Correct Placement of Incision. In any limb, a straight longitudinal incision is used. The biopsy incision is placed in the line of the planned subsequent resection (if malignant) so that the biopsy tract can be excised en bloc with the lesion at the time of the resection.
Minimal Dissection of Soft Tissue. The surgical approach for biopsy should be direct, with minimal dissection of soft tissue. Muscle, fascia, and capsule or pseudocapsule are preserved for later closure; and an approach through muscle allows for a barrier to avoid contamination of internervous planes.
Avoidance of Neurovascular Structures and Adjacent Joint. The biopsy site should be selected carefully to avoid exposure of major vessels, nerves, and joint capsules, thus preventing their contamination and the necessity of their subsequent sacrifice if surgical resection is required.
Adequate Specimen. During the biopsy procedure, frozen sections should be evaluated to ensure the adequacy of the tissue specimen. Cultures are performed if infection is in the differential diagnosis, and additional tissue may be required for histochemical stains, electron microscopy, flow cytometry, and other special studies.
Strict Hemostasis. If practical, a tourniquet should be used to prevent bleeding and the tumor capsule is closed meticulously. Strict hemostasis should be achieved with electrocautery or even suturing, if necessary, before wound closure. Holes in bone that may leak tumor cells can be plugged with methyl methacrylate cement. A drain may be inserted to avoid a hematoma, but it should be inserted in line with and close to the incision.
Tight Wound Closure. The pseudocapsule and fascial layers should be closed meticulously.
Complications. A poorly conceived and executed incisional biopsy may lead to a dissecting hematoma, which may contaminate previously uninvolved tissues with sarcoma cells. Thus, a subsequent excision of the tumor often requires a wider surgical margin. Widespread contamination may preclude a limb-salvage procedure or greatly increase the risk of local recurrence after limb-salvage resection
Alternative Biopsy Procedures. En bloc excisional biopsy is done for accessible clearly benign tumors.
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