also reported the safety and effectiveness of blind PLB based on an analysis of 1412 procedures, and showed that the rates of complications and failure were dependent on the experience of the operator. Moreover, the needle used was the Menghini-type suction needle, which carries a smaller risk of bleeding than cutting nee‐ dles such as the widely employed Tru-cut needle. They concluded that the risk of complica‐ tions and failure rate are low if the indications and contraindications are considered

carefully and the biopsy is performed by a skilled and experienced operator.

the high risk of possible bleeding complications.

**3. Transjugular Liver Biopsy (TJLB)**

topenia (less then 60,000/cm3

24 Liver Biopsy – Indications, Procedures, Results

Furthermore, with regard to bleeding after PLB, Alotaibi et al. [3] have reported that a posi‐ tive color Doppler sign in US indicates bleeding along the biopsy tract, and that US-guided compression is effective for achieving appropriate hemostasis. Also, tract-plugging of the bi‐ opsy tract with Gelfoam or other thrombotic agents, is an important procedure for reducing the risk of bleeding and subcapsular hematoma in PLB [2]. Nevertheless, in patients with as‐ cites or abnormal coagulation profiles, another procedure should be considered because of

TJLB was initially introduced in dogs as an experimental application by Dotter [29]. Rosch [7, 8] then reported its clinical application for transjugular cholangiography in 1973 and 1975. TJLB eliminates the need to traverse the peritoneal cavity and puncture the liver cap‐ sule. Furthermore, this technique is a safer biopsy option for patients with massive ascites, coagulopathy (prothrombin time greater than 3 seconds over the control value), thrombocy‐

ment of pressures or opacification of the hepatic vein and inferior vena cava. It can also be

), or those undergoing ancillary procedures such as measure‐

There are several approaches for LLB, including PLB under laparoscopic observation, LB through an additional port under laparoscopic observation, or LB combined with another laparoscopic procedure. LLB allows direct observation of the biopsy site and yields with macroscopic information about the liver surface. This facilitates an adequate sample volume to be obtained, including wedge resection, without sampling error, and also allows laparo‐ scopic confirmation of hemostasis. These are the advantages of LLB in comparison with PLB. If bleeding from the biopsy site persists, compression or coagulation can easily be ap‐ plied using several types of special forceps.

ticular, infection or bacterial contamination in the abdomen due to opening of the digestive tract is a great concern in NOTES. However, no studies have quantified the bacteriological load to which the peritoneum is exposed during transgastric procedures [19]. Steele et al. [20] reported a pilot feasibility study of transgastric peritoneoscopy and liver biopsy during laparoscopic Roux-en-Y gastric bypass. LB was performed from segment II, III or IVb of the liver to obtain tissue samples adequate for histologic examination. None of patients exhibit‐ ed any signs or symptoms of intra-abdominal or trocar wound infection after the procedure.

Types of Liver Biopsy

27

http://dx.doi.org/10.5772/52914

For TGLB [39], under general anesthesia a forward-viewing, double-channel endoscope is advanced into the stomach. Puncture of the gastric wall is performed with a 3-mm cuttingwire needle knife. The puncture site is enlarged to 8mm with a balloon dilator and then the endoscope is advanced into the peritoneal cavity. The peritoneal cavity is then inflated with air through the endoscope. The liver is easily visualized by retroflexion of the endoscope. LB is performed using routine biopsy forceps from the edge of the liver (segment III) (Fig. 1), and hemostasis of the biopsy site is achieved by electrocautery with biopsy forceps (Fig. 2).

The gastric artificial orifice is then closed using endoscopic clips.

**Figure 1.** Liver biopsy was performed using routine biopsy forceps from the edge of the liver.

Transgastric peritoneoscopy developed by Kalloo et al. [16, 18] showed no association with serious infection or other complications in the peritoneal cavity during long- term observa‐ tion. Furthermore, Hazey et al. [40] reported that although contamination of the peritoneal cavity was observed during laparoscopic Roux-en-Y gastric bypass, no clinically significant episode, such as abscess formation or infectious complications, occurred. From these find‐

However, LLB requires general anesthesia and specialized equipment, including insuffla‐ tion devices and laparoscopic instruments. On the other hand, PLB under laparoscopic ob‐ servation can be done under local anesthesia using pneumoperitoneum under sedation using midazolam and disoprivan, or under general anesthesia using an abdominal wall lift method [15]. For laparoscopy, pneumoperitoneum is created by N2O insufflation via a Ver‐ ess needle, generally inserted to the left of the umbilicus. A second port is added on the right side by inserting a trocar. A 16-gauge True-cut needle is inserted and biopsy samples of the liver can be taken from the left and right lobes under laparoscopic guidance. The bi‐ opsy sites can be prophylactically coagulated. Beckmann et al. [14] reported that the compli‐ cations observed after LLB were bleeding and bile leakage, and that the complication rate (2.7%) was roughly equal to that of PLB (3%) and TJLB (2.9%).

In general, LLB requires a long set-up time for starting the procedure, gas insufflation to cre‐ ate an adequate operative field, preparation of several laparoscopic instruments, and an op‐ erating theater. LLB is the most appropriate method for patients who need both a pathological diagnosis of liver dysfunction or tumor and laparoscopic procedures for intraabdominal diseases.
