Basic laparoscopic surgery (Case)

Question 1

MIS

Answer 1

• any sx that is less invasive or results in less tissue trauma compared to open surgery

Question 2

Endoscopy

Answer 2

• Performed with a telescope and a camera
• video displayed on screen

Question 3

Laparoscopy/thoracoscopy

Answer 3

endoscopy in the abdomen/endoscopy in the thorax

Question 4

OVE/OHE

Peritoneal access

Answer 4

• Veress needle (fills with gas)
• modified Hasson
• Mini-laparotomy
  
  • SILS

Question 5

Threaded cannula

Answer 5

• screw in
• rubber reducer valves
  
  • insufflation
  • no insufflation

Question 6

The tower

Answer 6

• light source
  
  • 200-300 watts now
• video control unit
• insufflator
  
  • CO₂ gas always and only
  • controls flow rate and max pressure

Question 7

Bipolar cautery

Answer 7

• Basic RF units
• Ligasure

Question 8

Forceps

Answer 8

• Babcock
• Scissor
• Kelly

Question 9

Endo-staplers

Answer 9

• EndoGIA

Question 10

Gas sterilization

Answer 10

• ethylene oxide or gas plasma
• preferred for scopes, cameras, & cables

Question 11

Steam sterilization

Answer 11

• Gravity dependent
• OK for scopes, cameras, cables
• reduced life

Question 12

Cold sterilization

Answer 12

• 2% glutaraldehyde
• sterilize scopes between procedures

Question 13

Indications for laparoscopy

Answer 13

• Elective procedures
  
  • ovariectomy, gastropexy, cryptorchidectomy, biopsy
• client requests
  
  • preceived benefits (cholecystectomy)
• patient morbidity
  
  • less pain, hospitalization, medication, infection, cost to owner?
• Hospital reputation
  
  • competition: quality and image of practice

Question 14

Contraindications for laparoscopy

Answer 14

• surgeon
  
  • inexperience or lack of comfort
  • must have developed psychomotor skills
• staff (anesthesiologist, technician)
  
  • inexperience or lack of comfort
• lack of instrumentation
  
  • cannulas, graspers, endoscopes, BIPOLAR
• advanced and exploratory procedures?
  
  • GI, cholecystectomy, adrenalectomy, splenectomy

Question 15

Physiologic effect abdominal insufflation

Answer 15

• pressure against diaphragm and vena cava
• dec thoracic compliance and venous return
• dec tidal volume and cardiac output
• outcome
  
  • hypoventilation
  • hypoxemia
  • acidemia
• Solution
  
  • PPV
  • limit IAP and duration
    
    • dogs: < 12mmHg
    • cats: < 8mmHg

Question 16

Sources of pain

Answer 16

• Incisions
• Peritoneal CO₂
• Stretching of diaphragm

Question 17

Incisions

Answer 17

• Source of pain
  
  • cutaneous and muscular nerve endings
  • nociceptors
• concl
  
  • limit incision size and number
  • local blocks
  • NSAIDS

Question 18

Peritoneal CO₂

Answer 18

• sources of pain
  
  • chemical irritation of peritoneum
  • Nonhumidified gas
    
    • desiccation of peritoneum
• concl
  
  • evacuate residual gas
  • use humidified gas

Question 19

Stretching of diaphragm

Answer 19

• Sources of pain
  
  • Neuropraxia
    
    • phrenic nerves
    • visceral afferents
• concl
  
  • limit insufflation pressure
    
    • dogs < 12 mmHg
    • cats < 8mmHg
  • limit duration of surgery

Question 20

AVMA consensus

Ovariectomy or Ovariohysterectomy

Answer 20

• yes we should neuter
  
  • doesn’t favor OHE over OVE
• pormotes gonadectomy as primary welfare issue for Americans

Question 21

Preparation

Lap OVE

Answer 21

• Wide abdominal clip
• Sterile preparation
• Wide draping
  
  • 2-port method
  • SPAGO

Question 22

LAP OVE

Peritoneal access

Answer 22

• veress needle
• modified Hasson
• Mini-laparotomy
  
  • SILS

Question 23

LAP OVE

Local analgesia

Answer 23

• Bupivicaine block
  
  • 1 mg/kg
• prior to port placement

Question 24

Ports for OVE

Answer 24

• Camera: 1 cm caudal to umbilicus
• Instruments: 2-4 cm crania to umbilicus

Question 25

Ports for OHE

Answer 25

* Camera: 1 cm caudal to umbililcus * Instruments * a. 2-4 cm cranial to umbilicus * b. 1/3 distance umbilicus to pubis

Question 26

Ligasure

Answer 26

* bipolar electorsurgery * compresses and denatures * creates tissue seal * \> 7mm vessels * 3X systolic pressure

Question 27

LAP OVE Closure of port incisions

Answer 27

* 5 mm: subcutaneous and skin * 10 mm and up * linea, subcutaneous * skin * interrupted or cruciate to hold in body wall, prevent herniation

Question 28

LAP OVE Complications

Answer 28

* Splenic laceration/ hemorrhage * Pedicle hemorrhage * Subcutanous emphysema * Loss of insufflation: slipped cannula * Dropped ovary or pedicle * **Conversion is NOT a complication**

Question 29

Prophylactic gastropexy indications

Answer 29

* at risk dogs * relative with GDV * large breed & deep chest * Danes (40% lifetime risk) * Irish wolfhound * stadard poodle

Question 30

LAP gastropexy Complications

Answer 30

* Seroma - very common * Splenic laceration/hemorrhage * serosal tearing * loss of insufflation * enlarged incision * dropped stomach * conversion to keyhole technique possible

Question 31

Summary MIS

Answer 31

* Less pain, tissue trauma, analgesics, infection * More precision, safety, inc reputation of a clinic * unique instrumentation required * unique physiologic consequences * start with elective procedures * **conversion isn't a complication**

Question 32

Surgical complications OVH or OVE

Answer 32

* Postoperative hemorrhage * ovarian a. * uterine a. * broad ligament * Ureteral ligation? * ovarian pedicles (11%) * uterine bodies (17%) * Ovarian remnant syndrome (ORS) * incision location * right pedicle 70%

Question 33

Long-term complications OVH or OVE

Answer 33

* Uterine neoplasia * 1/3000, 85% leiomyoma * 1/30,000 risk malignant * uterine stump leiomyosarcoma just as likely * Endometritis/Pyometra * 15-25% risk by 10 years * Requires functional ovarian tissue * Disease of luteal phase (diestrus)

Question 34

OVH or OVE for dogs and cats

Answer 34

* Evidence supports OVE over OVH * easier * fewer complications * less tissue trauma * less painful * faster * minimally invasive * discretion of practitioner, either is acceptable