0:00

I'm now going to go through the basic biopsy protocol.

0:03

Before I go through modifications you might need to do

0:07

for specific circumstances.

0:10

So in order you're going to prep the skin

0:12

and drape, do the local anesthesia,

0:16

put the introducer in if you're using

0:18

one, followed by the needle.

0:20

Take your biopsies, put a clip in,

0:22

and then do your post biopsy mammographic imaging.

0:27

So generally speaking, this is what you are going

0:29

to want on your tray

0:31

with obviously modifications depending on your

0:33

institutional protocols.

0:35

So we use a sterile probe cover,

0:38

I'm gonna talk about that in a moment.

0:40

We're going to have sterile drapes for the patient,

0:43

some form of antiseptic HIPA scrub,

0:47

or um, whatever you happen to use your institution.

0:51

1% lidocaine for local anesthesia, a

0:56

longer eating gauge needle for the local anesthesia,

1:00

which you may or may not need

1:01

depending on the depth of the lesion.

1:04

A scalpel if you tend to make skin necks.

1:06

We'll talk about that in a moment.

1:08

And then gauze and some steri strips.

1:12

So we have these all contained within a pack

1:14

and set ready by our technologist

1:16

before we start the procedure.

1:19

So after I've positioned the patient, I am going

1:22

to scan them, uh, find the lesion.

1:25

I may modify their positioning as we've talked about

1:27

before, depending on how that lesion appears

1:30

and how taught I can get their breast.

1:31

And then I'm going to mark right over the lesion

1:35

and I'm going to mark the entry site.

1:37

We'll talk about where the entry site should

1:39

be in a little bit.

1:41

Uh, you will not regret placing those marks,

1:44

but you may well regret not placing marks.

1:47

I'm then going to clean the skin with a hippie scrub

1:51

and drape with towels.

1:54

Allow a wide field, um, sometimes feel

1:56

that our residents want to be gynecologists

1:58

and they leave this little sort of tiny window for you

2:01

to be able to scan and you end up scanning

2:03

over the towels half a time.

2:04

So give yourself a little room to move there.

2:08

Generally going to use 1% lidocaine for anesthesia.

2:11

There are alternates such as ncae or carbocaine.

2:14

If your patient has, uh, that rare lidocaine allergy, um,

2:19

by the way, that's usually not a lidocaine allergy.

2:21

It's usually a reaction to epinephrine in my experience.

2:25

And you give three to 10 ccs

2:27

depending on the depth of lesion.

2:28

I personally always do the intradermal wheel

2:31

before I even place the probe on

2:34

because I've already marked that area.

2:35

And it's easier than sticking the anesthetic needle

2:38

through the probe cover.

2:39

I can't emphasize enough

2:40

that biopsies should not be painful.

2:43

I've had many a patient who's come to me for a repeat biopsy

2:48

for some reason, or the second lesion some years later

2:51

that had some horribly painful experience,

2:53

another institution.

2:55

And if they did, it's because that radiologist was not

2:58

Using enough lidocaine

3:00

or they weren't putting it in the right place.

3:03

So you need to have good dermal an anesthesia.

3:05

Often that's the most painful part for them.

3:07

And then you need to have good anesthesia down the track

3:11

following the angle that

3:12

you're going to be doing the biopsy.

3:14

So you can inject as you move the needle.

3:17

So kind of anesthetizing ahead of the needle.

3:19

You don't need to stop and withdraw, just keep moving.

3:23

And you need to include that stroke throw where

3:26

that device is going to end up.

3:28

So this part beyond the needle, uh, to include

3:32

that two centimeter use using a two centimeter throw

3:36

off the, um, needle itself.

3:38

If it's a very large lesion.

3:39

If you're biopsying into a, you know, a three

3:41

or four centimeter mass, you don't need to do that.

3:43

You don't need to anesthetize the mass itself

3:46

as masses don't have any nerves.

3:50

Most institutions infection control policies are going

3:54

to mean that you must use a sterile probe cover and

3:58

therefore sterile jelly when you're doing these biopsies,

4:01

it avoids a need for high level disinfection.

4:04

Uh, it is a CMS requirement, so, um,

4:06

I would recommend you do use one.

4:09

Now, do you need to make a little scalpel, nick or not?

4:12

Um, some radiologists do, some don't.

4:15

Uh, the needles are designed to penetrate intact skin,

4:18

although you sometimes have to use quite a lot of force

4:21

and there is a tough layer

4:24

of Cooper's ligaments directly under the skin

4:26

that quite challenging to get

4:28

through if you don't get a good skin neck through it.

4:31

Um, so it's up to you.

4:33

You'll get a smaller skin neck if you don't use a scalpel.

4:37

Um, but I always do.

4:38

I prefer particularly as it gives a cleaner incision.

4:41

And certainly if you use an introducer, it's helpful

4:44

and it is very important that you do do some form

4:47

of post-procedural imaging.

4:49

Apart from, in, um, a very few cases, you need to confirm

4:53

that clip placements we talked about previously

4:56

and what document the shape

4:57

for future procedures or imaging.

5:00

You need to be able to correlate with the original mammo

5:02

to make sure that your biopsy is concordant.

5:06

And generally speaking, um, this imaging is going

5:08

to be an an ML and a CC mammogram.

5:11

We do sometimes admit it, you know,

5:13

if it's a very young patient, you see the clip well

5:15

by ultrasound axillary biopsies, where generally speaking,

5:19

that clip's not gonna be in the field of view

5:21

or in very frail patients.