**5. Transgastric Liver Biopsy (TGLB)**

For TGLB, Hollerbach et al. [17] have reported an endoscopic ultrasound-guided fine-needle aspiration biopsy procedure for liver lesions. This method is one of several transgastric ap‐ proaches and can be an alternative to PLB, particularly for patients with a risk of bleeding or small lesions in the liver, although targeting may be limited according to tumor location.

Recently, natural orifice translumenal endoscopic surgery (NOTES) has been introduced, creating no skin scars and involving only minimal invasiveness. NOTES has created a new access route (via the stomach) to the peritoneal cavity. TGLB using NOTES creates no dam‐ age to the outside of the body and allows direct observation of the biopsy site inside the body, unlike PLB or TJLB. In an experimental study, Mintz et al. [35, 36] reported successful LB using a hybrid technique that included standard laparoscope vision and surgical endos‐ copy. As outlined in a white paper from the American Society for Gastrointestinal Endos‐ copy and Society of American Gastrointestinal and Endoscopic Surgeons [37, 38], for clinical application of NOTES, it is necessary to establish safe access to the peritoneal cavity, com‐ plete closure of the access route, prevention of infection, correct intra-abdominal orientation, development of a multitasking platform, methods for management of accidental complica‐ tions, awareness of unanticipated physiologic events, and training in the technique. In par‐ 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.

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‐

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

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 intra-

For TGLB, Hollerbach et al. [17] have reported an endoscopic ultrasound-guided fine-needle aspiration biopsy procedure for liver lesions. This method is one of several transgastric ap‐ proaches and can be an alternative to PLB, particularly for patients with a risk of bleeding or small lesions in the liver, although targeting may be limited according to tumor location.

Recently, natural orifice translumenal endoscopic surgery (NOTES) has been introduced, creating no skin scars and involving only minimal invasiveness. NOTES has created a new access route (via the stomach) to the peritoneal cavity. TGLB using NOTES creates no dam‐ age to the outside of the body and allows direct observation of the biopsy site inside the body, unlike PLB or TJLB. In an experimental study, Mintz et al. [35, 36] reported successful LB using a hybrid technique that included standard laparoscope vision and surgical endos‐ copy. As outlined in a white paper from the American Society for Gastrointestinal Endos‐ copy and Society of American Gastrointestinal and Endoscopic Surgeons [37, 38], for clinical application of NOTES, it is necessary to establish safe access to the peritoneal cavity, com‐ plete closure of the access route, prevention of infection, correct intra-abdominal orientation, development of a multitasking platform, methods for management of accidental complica‐ tions, awareness of unanticipated physiologic events, and training in the technique. In par‐

plied using several types of special forceps.

26 Liver Biopsy – Indications, Procedures, Results

**5. Transgastric Liver Biopsy (TGLB)**

abdominal diseases.

(2.7%) was roughly equal to that of PLB (3%) and TJLB (2.9%).

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‐ ings, although peroral TGLB requires the creation of an artificial injury in a normal organ, it will likely become a widely used alternative to other LB methods.

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**Figure 2.** Hemostasis was confirmed at the site of liver biopsy.
