Step 1.

Perform a midline laparotomy from the caudal margin of the xiphoid process to the umbilicus. Excise the falciform fat to improve liver exposure. Place a selfretaining Balfour retractor. Evaluate abdominal viscera and peritoneal surfaces, and sample abnormal tissue for histopathology.

Author Insight

The nondominant hand can be used to retract the ventral surface of the liver caudally to improve exposure during biopsy.

Step 2.

Expose the liver lobe or lesion to be biopsied. Then insert a 4- or 5-mm Baker biopsy punch into the lobe/lesion perpendicular to the surface, centered over the margin of normal and abnormal tissues, if possible. Hold the punch in place, penetrating the hepatic parenchyma, rotate the instrument ~180° axially, and then remove it. Grasp the sample gently with thumb forceps, and excise it using fine Metzenbaum scissors to transect the base. Repeat this step for multiple lesions or lobes as needed. Place biopsy samples in a sterile container.

Step 3. 

Control any mild, brisk hemorrhage at the biopsy site by applying steady digital pressure and/or placing a core of hemostatic gelatin foam into the biopsy site for 3–5 minutes; the gel foam will remain in the defect and be completely absorbed 4–6 weeks postprocedure. Perfectly sized hemostatic foam plugs can be fashioned to fit the biopsy site and improve hemostasis (A–C).

Evaluate the abdomen for hemorrhage or complications and close the abdomen routinely.

Step 1A.

Make an incision no longer than the inner diameter of the cannula through the skin 1–2 cm caudal to the umbilicus (A). Continue the incision to the depth of the linea alba.

Step 1B.

Through this incision, place the initial port 1–2 cm caudal to the umbilicus and use a Veress needle or the Hasson method (a variation of the Hasson method using a catheter is described here) to elicit a pneumoperitoneum. Place apposing stay sutures at the margins of the linea alba to allow ventral traction. In the same incision site, make a 2- to 3-mm–deep stab incision into the linea alba. Use a mosquito hemostat to insert the tip of an 8-Fr malleable catheter into the abdominal cavity (B), then flush 3 mL of sterile saline through the catheter to ensure that no resistance is felt; resistance indicates catheter malposition, most commonly in the falciform fat. If resistance is felt, withdraw and reinsert the catheter.

Step 1C.

Once the catheter is appropriately placed (C), attach CO₂ insufflation tubing to the catheter to pressurize the peritoneal cavity to a maximum of 10–12 mm Hg.

Step 2.

For proper orientation, patient should be positioned in dorsal recumbency (A). When a pneumoperitoneum has been achieved, as indicated by a pressure reading of 10–12 mm Hg on the insufflator, remove the catheter and insert a blunt trocar–cannula assembly or threaded screw-in cannula via the original stab incision (B). In some cases, minimal extension (1–2 mm) of the incision may be needed to facilitate cannula insertion. Insert the laparoscope into the cannula and observe the peritoneum briefly to ensure that no iatrogenic trauma or hemorrhage has occurred. Then make a second incision and place a second 5-mm cannula under laparoscopic visualization 2–3 cm craniad and in a similar fashion to the initial port.

Author Insight

Following initial port insertion, all subsequent ports (in this case only two are used) are placed under laparoscopic visualization (C). Once both ports have been placed, reduce the insufflation pressure to 8 mm Hg as this will reduce the cardiovascular and pulmonary effects of the pneumoperitoneum.

Step 3.

Evaluate the peritoneal cavity by pivoting the laparoscope in a clockwise manner around the port site. Insert the clamshell forceps, using the laparoscope to visualize and guide the forceps to the cranial abdomen.

Author Insight

The falciform terminates at the level of the umbilicus and can obscure the view of the liver, as shown here. Thus the initial camera port must be caudal to the falciform. The camera is easily maneuvered to the left or right of the falciform to obtain a clear view of the liver.

Step 4.

Inspect the ventral and dorsal (shown here) surfaces of each liver lobe thoroughly, using a blunt probe for manipulation.

Step 5A.

Obtain samples from distinct lesions and/or different lobes for diffuse disease. Position the forceps (A).

Step 5B.

Close the instrument over the desired lesion/tissue (B); maintain pressure for 90 seconds. Gentle axial rotation of the forceps while applying pressure can help release parenchymal attachments.

Step 5C.

With the forceps closed, detach the sample by swiftly tugging caudally. Elevate the lobe to evaluate the dorsal surface (C).

Step 5D.

Observe the biopsy site for hemorrhage (D).

Author Insight

Laparoscopic clamshell forceps are ideal for lesions on the liver margins but can be used to obtain mid-lobe biopsies as well.

Step 6A.

Fashion gel foam to roughly the size of the biopsy sample. Place this foam inside of the laparoscopic forceps and apply to the cut surface, pressing the foam against the biopsy site (A).

Step 6B.

Evaluate all biopsy sites for hemorrhage (B). Photographically document hemostasis and lesions. Liberate residual gas from the peritoneal cavity by removing the CO₂ hose and leaving the valve open. Remove all ports and close incisions routinely.