Laparoscopy is an innovative diagnostic and surgical tool in veterinary field. Laparoscopic surgeries revolutionizes the minimally invasive surgical approaches with less surgical trauma and faster recovery.

1. “LAPAROSCOPIC
SURGERY IN DOGS :
AN OVERVIEW”
Speaker
BHUBANESWAR SAHOO
Reg. No. 2020010160011035
Ph.D. Scholar
ARGO
1

2. 2
1. Introduction
2. History
3. Instrumentation
4. Anaesthetic Considerations
5. Surgical Procedure
6. Application of Laparoscopy
7. Conclusion
Topics of Seminar

3. 1. INTRODUCTION
3
‘Seeing is believing’
Laparoscopy is a surgical procedure in which a fibre-optic
instrument is inserted through the abdominal wall to view the
organs in the abdomen or permit small-scale surgery.
LAPAROSCOPY … Derived from the Greek word “Lapara” (Flank)
and “Skopein” (to see)
LAPAROSCOPY … Diagnostically & surgically useful tool

4. 4
 Minimally invasive surgery (MIS)
 MIS … decreases the severity or incidence of certain surgical
morbidities compared to open surgery.
 Laparoscopy enables surgeons to carry out a thorough visual
inspection of the abdominal cavity and obtain tissue samples
quickly, with minimal trauma to the patient.
1. INTRODUCTION

5. 5
Philipp Bozzini (1805) - Modern era of endoscopy really started
Introduction of the Lichtleiter or light
conductor (Beewax candle)
Antonin Desormeaux (1868) - An urologist, designed the first
functional cystoscope (Gazogene lamp)
Maximilian Nitze and Josef Leiter (1879)-
Produced a rigid cystoscope with a built-in light
source made from electrically heated platinum wire. Antonin Jean Desormeaux
Light-carrying Tubes
2. HISTORY
Both the devices was uncomfortable or even painful for the patient
(with the additional risk of burns).

6. • Kelling (1902) : 1st reported cystoscopy in dogs &
later was know as “Father of Veterinary Laparoscopy”.
• Jacobaeus (1910) … Used Word … “LAPAROSCOPY”
• Goetze (1924) : Carbon dioxide as the insufflation gas
• Kurt Semm (1927–2003) : Widely acknowledged
as the “Father of Modern Laparoscopy”. 6
2. HISTORY
Kelling
Jacobaeus
Kurt Semm

7. 3. Instrumentation
7

8. Monitor
Video Capture Unit
Light Source Unit
CO2 Insufflator Unit
Electrocautery Unit
Laparoscopic Tower 8

9. VERESS NEEDLE CO2 INSUFFLATOR TUBING
9

10. Trocar and Canula
Size Working Length
2.5 mm
3.5 mm
6.0 mm
11.0 mm
13.5 mm
5.0 cm
10.0 cm
10

11. Telescope
Size Working
Length
Angle
3.3 mm 25 mm 0⁰, 30⁰
5.0 mm 24 mm
29 mm
0⁰, 30⁰
0⁰, 30⁰
5.5 mm 50 mm 0⁰, 30⁰, 45⁰
10.0 mm 31 mm
42 mm
0⁰, 30⁰, 45⁰
0⁰, 30⁰, 45⁰
Variable direction of view 0⁰ - 90⁰.
11

12. Optic Cable
12

13. HAND INSTRUMENT
13
Insulated Seath
Jaw Insert
HANDLE

14. Dissectors
Meryland Biopolar Meryland
Right Angle Meryland
14

15. Graspers
Traumatic Graspers Atraumatic Graspers
Replica of Alis tissue forceps
Puncture the tissue
Used in edematous tissue
Elastic deformation
First instrument to be introduced
irrespective of surgeries
15

16. Palpation Probe Scissors
16

17. Irrigation and Suction Unit Needle Holder
17

18. Clip Applicators with
Titanium Clips
Electrocautery
18

19. Biopsy Forceps
Hooks

20. • Performed under general inhalation anaesthesia.
• The increase in intra-abdominal pressure associated with laparoscopy can
also potentially cause compression of the caudal vena cava and liver,
decreasing venous return to the heart.
• Diaphragmatic movement is also reduced. These effects are not usually
significant at the recommended intra-abdominal insufflation pressures.
• For these reasons the patient’s respiratory status should be carefully
evaluated prior to laparoscopy.
4. Anaesthetic Considerations
20

21. • Intra-abdominal insufflation pressures …. < 15 mmHg (8–10 mmHg)
• Prior to laparoscopy … urinary bladder should be evacuated
(inadvertent puncture with trocar-cannulae)
• A local block with Bupivacaine is recommended at each cannula site at the
beginning of the procedure to aid in analgesia and balanced anaesthesia.
4. Anaesthetic Considerations
21

22. 5. SURGICAL PROCEDURE
22

23. • Most common approaches - TWO
A. Ventral midline : Diagnostic evaluation of the
liver, gallbladder, right limb of the pancreas,
duodenum, right kidney and right adrenal
gland
• In ventral approach, the primary portal is
placed on the midline caudal to the umbilicus
(Falciform ligament may hinder visualization
of the anterior abdomen).
SURGICAL APPROACH
23

24. B (i) Right lateral : Useful for surgical procedures, good
visualization of the liver, gall bladder, pancreas, stomach,
intestines, reproductive system, urinary bladder and
spleen
B (ii) Left lateral : May be used, but because the spleen lies
directly under the normal entry sites (Visualization of the
left kidney and left adrenal gland)
• Plan the procedure such that the ports are sufficiently
distant to the site of interest, instruments are not crowded
together and can be introduced at a comfortable angle for
the surgeon. 24
SURGICAL APPROACH

25. INSUFFLATION
Pneumoperitoneum is achieved by introducing CO2 into abdomen.
Two technique : Veress needle technique (Closed type); Hanson’s technique (Open type)
Veress Needle Technique
• A skin puncture incision is performed in the selected
abdominal area, and the abdominal wall is lifted and
tensed upwards.
• The Veress needle is then inserted and directed
caudally at a 50° angle from the skin (Ideally towards
the right caudal quadrant and away from the spleen).
• Preferably carried out in the same site intended for the
introduction of a trocar-cannula; the site is often
caudal or cranial to the umbilicus.
25

26. • A small (0.5–1 cm) surgical incision is
given though the skin.
• Stay sutures are then placed at each end
of the incision and a small incision
(slightly smaller than the trocar-cannula
diameter) is made through into the
abdominal cavity, through which a blunt
trocar and cannula are placed.
• The abdomen is then insufflated through
this cannula.
Hasson Technique
Doerner et al. (2012)
26

27. • Once the skin incision has been made the
trocar– cannula unit is passed through the
abdominal wall.
• Holding the upper end of the cannula in the
palm of the hand, pressure is exerted in a
twisting motion until the tip of the cannula
enters the peritoneal space.
• Depth of penetration of the cannula is
limited by a finger placed along the shaft.
• Sharp trocar is removed Immediately from
the cannula to prevent organ trauma and the
cannula can be pushed gently into the
abdomen a little further.
Cannula Placement
27

28. • This has no sharp trocar and is introduced
with a clockwise screw motion to allow blunt
dissection through the abdominal wall.
• Initial incision must penetrate the fascial
sheath below the skin to facilitate blunt
dissection through deeper tissues without the
need for a sharp cannula.
• Telescope allows entry into the peritoneal
cavity to be seen. The threaded barrel also
helps prevent displacement during surgery.
• Various tissue layers can be seen.
28
Ternamian EndoTIP® Cannula

29. 29
A
D
C
B
TERMANIAN ENDOTIP cannula engaged. Cannula penetrates automatically.
Pre-peritoneal space exposed. Peritoneal membrane

30. • Insufflation tubing can now be transferred from the Veress needle to the
inlet port of the cannula. This allows removal of the Veress needle.
• Telescope is then connected to the light source and the camera, and
advanced through the cannula and into the abdomen.
• To prevent fogging, upon entry into the abdominal cavity, it is
recommended to use a commercially available anti-fogging solution or
alternatively a povidone–iodine solution or immerse the telescope in warm
saline for a minute or two before its introduction into the abdomen.
30

31. • Following insertion of the telescope, the area immediately underlying the
primary port and Veress needle is examined for iatrogenic damage.
• The site of entry for the second (accessory) portal is selected under direct
visualization and percutaneous palpation of the body wall.
• Exploration of the abdominal cavity is assisted by the palpation probe to
‘feel’ and move the organs as needed.
• Instruments should never be passed blindly into the abdomen but rather
viewed internally as they pass through the cannula, and directed to the
area of interest.
• It may sometimes be helpful to tilt the patient from side-to-side or
up/down, to allow gravity to move viscera out of the field of view and
facilitate examination.
Examination Technique
31

32. • At the conclusion of the laparoscopic procedure the instruments and
telescope are removed.
• The pneumoperitoneum is relieved by discontinuing carbon dioxide
insufflation and opening the two-way stopcocks on the cannulae.
• The cannulae are then removed.
• Gentle pressure on the abdominal wall will help remove any gas not
removed via the cannulae.
• The puncture sites are sutured in two layers in a routine manner.
32
Ending Procedure

33. • Ascites patient is partially drained prior to laparoscopy.
• Gas-filled loops of intestine floating on top of ascitic fluid are more prone to
damage by the Veress needle or cannulae.
• Drainage by syringe and three-way tap, with a large bore intravenous
catheter placed in the midline will usually suffice.
• If ascites is present all abdominal incisions should be closed in at least two
layers to prevent seepage of fluid postoperatively.
• With any laparoscopic procedure, the surgeon should always be prepared to
convert to conventional open surgery should it be required.
33
Additional Considerations

34. 6. APPLICATION OF LAPAROSCOPY
34

35. BIOPSY
Liver
35
Portal position for liver biopsy (O) Inspecting the liver with palpation probe
Biopsy of the liver using cup biopsy forceps Liver biopsy site

36. • Seventy-six of the 80 (95%) dogs survived hospital discharge rate
after hepatic biopsy.
• Three (4%) dogs required conversion to laparotomy, but in none of
the dogs was conversion to laparotomy needed to control
hemorrhage associated with the laparoscopic biopsy procedure.
• Another 3 (4%) dogs required a blood transfusion; all 3 had been
anemic prior to surgery.
• All laparoscopic biopsy samples were considered to be of sufficient
size to obtain a histologic diagnosis. However, disagreements in
histologic diagnoses were identified for 7 of the 49 (14%) dogs.
36
Petre et al. (2012)
Liver

37. 37
Pancreas
Pancreatic biopsy is performed via a right lateral
approach.
The normal pancreas is pale pink and uniformly
nodular in texture.
Punch-type biopsy forceps
Biopsy site
Punch-type biopsy forceps are preferred, although
cup biopsy forceps can also be used.
Harmoinen et al. (2002)
Out of 13 cats and 18 dogs, in 14 animals a
laparoscopic biopsy of the pancreas resulted in a
histopathologic diagnosis when the sonographic
findings or the gross assessment failed to do so.
Webb and Trott (2008)

38. 38
Kidney
• The right kidney is preferred because it is
less mobile.
• A left kidney biopsy through a left lateral
approach is more difficult because of the
location of the spleen underlying the usual
cannula entry site.
• The usual location for sample collection is
the cranial or caudal pole of the kidney.
With a 16 gauge core biopsy needle
With 5 mm cup biopsy forceps

39. TABLE 1. Histologic features of laparoscopic kidney biopsies taken by 5 mm cup biopsy
forceps (CupBF) or 16 gauge core biopsy needle (CoreBN) (Park et al., 2016)
39
Kidney

40. 40
• This procedure is performed in dorsal
recumbency from a standard ventral midline
approach.
• Technique involves grasping and then
exteriorizing a portion of intestine through the
abdominal wall.
• Sufficient samples for histologic examination
were obtained from all 7 dogs that underwent
laparoscopic-assisted jejunal biopsy
(Rawlings et al., 2002).
Portal positions
Exteriorized loop of small intestine.
Intestine

41. • Laparoscopic exploration was performed through a multicannulated
single port (n = 18), multiple ports (5), or a single 6 mm cannula (4)
client-owned dogs.
• All biopsy samples obtained had sufficient diagnostic quality.
• The 2 most common histologic diagnoses were lymphoplasmacytic
enteritis (n = 14) and intestinal lymphoma (5).
• Twenty-five of 27 (93%) dogs survived to hospital discharge, and 3
(12%) dogs had postsurgical abnormalities unrelated to surgical
technique.
41
Intestine
Shamir et al. (2019)

42. • A gastrostomy feeding tube can also be placed using
laparoscopy by exteriorizing the body of the stomach
through the left abdominal wall and inserting the tube
externally following a gastropexy.
• Duodenostomy or jejunostomy feeding tubes can be
placed using the laparoscope simply by exteriorizing
the respective piece of intestine through the
abdominal wall and inserting the tube externally.
42
FEEDING TUBE PLACEMENT

43. 43
FEEDING TUBE PLACEMENT
• Enterostomy tube was properly positioned and
functional in all 8 dogs that underwent
laparoscopic-assisted enterostomy tube
placement.
• Suture material was seen in the area of the
adhesion in all 8 dogs and was surrounded by
fibroplasia in 2 dogs, purulent inflammation in 1,
granulomatous inflammation in 1, and a
combination of these in 3; no tissue reaction was
seen surrounding the suture material in the
remaining dog.
• All the dogs recovered uneventfully.
Rawlings et al. (2002)

44. 44
• Gastropexy is recommended for animals at high-
risk of developing gastric dilatation volvulus
(GDV).
• Laparoscopic gastropexy is performed by
exteriorizing the pyloric antrum through the right
abdominal wall.
• A 3 cm incision is made into the muscularis of
the gastric wall to develop a serosomuscularis
flap, without penetrating into the gastric lumen.
• The edges of this incision are then sutured to the
transverse abdominal muscle with a simple
continuous pattern.
GASTROPEXY

45. • Sixty-three dogs underwent total laparoscopic gastropexy with a
single, simple continuous, barbed suture line.
• Median gastropexy surgery time was 70 minutes.
• Short term (>24 hours to 6 months postoperative) complications
included incisional seroma formation (n = 52) and suture reaction (n =
51).
• Long term (>6 months postoperative) complications included
intermittent regurgitation and chronic diarrhoea in 1 dog.
• Fifteen dogs had postoperative ultrasound and all had intact
gastropexy sites.
45
Takacs et al. (2016)
GASTROPEXY

46. 46
Port placement for laparoscopic-assisted OVH Uterine body and horns emerging from beneath the
urinary bladder
Ovarian pedicle exposed Vascular clips have been placed
OVARIOHYSTEROCTOMY

47. 47
Transecting the ovarian pedicle
Wound closure
Ovaries and uterus exteriorized from the caudal port
Gower (2016)

48. • This is a simpler and faster procedure than
ovariohysterectomy.
• ‘Ovario-hysterectomy’ is technically more
complicated, time-consuming, and is probably
associated with greater morbidity (larger incision,
more intraoperative trauma, increased
discomfort) compared with ovariectomy, making
ovariectomy the preferred method of
gonadectomy in the healthy bitch.
48
Goethem et al. (2006)
OVARIECTOMY

49. 49
• Laparoscopic oophorectomy in bitches was conducted to compare two
different modalities viz., electro-cautery (Group I; n=6) and endo-looping
(Group II; n=6).
• The total time required to perform laparoscopic oophorectomy by
electro-coagulation was comparatively lesser (31.53±0.9 min) than endo-
looping (34.24±0.64 min).
• The stress induced by laparoscopic procedure led to temporary
increase in serum cortisol level.
• Both the laparoscopic oophorectomy procedures were found to be
effective but endo-looping required additional precision and perfection.
• The electro-coagulation followed by extraction of ovary may be
preferred for wider clinical use.
OVARIECTOMY
Shirodkar (2008)

50. 50
• Location of ovarian remnants in open surgery can
be difficult and time-consuming.
• Only two portals are required and the technique is
the same as for laparoscopic ovariectomy.
OVARIAN REMNANT REMOVAL
• Mean surgery duration was 97.5 min in 32 dogs
with ovarian remnant syndrome.
• Histology confirmed ovarian origin of removed
tissue in all dogs.
• GnRH stimulation test was performed in fourteen
dogs after 10.5 months for verification. Nimwegen et al. (2018)

51. 51
Removal of an ectopic testicle
Normal inguinal canal showing the
vas deferens and testicular vessels.
• A testicle that is located in the abdominal
cavity can be removed easily using
laparoscopy.
• Two cannulae are adequate to perform the
surgery.
• If the vas deferens and testicular vessels are
seen entering the inguinal ring, then the
testicle is in the inguinal canal.
• An absence of the vas deferens and testicular
artery in the inguinal canal means that the
testicle is ectopic.
• The ectopic testicle is usually readily visible
upon entering the abdominal cavity.
Mayhew (2009)
CRYPTOCHID SURGERY

52. 52
Primary telescope portal is in place
Babcock forceps are placed in the secondary
portal.
Bladder wall sutured to the abdominal
incision.
Telescope and laser fibre inserted into the
bladder.
LAPAROSCOPIC ASSISTED CYSTOSCOPY

53. 53
Small bladder polyp seen at laparoscopic
cystoscopy
Wound closure after cystoscopy
View of urethra
Defarges et al. (2013)

54. 54
• Cholecystectomy is indicated in cases of chronic
cholelithiasis/mucolithiasis, obstruction of the
cystic duct, gallbladder neoplasia and chronic
cholecystitis.
• Once the liver has been adequately retracted,
dissection of the gallbladder and vascular supply
is undertaken.
• Dissection should be carried out to the neck of the
gallbladder at the origin of the cystic duct.
• Five mm clips are applied in blood vessels, the
neck of the gallbladder and the proximal portion of
the cystic duct, which are also transected.
CHOLECYSTECTOMY

55. 55
A retractor is used to elevate the gall
bladder for visualization of the cystic duct
Cystic duct is dissected with an
articulating dissector
Placement of surgical clips prior to
transection

56. • Out of 20 dogs, 6 (30%) required conversion from laparoscopic to open
cholecystectomy due to inability to ligate the cystic duct (3), evidence of
gall bladder rupture (1), leakage from the cystic duct during dissection (1),
and cardiac arrest (1).
• Cystic duct dissection was performed in 19 dogs using an articulating
dissector (10), right angle forceps (7), and unrecorded (2).
• The cystic duct was ligated in 15 dogs using surgical clips (5), suture (6),
or a combination (4).
• All dogs were discharged from the hospital and had resolution of clinical
signs, although 1 dog developed pancreatitis and 1 dog required revision
surgery for bile peritonitis.
56
CHOLECYSTECTOMY
Scott et al. (2016)

57. 57
Tapia-Araya and Martin- portugues (2016)
OTHER POTENTIAL SURGICAL PROCDURES
Other surgical procedures that can be performed using laparoscopy are:
 Adrenalectomy
 Correction of portosystemic shunts
 Nephrectomy (hand-assisted)
 Removal of abdominal masses
 Removal of intestinal masses
 Hernia repair

58.  Anaesthesia
 Veress needle/trocar insertion
– Injury to abdominal wall
– Penetration of organs
– Perforation of hollow organs
 Insufflation : subcutaneous
emphysema
 Peritoneal tenting
 Inappropriate insufflation
 Pneumothorax
 Gas embolism
 Operative complications
– Bleeding
– Tissue injury
 Technical problems
– Lack of experience
– Equipment-related
58
COMPLICATIONS DURING SURGERY

59. 59
• Overall complications occurred in 33 of 159 (21%) surgeries in dogs and were
considered minor (CO2 leaks, omental insufflation, repeated entry) in 30 of 33
(91%) cases.
Table 2. Multivariate regression analysis of risk factors for all entry
complications with backward elimination (Anderson and Fransson, 2019)

60. 60
• Intra-operative complications of laparoscopic and thoracoscopic surgery
in veterinary medicine range from 2% to 35%, and are usually due to the
introduction of a Veress needle or excess trocar-cannula units, or
improper instrument and tissue handling (McClaran and Buote, 2009).
• Anaesthetic complications related to CO2 pneumoperitoneum were
anaemia, hypotension or respiratory compromise with reduced
diaphragmatic excursion and lung volume.
• Occurrence of complications has been significantly higher in feline, elderly
and lightweight patients.
• MIS complications are closely related to the inexperience of the surgeon
and their team, with higher incidence during the earlier phases of the
learning.
.
(Mayhew, 2011)

61. • The approach for a single-port device presents an
evolution in technique, potentially allowing for
morbidity reduction and improved postoperative
recovery.
• The larger incision associated with single-port
surgery facilitates specimen removal (i.e.,
Hysterectomy).
• The main drawbacks for the surgeon are the
continuous collisions between the instruments,
decreased working space and un-ergonomic
positions.
Laparo-endoscopic Single-site Surgery (LESS)
Georgiou et al. (2012) 61
NOVEL SURGICAL APPROACHES

62. • This is a new approach that combines aspects of flexible endoscopy and
laparoscopy and whose ultimate goal is the absence of scars on the skin of
the patient and reduced incision site pain.
• NOTES surgery can be hybridized if external laparoscopic assistance is
required, or pure if it does not need any accessory trocar-cannula.
• Limitations of this technique include inefficient tissue grasping, reduction in
degrees of movement for instrumentation and possible risk of infection due
to incorrect disinfection or organ closure.
• Surgical approaches: transgrastric, transesophageal, transvaginal,
transcolonic and transvesical among others.
62
Natural Orifice Trans-luminal Endoscopic Surgery (NOTES)

63. Linhares et al. (2018)
63
Ovariectomy by total NOTES

64. • Ovariectomy time in dogs did not differ between the experimental hybrid
NOTES group (HNG = 46.3±18.5 minutes; n=8) and total NOTES group (TNG
54.6±31.1 minutes; n=8).
64
Table 3. Summary results for the 2 procedures (HNG, hybrid NOTES group;
TNG, total NOTES group) Linhares et al. (2018)

65.  Reduced chronic wound pain
 Reduced incisional hernia rate
 Fewer adhesion, less likely to
develop obstruction
 Better visualization for
surgeon
 Improved cosmetics
 Reduced postoperative pain and
analgesic requirements
 Reduced operative trauma
 Reduced bleeding
 Faster recovery
 Reduced wound infection,
haematoma, seroma
65
ADVANTAGES OF LAPAROSCOPY
Lhermette and Sobel (2008)

66. • High risk of injury to visceral organs
 e.g., common bile duct, bowel, urinary bladder, spleen, vascular injury by Veress
needle
• Increases operating time
• Loss of tactile sensation
• Loss of depth perception of surgeon
• Long learning curve
• High cost of the equipments
• Another risk is blood clot may enter the arterial system and clog the lung
arteries, causing heart attack. 66
Lhermette and Sobel (2008)
Disadvantages Of Laparoscopy

67. • Minimally invasive surgery has multiple benefits, viz., less surgical trauma,
better recovery and shorter hospital stays.
• Laparoscopic biopsy is an established technique with excellent results.
• Laparoscopic ovariectomy is one of the most commonly performed
procedures.
• There are many different instruments and surgeons need to adapt to the
decreased tactile sensation by training and improving their hand-eye and
hand-hand coordination.
67
7. CONCLUSIONS

68. • MIS complications are closely related to the inexperience of the
surgeon and their team, with higher incidence during the earlier
phases of the learning curve.
• As a result of the continued interest in reducing surgical trauma, a
series of novel surgical approaches have been described, including
LESS and NOTES, constituting an evolution of laparoscopic surgery,
with the potential benefits of further reduced morbidity and faster
postoperative recovery.
68
7. CONCLUSIONS

69. • Simulation training and advanced training tools can rapidly increase the
surgeon’s skills to an advanced level
• The knotless suture (Barbed suture) and suture-assist devices can further
facilitate intracorporeal suturing.
• Instruments with multi-functional features are highly desirable and can be
efficient to eliminate the problems faced in the latest surgical developments.
• Advanced surgical platforms, such as robotic surgery, have not yet been
evaluated in the veterinary field but likely to appear within the next few years.
69
FUTURE PROSPECTS

70. 70
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