Review Question - QID 212980

When performing an open incisional biopsy of a musculoskeletal neoplasm, the use of a tourniquet is not contraindicated. However, when using a tourniquet, exsanguination is discouraged.

When performing an open incisional biopsy, it is important to minimize contamination and make subsequent surgical resection less challenging and morbid. To do so, the following principles should be appreciated: (1) utilize longitudinal extensile incisions in line with the intended future resection, (2) utilize an intramuscular plane to minimize the number of muscle compartments contaminated, (3) avoid violating the joint when possible, (4) avoid dissection close to nerves/vessels as these structures will then have to be resected subsequently, (5) avoid biopsy through (and later resection of) the rectus femoris where possible due to the high morbidity of resection, (6) place drains in line with the incision, (7) maintain meticulous hemostasis, and (8) close the tumor pseudocapsule. Tourniquets may be used when performing a biopsy; however, exsanguination is discouraged.

Mankin et al. published a study on the hazards of biopsy in patients with malignant primary bone and soft-tissue tumors. They reported that the biopsy should be planned as carefully as definitive surgery, and that careful attention should be paid to asepsis, skin-handlng, hemostasis, and wound closure. In particular, the skin incision should be placed in such a manner so as to not compromise subsequent surgery.

Rougraff et al. published a review on biopsy of soft tissue masses. They report that the biopsy tract must be placed in a location that is resectable at the time of tumor excision (if the lesion is malignant). This requires longitudinal incisions placed in a position that can be safely excised en bloc with the resected specimen. They also report that it is important to avoid exposing critical neurovascular structures that could become contaminated with sarcoma and to maintain complete hemostasis in order to prevent hematoma dissection outside of the tumor bed, which could potentially transport tumor cells into wider or newer areas.

Illustration A is a table outlining the principles of open biopsy.

Incorrect Answers:
Answer 1: When performing an incisional biopsy, dissection through intermuscular planes should be avoided.
Answer 3: When performing an incisional biopsy, the incision should be placed longitudinally and in line with the intended future resection.
Answer 4: When performing an incisional biopsy, excellent hemostasis should be obtained, as post-operative hematomas are considered contaminated with tumor. It is therefore recommended that tourniquets be released prior to wound closure.
Answer 5: When performing an incisional biopsy, neurovascular structures should not be exposed, as all tissue exposed during the biopsy is considered contaminated with tumor.