Comparison of a single-access glove port with a SILS™ port in a surgical simulator model using MISTELS.

BACKGROUND: Recent advances in laparoscopy both in human and veterinary medicine have looked at means of being less invasive by using single-port access surgery as opposed to multiport access surgery. The glove port has gained popularity as a cost-effective alternative to commercially available single-port access devices. The primary aim of this study was to compare the glove port to the SILS™ port in a simulator model using the first two MISTELS (McGill inanimate system for training and evaluation of laparoscopic skills) tasks (peg transfer and pattern cutting). METHODS: Twenty-two novices were enrolled in this experimental study. Each participant had 60 min to practise both MISTELS tasks using two-port laparoscopy. Thereafter participants performed both tasks using the glove and SILS™ port with scores being calculated based on task completion time and errors. Higher scores were indicative of better performance. Participants were assigned into two groups with the starting order of the single ports being randomly selected. A self-evaluation questionnaire with three questions was completed by each participant after testing, rating each port. RESULTS: Significantly (p < 0.05) higher scores were achieved using the glove port compared to the SILS™ port when performing both tasks. The glove port was subjectively evaluated as easier to use with more manoeuvrability of the instruments than the SILS™ port. IMPLICATIONS OF THE STUDY: The glove port's improved manoeuvrability and ease of use make it a cost-effective alternative to the SILS™ port, for use in single-port laparoscopic veterinary surgery.

Evaluation of the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy to a small animal general practice.

OBJECTIVE To evaluate the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy to a small animal general practice. DESIGN Prospective study. SAMPLE A single 2-veterinarian small animal practice in southern California. PROCEDURES In early 2012, endoscopic equipment was purchased, and both veterinarians in the practice undertook training in rigid endoscopic and laparoscopic procedures. Subsequently, information for client-owned animals that underwent endoscopic and laparoscopic procedures during a 12-month period (2012 to 2013) was collected. Cost of equipment and training, revenue generated, specific procedures performed, surgery time, complications, and client satisfaction were evaluated. RESULTS 78 endoscopic procedures were performed in 73 patients, including 71 dogs, 1 cat, and 1 rabbit. Cost of endoscopic and laparoscopic equipment and training in the first year was $14,809.71; most equipment was financed through a 5-year lease at a total cost of $57,507.70 ($ 10,675.20/y). Total revenue generated in the first year was $50,423.63. The most common procedures performed were ovariectomy (OVE; n = 49), prophylactic gastropexy (6), and video otoscopy (12). Mean ± SD surgery times for OVE (n = 44) and for OVE with gastropexy (5) were 63.7 ± 19.7 minutes and 73.0 ± 33.5 minutes; respectively. Twelve of 54 patients undergoing laparoscopic procedures experienced minor intraoperative complications. Conversion to laparotomy was not required in any patient. There were no major complications. All 49 clients available for follow-up were satisfied. CONCLUSIONS AND CLINICAL RELEVANCE With appropriate training and equipment, incorporation of basic rigid endoscopy and laparoscopy may be feasible in small animal general practice. However, results of the present study are not applicable to all veterinarians and practice settings, and patient safety considerations should always be paramount.

A new device to inseminate cows at the base of the uterine horns.

A new device (Chapingo device) to deposit semen at the base of the uterine horns of cattle was developed at Universidad Autonoma Chapingo, Mexico. Nine Holstein heifers were inseminated by transvaginal laparoscopy, using a laparoscope for cattle and the Chapingo device. A dose of sexed semen (2.1 × 106 spermatozoa) was deposited at the base of the uterine horn ipsilateral to the ovary where the preovulatory follicle was identified. Insemination was achieved in all the heifers, taking on average 13.7 ± 3.1 min per animal. In all cases, it was possible to see both ovaries, the base of the uterine horns and the oviducts. After the procedure, none of the heifers showed any type of complications such as haemorrhage, adhesions or trauma. On days 21 and 22 after insemination, four of the nine heifers (44.4%) returned into oestrus; on day 30 after insemination, one heifer was found to be pregnant by ultrasound. The results show the feasibility of generating pregnancies by transvaginal laparoscopy in heifers inseminated with sexed semen.

Exploratory rigid laparoscopy in an African elephant (Loxodonta africana).

In March 2009, a 25-yr-old captive female African elephant (Loxodonta africana) underwent an exploratory laparoscopy after several weeks of diarrhea, submandibular and ventral edema, and swelling on medial and lateral aspects of all feet. Although there have been recent advances in laparoscopic vasectomies in free-ranging African elephants in South Africa utilizing specially designed rigid laparoscopes and insufflation devices, this was the first attempt at using these same techniques for an exploratory purpose. The elephant was sedated in a static restraint chute and remained standing for the duration of the procedure. Laparoscopy provided visibility of the dorsal abdomen, enabled collection of reproductive tract biopsies and peritoneal fluid samples, and allowed for instillation of antibiotics and crystalloid fluids directly into the abdominal cavity. Abdominal exploration, collection of tissue samples, and local therapy is possible via standing laparoscopy in megavertebrates.

Diagnostic laparoscopy in the cat: 1. Rationale and equipment.

PRACTICAL RELEVANCE: The integration of minimally invasive techniques into feline practice seems to be an intuitive step forward, especially for those cases where the owner may be reluctant to subject their cat to major surgery 'just for a biopsy'. Although ultrasound is frequently employed as a diagnostic tool in similar cases, this modality can only provide information on gross abnormalities in organ size and shape, echogenicity and internal architecture; even with ultrasound-guided fine-needle aspiration a definitive diagnosis is rarely achieved. So the clinician and owner are left with unanswered questions that are central to the diagnosis, the most appropriate treatment to pursue and the prognosis for the cat. Laparoscopy does require anesthesia and is more expensive than ultrasound; however, when performed correctly, it is only marginally more invasive and vastly more informative, with a proven track record of minimal morbidity. AUDIENCE: This article is aimed at all feline practitioners, from first opinion through to the referral setting. It is intended to encourage practitioners untrained in minimally invasive procedures to seek formalized training, especially those who want to expand their diagnostic capabilities. For those already performing minimally invasive surgery, it describes how laparoscopic techniques can be applied to many feline gastrointestinal cases. EVIDENCE BASE: Information provided in this article is based on published literature, comprising original studies, case review series and textbook chapters, and the authors' own clinical experience.

Diagnostic laparoscopy in the cat: 2. Common procedures.

PRACTICAL RELEVANCE: Minimally invasive techniques are becoming increasingly available in both first opinion and referral veterinary surgeries. Clients may be reluctant to pursue open surgery for the collection of biopsy samples in a sick cat but may be more open to a laparoscopic approach. Furthermore, a laparoscopic approach provides excellent visualization of the abdominal organs and enables high quality biopsies to be taken that are invariably more diagnostic than percutaneous needle biopsies. Although the feline patient is small in size, its distensible abdomen allows more room for surgical manipulation than afforded by a similar sized canine patient. CLINICAL CHALLENGES: Clinical challenges for the most part relate to mastering laparoscopic technique. Familiarity with the use of long instrumentation viewed on a two-dimensional screen is essential. Hemostasis is an important consideration and suitable instrumentation for achieving hemostasis should be available at all times. Insufflation of the abdomen carries its own challenges with regard to anesthesia and this is covered in an accompanying article in this Special Issue series. AIM: This article introduces the feline practitioner to basic techniques required to effectively utilize diagnostic laparoscopy within feline medical investigations. It focuses on the common procedures of liver biopsy, cholecystocentesis, pancreatic biopsy, kidney biopsy and laparoscopic-assisted intestinal biopsy. EVIDENCE BASE: Information provided in this article is drawn from the published literature and the authors' own clinical experience.

Effect of two instrument designs on laparoscopic skills performance.

OBJECTIVE: To determine whether laparoscopic skills performance is affected by instrument design. STUDY DESIGN: Randomized crossover study. SAMPLE POPULATION: Veterinarians (n = 14) with variable laparoscopic experience. METHODS: Laparoscopic skills performance was assessed with the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS). Participants performed 3 MISTELS tasks twice during 2 sessions (4 tests total). Each set of instruments (set A, B) was used once during each session, and instrument order was switched between the first and second sessions. Surgeons were randomly allocated to either the AB-BA or the BA-AB sequence in a balanced fashion. Scores were compared between instrument sets A and B. RESULTS: Overall, participants performed better when using set A compared with set B. This difference was most striking in the pattern-cutting task (which used scissors and graspers), less convincing in the peg transfer task (which used 2 graspers), and nonexistent in the ligature loop task (which used 1 grasper and 1 pretied ligature loop). CONCLUSIONS: Laparoscopic skills performance, as assessed by MISTELS testing, is affected by instrument design.

Laparoscopic ovariectomy in dogs using a single-port multiple-access device.

The aim of this case series was to describe a novel technique of single-incision laparoscopic ovariectomy in dogs using the SILS Port (Covidien), a single-port multiple-access device, in 40 client-owned dogs. A single 3 cm incision was made caudal to the umbilicus and the SILS Port device was bluntly introduced. Three cannulae were inserted in the SILS Port through the access channels. In the first 20 cases, a transabdominal suspension suture was used to transfix the ovaries. In all cases, ovariectomy was performed using a standard straight non-roticulated laparoscopic grasper and a vessel sealer/divider device. Mean (sd) duration of the ovarian resection was 25.1 (6.1) minutes (range 16 to 39 minutes). In five dogs (with transabdominal suspension suture), minor bleeding in the mesovarium or in the spleen was observed. Since the SILS Port allows simultaneous use of two instruments and a telescope through a single incision, the suspension suture is not mandatory. The lack of a transabdominal suspension suture increased collision between instruments and the telescope, but triangulation capabilities remained sufficient to achieve visualisation, sufficient manoeuvrability and safe vessel sealer/divider device application. The time to perform ovarian resection remained unaltered with or without suspension suture and regardless of the fat score of the ovarian ligament. Complications were less frequent without a suspension suture.

Equine laparoscopy: equipment and basic principles.

Laparoscopic techniques for veterinary surgery are growing in popularity for the same reason the use of minimally invasive procedures has increased tremendously in human surgery. Compared with open surgery, the benefits of laparoscopic surgery include smaller incisions, reduced postoperative morbidity and pain, shorter hospitalization, a more rapid return to normal activities, and, in some instances, superior access. Laparoscopic surgery is different from open surgery in equipment/instrumentation and psychomotor skills. This first article in a series on equine laparoscopic surgery introduces the necessary equipment and reviews basic techniques (e.g., triangulation, optimal coaxial alignment, ergonomics, instrument use) common to all procedures.

Evaluation of a motorized morcellator for laparoscopic removal of granulosa-theca cell tumors in standing mares.

OBJECTIVE: To describe a motorized morcellator technique for laparoscopic removal of granulosa-theca cell tumors (GCT) in standing mares and to evaluate long-term outcome. STUDY DESIGN: Case series. ANIMALS: Mares (n=7) aged 4-15 years, with unilateral GCT. METHODS: Tumor size was determined by transrectal palpation and ultrasonography. Standing sedated mares had 3 laparoscopic portal sites in the paralumbar fossa. After laparoscopic observation of the GCT, the mesovarium was desensitized, the ovarian pedicle transected with a LigaSure device, and the ovary grasped with forceps and cut in cylindrical tissue blocks using a motorized morcellator. Tissue blocks were removed through the laparoscopic sleeve. Outcome was determined by telephone interview of owners 6-40 months after surgery. RESULTS: Estimated ultrasonographic median GCT diameter was 17 cm (range, 10-22 cm). Surgical time was 2-4.5 hours. There were no surgical complications. Two mares had mild subcutaneous emphysema at the portals after surgery. Convalescence was short, owners were satisfied with cosmetic outcome, and clinical signs associated with GCT did not recur. CONCLUSION: The motorized morcellator allows piecemeal removal of large GCT through a relatively small laparoscopic portal. Surgical complications were rare and the cosmetic outcome is favorable. CLINICAL RELEVANCE: A motorized morcellator is a safe and minimally invasive technique for laparoscopic removal of GCT in mares.

Equipment and instrumentation in veterinary endoscopy.

Endoscopic procedures are minimally invasive in nature, and have been found to decrease the postoperative stress response and postoperative pain compared with similar procedures performed by an open approach. There is an ongoing effort to make minimally invasive surgery even less invasive through research and the development of new and improved medical devices. This article provides a general overview of the necessary equipment and instrumentation that will assist practitioners in making decisions for the incorporation of endoscopy/endoscopic surgery into their practice.

Gastrointestinal laparoscopy in small animals.

Since 1999, when the author first described the research and potential applications of minimally invasive gastrointestinal surgery in animals, veterinarians have begun to apply some of these techniques in treating client owned animals. Minimally invasive surgery is advocated with diagnostic, prophylactic, and therapeutic intent. There has been a transition from a minimally invasive caseload toward the expansion of diagnostic procedures, adoption of prophylactic procedures (such as lap-assisted gastropexy), and performing more difficult therapeutic procedures. Small animal patients benefit from reduced tissue trauma and experience a rapid recovery. In this article, current research and minimally invasive gastrointestinal procedures in animals are discussed.

Advanced laparoscopic procedures (hepatobiliary, endocrine) in dogs and cats.

This article discusses several advanced laparoscopic procedures that have now been described in clinical veterinary patients. Laparoscopic-assisted cholecystostomy tube placement, laparoscopic cholecystectomy, and adrenalectomy can all be performed safely and efficiently. Case selection guidelines as well as indications, techniques, and possible complications are discussed in detail.

One-port video assisted laparoscopic kidney biopsy in standing steers.

The purpose of this study was to simplify the two-port laparoscopic renal biopsy technique used in support of pharmacokinetic studies through the application of a one-port system. Twelve Holstein steers were fasted for 24 h and sedated with acepromazine and xylaxine in preparation for laparoscopic surgery in standing stocks. Lidocaine 2% was injected to provide local anesthesia for introduction of the trocar-cannula assembly. The operating endoscope was inserted and the abdomen was insufflated with CO(2). A biopsy forceps was introduced into the channel of the operating endoscope to obtain a 100mg kidney cortex sample. Eighteen laparoscopic procedures provided 18 kidney samples suitable for pharmacokinetic studies. No complications were encountered. The one-port laparoscopic kidney biopsy is feasible and safe, and advanced skill required for triangulation is not necessary for its performance.

Laparoscopic ovariectomy in standing cows.

The main objective of this study was to evaluate laparoscopic ovariectomy and to develop an optimal surgical technique for this procedure in standing cattle. Eight cows underwent laparoscopic ovariectomy. In two cows, a bilateral flank approach was used and in six cows, both ovaries were removed via a left flank approach. An important prerequisite for ensuring sufficient intrabdominal space for instrumentation, optimal endoscopic orientation and easy access to the ovaries and uterus was withholding feed for at least 36 h prior to surgery. The cows were sedated with xylazine and the portal sites infiltrated with lidocaine. The portal for the laparoscope was at the ventral angle of the left paralumbar fossa, approximately 10 cm cranioventral to the tuber coxae. The instruments were inserted through two portals approximately 20 cm and 30 cm ventral to the tuber coxae. After abdominal insufflation with carbon dioxide, the left ovary was grasped and local anesthetic was injected into the mesovarium and mesosalpinx. The mesovarium was transected using bipolar cauterization and the ovary removed through an extended instrument portal. The right ovary was removed in the same way. The incisions were closed with single interrupted absorbable sutures in the musculature and single interrupted non-absorbable sutures in the skin. The procedure lasted 120-150 min. Bilateral laparoscopic ovariectomy via left flank approach in standing cows is feasible. This procedure involves special instrumentation, but is minimally invasive and allows optimal visualization of the ovaries and uterus.

General principles of laparoscopy.

Laparoscopic surgery is minimally invasive and minimally traumatic in cattle. It allows the animal to return rapidly to production. These techniques are destined to develop further, especially in the dairy and show cattle industries, where recovery periods must be as short as possible. Although it is important to remain skeptical about new procedures if they do not offer advantages over open techniques, in many cases laparoscopy is clearly superior. Laparoscopy is not an easy surgical technique. It requires a good knowledge of anatomy and abdominal topography and rigorous training. It must be performed with great care and delicacy because complications, such as perforated organs, can occur. Laparoscopy also requires the use of sophisticated and costly technology.

Laparoscopic surgery in adult cattle.

Laparoscopy in cattle is a promising tool for clinical diagnosis and treatment. The lower cost of the materials available in addition to the possibility of an intervention on an animal that is sedated does not entail more costs than an exploratory laparotomy. The application of this tool during abdominal explorations and biopsies allows the avoidance of invasive and often useless surgical interventions and even with the diagnosis and prognosis of certain conditions. Surgical techniques currently are limited to abomasopexies; however, never-ceasing progress and improvements in human surgery are expected to affect the future of bovine surgery. With the advancements in the multimedia technology used by universities, the use of laparoscopy as a pedagogic tool definitely has a promising future. Endoscopic exploration of the thorax is possible using the same material as for laparoscopy. In addition, diagnostic and biopsy applications are useful. The use of the laparoscope in different body cavities and for different applications would make the purchase of the required materials more cost-effective.

Use of a hand-assisted laparoscopic technique for removal of a uterine leiomyoma in a standing mare.

A 20-year-old Thoroughbred mare was evaluated because of a 2-year history of infertility. The mare had normal estrous cycles and had been bred 7 times by different stallions. Ultrasonographic examination revealed a homogeneous hyperechoic intramural mass in the tip of the right uterine horn; the mass was also detected via hysteroscopy Unilateral ovariectomy and partial hysterectomy were performed by use of a hand-assisted laparoscopic technique. Leiomyoma was diagnosed via histologic examination of the mass. Unilateral ovariectomy and partial hysterectomy are recommended in mares with leiomyoma in a uterine horn, especially if the tumor is associated with infertility. The hand-assisted laparoscopic technique allows direct visualization of abdominal structures and accurate placement of ligatures without applying tension on the broad ligament, and eliminates the risks and costs of general anesthesia.

Hand-assisted laparoscopic ovariohysterectomy in the mare.

OBJECTIVE: To develop a minimally invasive, hand-assisted laparoscopic ovariohysterectomy (HALS-OHE) technique in the mare and to evaluate safety and any associated complications. STUDY DESIGN: Experimental study. ANIMALS: Eight, 11-24-year-old mares with anatomically normal urogenital tracts. METHODS: The surgical technique was developed in 2 non-survival mares and subsequently evaluated in 6 survival procedures. Food was withheld for 48 hours, then mares were anesthetized and positioned in dorsal recumbency for laparoscopic surgery. A hand access device (Omniport) was placed followed by 4 laparoscopic portals. Transection of the ovarian pedicles and broad ligaments was achieved using a combination of a laparoscopic stapling instrument (Endo GIA II), an ultrasonically activated instrument (Harmonic Scalpel), and endoscopic clips (Endo Clip II ML). The genital tract was exteriorized through the laparotomy, and the uterus transected and sutured in a conventional pattern. Horses were evaluated through postoperative day 14 when a necropsy was performed. RESULTS: Four mares recuperated well after surgery, 1 mare was euthanatized because of bilateral femur fracture during anesthetic recovery, and another developed severe pleuropneumonia. At necropsy all but 1 abdominal incision was healing routinely. One mare had abscessed along the celiotomy incision and developed visceral adhesions. Uncomplicated healing of transected mesovarial, mesometrial, and uterine remnants was observed. CONCLUSIONS: Ovariohysterectomy in horses can be accomplished using HALS technique. CLINICAL RELEVANCE: HALS-OHE technique represents a minimally invasive and technically feasible alternative for conventional OHE. Careful patient selection and preparation may reduce the complications observed. The HALS technique may be useful in other laparoscopic surgical procedures.

Complications associated with cannula insertion techniques used for laparoscopy in standing horses.

OBJECTIVE: To report our experience and complications associated with different cannula insertion techniques for laparoscopy in standing horses. STUDY DESIGN: Retrospective study. SAMPLE POPULATION: Forty horses that had laparoscopy for diagnostic or surgical purposes. METHODS: After a physical examination, including rectal palpation, standing laparoscopy was performed in 40 sedated horses. Local anesthetic was injected at each site of cannula insertion in the left flank. Horses were divided into 5 groups: Pneumoperitoneum was induced before cannula insertion using a Verres needle (group 1, n = 3) or a 12-g catheter (group 2, n = 14); the cannula was inserted before inducing a pneumoperitoneum (group 3, n = 9); the cannula was inserted under visual control, using an operating laparoscope (group 4, n = 2) or a Visiport Optical Trocar (group 5, n = 12). Horses were observed for 7 days. RESULTS: Problems with insufflation or cannula insertion occurred in 12 horses: 6 had peritoneal detachment, 4 had a splenic puncture, and 2 had descending colon puncture. Eleven of these complications occurred in groups 1 to 3 and only 1 in groups 4 and 5. CONCLUSIONS: The Visiport optical device allows controlled insertion of the initial trocar, and thus avoided potential problems associated with "blind" cannula insertion techniques and was used effectively in horses that had feed withheld for 12 hours. This technique enables direct insertion of a cannula directly into the right flank. CLINICAL RELEVANCE: Complications associated with initial cannula insertion in the paralumbar fossa, for laparoscopy, in standing horses can be minimized with the use of an optical cannula.