UNIVERSITA’ DI PISA
Dipartimento di Scienze Cliniche Veterinarie
CORSO DI LAUREA MAGISTRALE IN MEDICINA
VETERINARIA
TESI DI LAUREA
‘‘Comparison of Laparotomic Versus Laparoscopic
Ovariectomy in bitches of different sizes: a study based on our
experience.’’
RELATORE:
prof. IACOPO VANNOZZI
CORRELATORE:
dott. GIOVANNI BARSOTTI
LAUREANDA:
MARIA TSELEMEGKOU
CONTENTS
RIASSUNTO……… 4
SUMMARY……….. 5
CHAPTER ONE: Introduction……….………...…. 6
CHAPTRE TWO: Literature survey of current contraception methods in the bitch……….…... 9
2.1 Anatomy of the female reproductive tract……….…………... 9
2.2 Surgical techniques of contraception……….……... 11
2.2.1 OHE versus OVE: advantages and disadvantages…………..… 11
2.2.2 Comparison of Traditional midline OVE and Laparoscopic OVE……….... 14
2.2.2.1 Traditional midline (Laparotomic) OVE…………...…... 14
2.2.2.2 Laparoscopic OVE……….... 19
2.2.2.2.1. Laparoscopic OVE: an overview of different methods………... 25
2.2.2.3 Laparotomic Versus Laparoscopic OVE………..… 28
CHAPTER THREE: Material and methods……….... 30
3.1. Materials………..… 30
3.1.1. Patients……….……..… 30
3.1.2. Equipment………..……... 57
3.1.2.1. Laparotomic surgery equipment………..…. 57
3.1.2.2. Laparoscopic surgery equipment………..… 58
3.2. Methods……….…………... 59
3.2.1. Anaesthesia………...……….. 59
3.2.2. Laparotomic surgery………... 59
3.2.3. Laparoscopic surgery……….. 60
4.1. Statistical results on Laparotomic Versus Laparoscopic
ovariectomy………..……. 62
4.2. Statistical results on Laparotomic Versus Laparoscopic ovariectomy based on the patient’s weight………... 63
4.3. Statistical results on Laparotomic Versus Laparoscopic ovariectomy based on the most important different steps of the procedure and the patient’s weight……….……….. 65
4.3.1. Laparotomic Versus Laparoscopic ovariectomy based on stretching the 1st ligament………..….… 66
4.3.2. Laparotomic Versus Laparoscopic ovariectomy based on cutting the 1st ovary……….… 67
4.3.3. Laparotomic Versus Laparoscopic ovariectomy based on stretching of the 2nd ligament………..…… 68
4.3.4. Laparotomic Versus Laparoscopic ovariectomy based on cutting the 2nd ovary……… 70
4.4. Statistical results on Laparotomic Versus Laparoscopic ovariectomy based on the patient’s BCS………..…… 72
4.5. Statistical results on Laparotomic Versus Laparoscopic ovariectomy based on the patient’s age……… 75
4.5. Statistical results on Laparotomic Versus Laparoscopic ovariectomy based on the surgical time of the operation……….…….… 77
CHAPTER FIVE: Discussion and Conclusion ………..…….… 79
CHAPTER SIX: Annex………..…… 85
6.1. List of figures………. 85
6.2. List of tables………... 85
6.3. List of abbreviations………... 87
BIBLIOGRAPHY………... 88
RIASSUNTO
Nonostante oggigiorno l’ovariectomia laparotomica è una chirurgia di routine per la castrazione delle cagne, l’ovariectomia laparoscopica sembra aver conquistato il mondo anche se è una tecnica più giovane. Questo studio è stato creato per valutare la presenza o meno di differenze o complicazioni tra le due diverse tecniche nel tempo intraoperatorio tra le cagne di diverse taglie e BCS. Il confronto è stato fatto tra la laparotomia e la laparoscopia a due entrate. A disposizione per questo studio ci sono state 24 cagne separate in due gruppi disomogenei (8 in laparotomia e 16 in laparoscopia).
L’età, il peso, il BCS e la durata dell’intervento sono stati registrati in tutti e due i gruppi. Frequenza cardiaca, frequenza respiratoria, pressione arteriosa sistolica, pressione arteriosa diastolica, pressione arteriosa media, temperatura e le complicazioni sono state registrate in tutta la durata intraoperatoria di ogni intervento. Tutte le operazioni sono state effettuate dallo stesso chirurgo presso la clinica del Dipartimento di Scienze Cliniche Veterinarie dell’Università di Pisa. I risultati hanno evidenziato che la durata media dell’operazione è stata minore in laparotomia e inoltre è stato visto che in laparoscopia la frequenza cardiaca è stata maggiore nella maggior parte dei casi.
Concludendo, la laparotomia e la laparoscopia sono pressoché equivalenti, avendo ovviamente ognuna i suoi vantaggi e svantaggi. Tuttavia, la scelta non dovrebbe essere soltanto basata sul tipo di procedura come tale ma avrebbe maggior importanza una scelta basata sulle necessità di ogni cagna.
Key words: cagne, ovariectomia, laparotomica, laparoscopica, taglie, Body condition score
SUMMARY
Laparotomic ovariectomy (OVE) is a routine surgical procedure for neutering in the female dogs. Nevertheless, laparoscopic ovariectomy has already conquered the world and has become an era, even though is a younger surgical technique. The present study was conducted to evaluate the possible differences or complications in the operative time between bitches of different sizes and body condition scores (BCS). The comparison was made between laparotomy and two-hole laparoscopy in 24 bitches divided in two unequal groups (8 in laparotomy and 16 in laparoscopy). The age, the weight, the BCS and the surgery duration were recorded in both groups. Heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, mean blood pressure, temperature and the complications were recorded in hole intraoperative time of every surgery. All the surgeries have been performed by the same surgeon at the hospital of the Department of Clinical Veterinary Science in Pisa University. The mean operative time was found lower in laparotomy and blood pressure was in many cases higher in laparoscopy. In conclusion, laparotomy and laparoscopy seems to be equal enough, having their advantages and disadvantages like any operation. However, the choice should not be about the preferable procedure as a type, but it should be based on which is the better choice for the necessities of every female dog.
Key words: bitch, ovariectomy, laparotomy, laparoscopy, two-portal, weight, Body condition score
CHAPTER ONE: Introduction
In veterinary medicine, gonadectomy is one of the most frequently performed surgical techniques, and that is because it is the most reliable means of pet population control. (Stockner PK., 1991).
The importance of pet population control, based on a study, is that millions of dogs are euthanatized annually in the United States. (Nassar R., 1991).
Gonadectomy can be performed by ovariectomy (OVE) or ovariohysterectomy (OVH). In the United States OVH is the most selected approach. (Fingland RB., 1998 and Hedlund CS., 1997 and Stone AE. et al, 1993).
This preference is most likely based on the presumption that future uterine pathologies is prevented by removing the uterus. On the other hand, many European countries have as a standard approach for gonadectomy the OVE. Even though there are many studies that compare risks and complications associated with these two techniques, and favour OVE, the United States still prefer OVH. (Okkens AC. et al, 1997 and Janssens LA., 1991 and Okkens AC. et al, 1981).
In our study, we will be focused mainly at the approach of most European countries for gonadectomy: OVE.
In the Hippocrates (460-375 B.C.) aphorisms, we can find him aphorizing “Ὁκόσα φάρµακα οὐκ ἰῆται, σίδηρος ἰῆται [...]” meaning “What medicines do not heal, the lance will [...]”. With his words, the invasive character of surgical therapy has been elegantly highlighted. (Hippocrates, Aphorisms. 7; 87)
Ovariectomy has become one of the most common surgical operations. It is a minimally invasive surgical procedure for the sterilization of female dogs. (Dupré G. et al, 2009)
Minimally invasive techniques have been applied in many different fields in veterinary medicine, such as OVE, OHE, gastropexy, cystopexy and cryptorchidism.
A new era has been given by the introduction of minimally invasive techniques in surgery. Substantiating, in this way, the diachronic efforts to minimize surgical trauma. (Antoniou SA. et al, 2012)
For that exact reason, in the last decade, laparoscopic ovariectomy has been considered a valid alternative to the conventional one. (Dupré G. et al, 2009)
The evolution of laparoscopy is been considered as a further step toward investigating human body cavities. Mainly based on the efforts that began as early as the 5th century BC, when the first endoscopic examinations of the rectum and the vagina were performed by the Hippocratic school (Gorden A., 1993 and Pantermali D., 2000).
At the beginning the major problem in laparoscopic procedures was the insufficient light source. In order to resolve this problem Philipp Bozzini (1773-1809) analysed it and successfully developed a fiber optic. With this new optic, endoscopic examination has been evolved. Georg Kelling (1866–1945) has performed the first laparoscopic surgery in dogs in 1901. (Fröhlich C., 2008).
Kelling’s interest in the laparoscopic procedure was based on his observation that opening the abdomen could worsen the patient’s condition. He was the one that produced an insufflation technique, which had been a real revolution because it had offered a better visualization. (Litynski GS., 1997)
In the meanwhile, Hans Christian Jacobaeus (1879–1937) established and performed the minimal invasive technique in humane medicine in 1912 (Fröhlich C., 2008).
Laparoscopic ovariectomy because of its decreased duration of hospitalization, faster recovery time, decrease stress and pain, and improved visualization of the abdominal organs, has become more widespread in veterinary medicine (Twedt DC. and Monnet E., 2005).
Laparoscopic ovariectomy has shown to be efficient for spaying in female dogs, yet it has not been able to eliminate the classical laparotomic procedure, even though it
is elected by many veterinarians today. The main reasons will be described in Chapter two.
Both procedures are currently practised at the Veterinary Hospital of Pisa’s University. The obvious preference is on the laparoscopic one because of its small incisions, time-effective surgery and early release of the animal. However, laparotomic ovariectomy has its own place and importance. And with this thesis we will try to find out a little bit more in the main argument of the choice between laparotomic and laparoscopic ovariectomy.
24 bitches were chosen for this study and they have been separated into two groups based on the different ovariectomy procedure chosen, which was performed by the same surgeon. The comparison of those two procedures was mainly based on the different size and Body Condition Score (BCS) of the bitches.
CHAPTRE TWO: Literature survey-current contraception methods in the bitch.
2.1. Anatomy of the female reproductive tract
source:http://www.safarivet.com/care-topics/dogs-and-cats/reproduction/.
Fig. 1 Anatomy of the female reproductive tract.
‘‘The female reproductive tract includes the ovaries, oviduct, uterus, vagina, vulva and mammary gland.
The ovaries are located within a thin-walled peritoneal sac; the ovarian bursa is located just caudal to the pole of each kidney. The uterine tube or oviduct courses through the wall of the ovarian bursa.
The right ovary lies dorsal to the descending duodenum, and the left ovary lies dorsal to the descending colon and lateral to the spleen. Medial retraction of the mesoduodenum or mesocolon exposes the ovary on each side.
Each ovary is attached by the proper ligament to the uterine horn and via the suspensory ligament to the trasversalis fascia medial to the last one or two ribs. The ovarian pedicle (mesovarium) includes the suspensory ligament with its ovarian artery and vein, and variable amounts of fats and connective tissue. Canine mesovarium contains a grate quantity of fat, making it more difficult to visualize its vasculature. The ovarian vessels take a tortuous path within the ovarian pedicle. Ovarian arteries originate from the aorta.
The right ovarian vein drains into the caudal vena cava; the left ovarian vein drains into the left renal vein.
The uterus is suspended by mesometrium (ligament) which is a peritoneal fold. The round ligament travels in the free edge of mesometrium, from the ovary through the inguinal canal with the vaginal process.
The uterus has a short body and long narrow horns. Blood supplies come from uterine arteries and veins.’’ (Fossum TW. et al, 2013)
2.2. Surgical techniques of contraception
2.2.1. OHE versus OVE: advantages and disadvantages
Surgical contraception of routine gonadectomy can be performed by OVE and OVH (Van Goethem BE. et al, 2006).
In several studies ovariectomy is considered the elective neutering method.
OVE is not been selected only for neutering. It is also indicated for treatment of ovarian tumors, or to promote involution of placental sites when they are not responding to treatment. Another important reason is to prevent hormonal changes that are responsible for the vaginal hyperplasia recurrence (Fingland RB., 1998 and Stone AE. et al, 2003).
Furthermore, it is used to eliminate the transfer of inherited diseases. (Wheeler SL et al, 1984)
‘‘OVE is also performed in young dogs (£ 2,5 years) to decrease the incidence of mammary gland tumours.
The relative risk for developing mammary gland tumors decreases when neutering is performed:
v before first estrus (0,5%),
v between first and second estrus (8%) and
v between second estrus and 2,5 years of age (26%).’’ (Schneider R. et al, 1969)
On the other hand, for most uterine diseases the elective treatment is OVH. (Fingland RB., 1998)
The selection between OVE and OVH it is rationally based on their short-term and long-term complications. (Pollari FL. et al, 1996)
In the short-term complications are included (Van Goethem B. et al, 2006): § Intraabdominal haemorrhage (Pearson H., 1973)
§ Vaginal bleeding (Pearson H., 1973)
§ Ovarian remand syndrome (is a specific long-term complication of female gonadectomy when the ovarian cortex is not fully removed. Ovarian remand syndrome is an iatrogenic condition.) (Miller DM., 1995 and Wallace MS., 1991 and Ball RL. et al, 2010)
§ Stamp granuloma (which is a suture reaction) (Werner RE. et al, 1992) § Miscellaneous incidental complications. (Stone AE. et al, 1997)
In a clinical review of 853 OVH cases, haemorrhage has been the most common complication (almost 80%) in dogs > 25Kg. (Berton JL., 1979)
‘‘Clinical important haemorrhage primarily occurs from the ovarian pedicles, the uterine vessels, or the uterine wall when ligatures are improperly placed (Pearson H., 1973), and rarely occurs from vessels that accompany the suspensory ligament or within the broad ligament (Hedlund CS., 1997)’’ (Van Goethem B. et al, 2006). Based on the above, we can easily comprehend that clinically important haemorrhage from the ovarian pedicle it could be similar between OVE and OVH. (Van Goethem B. et al, 2006).
In the long-term complications, when we consider OVE and not OVH, are included (Van Goethem B. et al, 2006):
§ Endometritis and pyometra (Fransson BA. and Ragle CA., 2003 and Fukuda S., 2001)
§ Uterine tumour formation (Klein MK., 1996)
§ Urinary sphincter mechanism incontinence (Kyle AE. et al, 1996) § Body weight gain. (Edney AT. and Smith PM., 1986)
Both techniques, OVE and OVH, can be used for canine gonadectomy, but the choice is on the surgeon. He is the one that must compere and make a choice based on:
v the least invasive, v the fastest and
‘‘Without benefit of more prospective studies comparing surgical complications between OVE and OVH, most evidence extracted from the literature leads to the conclusion that there is no benefit and thus no indication for removing the uterus during routine neutering in healthy bitches. Thus, we believe that OVE should be the procedure of choice of canine gonadectomy.’’ (Van Goethem B. et al, 2006).
2.2.2. Comparison of traditional midline OVE and Laparoscopic OVE 2.2.2.1 Traditional midline (Laparotomic) OVE
An interesting and important part of the laparotomic ovariectomy is what you must do to begin the surgery.
It is important to give all the necessary time on the patient’s preparation. (Gómez JR.
et al, 2013)
The preparation begins with the trichotomy applied on the ventral abdomen of the patient, making sure to be careful and do not lesion the skin because that could interfere with the post-operative evolution of the patient. After finishing the trichotomy, the vacuum cleaner should be used to eliminate the hair. (Gómez JR. et al, 2013)
This is important because in the surgery the hair can be the carrier of many pathogens. If the patient has not urinated before the surgery, she must be catheterized. (Gómez JR. et al, 2013)
The best thing to do, is to catheterize either way, so there will not be any risk of urination on the surgery table.
The animal is positioned in dorsal recumbency.
Aseptic preparation is carried out using alcohol and betadine. The sequence is alcohol followed by betadine. Alcohol is used to eliminate the biofilm of proteins and lipids that is found normally on the skin and deactivate betadine. The sequence is repeated three times with a movement from the centre to the periphery. As centre is chosen the point that the surgeon will make the incision. Betadine is left on the skin as a layer because it needs a couple of minutes to act.
The surgeons begin the operation with the application of drapes. If the drape does not have a fenestration, the surgeon will cut one in the appropriate size for him to be able to proceed the surgery. (Fossum TW. et al, 2013)
source: from our own laparotomic surgeries
Fig.3 Drape application.
It is maybe obvious at this point, that it is not important if we are talking about ovariectomy or not, because the initial part, the one that it has just been described, it’s the same for all the laparotomic surgeries. And for being correct, it is the same even for the laparoscopic one.
Immediately after, the first thing to do is the identification of the umbilicus. In the bitches the incision of the skin should be made midline and caudal to the umbilicus. In the middle third of the caudal abdomen. (Fossum TW. et al, 2013)
The size of the incision is the surgeon’s choice. This choice is made based on:
Ø how easily the surgeon can operate with the precise size chosen and
Ø how smooth the post-operative time would be for the animal, which means that the size needs to be as smaller as possible.
In Fossum TW. et al, (2013), it is indicated an incision from 4 to 8 cm.
The incision of the skin and the subcutaneous tissue brings in the surface the linea alba. The surgeon must pass it through for being able to expose the abdomen cavity. The procedure is delicate and the surgeon must be extremely careful, because underneath is being hosted all the abdomen viscera. (Fossum TW. et al, 2013)
Once the abdomen cavity is opened, the surgeon will choose the way he will go on search for the ovaries.
There are two possible choices:
v the ovariectomy hook. (Fossum TW. et al, 2013) v or the thumbs
In the meanwhile, the second surgeon elevates both left and right abdomen walls, in this way he separates the abdomen wall from the viscera underneath and gives a better vision of the cavity.
In Fossum TW. et al, (2013) the search of the ovary is made with the hook.
It is easier to find the ovary if firstly the correspondent uterine corn is identified, its anatomy confirms its presence. (Fossum TW. et al, 2013)
Following the uterine corn two things can be found: § the ovary or
§ the uterine bifurcation. (Fossum TW. et al, 2013)
By pulling the uterus horn in caudal and medial direction the suspensory ligament will be exposed and identified. The traction must be gentle because in the suspensory ligament are hidden the ovarian vessels. The ligament must be broken for the ovary to be exteriorized. The break must take place near the kidney, use the index finger to apply the traction, making sure that the ovarian vessels will not be torn apart. (Fossum TW. et al, 2013)
A hole must be created in the broad ligament for the ligatures to be applied. Firstly, two forceps will be placed to compress suspensory ligament and its vessels. The one forcep will be removed when the first ligature will be placed. The ligature must be secure tightly, to endure haemostasis and to assure that it is not going to slit. A second ligature may be applied, close to the first one, to secure the proper clamping of the vessels. (Fossum TW. et al, 2013)
Another ligature must be applied at the location of the proper ligament of the ovary to close the uterine horn. (Shariati E. et al, 2014)
A second one could be placed, close to the first one.
The uterus horn must be checked for haemorrhage and released to the abdomen. (Zahedani NS. et al, 2014)
A second control must be made in the abdomen, to ensure there is no haemorrhage in act.
Open the ovary bursa to examine that the entire ovary has been removed, if not there will be risk of the ovarian remand syndrome. (Miller DM, 1995)
The same procedure must be performed for the second ovary.
Finally, the incision should be closed in a routine three-layer manner. (Zahedani NS. et al, 2014)
2.2.2.2 Laparoscopic OVE
Even for laparoscopic OVE, as it has already been written, the first part of the patient’s preparation is the same one described for the laparotomic procedure.
In laparoscopic surgery, the surgeons should take care and have under control some basic factors of the procedure:
v patient’s decumbency and position v the optic fiber
v all the surgical equipment
v mechanisms of access and progression v pneumoperitoneum
v mechanisms of visualization (Gómez JR. et al, 2013).
source: from our own laparoscopic surgeries
The patient is positioned in dorsal recumbency and reverse Trendelenburg. (Shariati E. et al, 2014)
When the patient is clipped and aseptically prepared, the video monitor is placed at the caudal end of the dog. (Culp WTN. et al, 2009)
The technique which was used in our study is the two-midline portal.
After the final preparation of the patient on the surgery table, follows the creation of pneumoperitoneum. (Fossum TW. et al, 2013)
Cardinally, for the creation of pneumoperitoneum is needed one of the two portals. Mainly it is preferred the caudal one. An approximately 4-5mm ventral medial incision is made in the skin and subcutaneous tissue, leaving the linea alba intact, at about 1-2cm caudal to the umbilicus.
source: from our own laparoscopic surgeries
Fig. 6 Incision of the skin and subcutaneous tissue.
‘‘A blunt dissection to the linea alba is followed by a 2-3mm stab incision through the linea alba into the abdominal cavity.’’ (Culp WTN. et al, 2009)
The observation of the abdominal fat confirms the penetration of the abdominal cavity. (Culp WTN. et al, 2009)
source: from our own laparoscopic surgeries
Fig. 7 The abdominal wall is being pulled up for the insertion of the primary trocar.
The abdominal wall is pulled up while the primary trocar is inserted. In this way, a possible trauma to visceral organs could be prevented. (Shariati E. et al, 2014) For avoiding gas leakage during the insufflation and the trocar slitting through the incision, the linea alba incision is made on purpose smaller than the 5mm needed for the trocar to be inserted. (Culp WTN. et al, 2009)
So, through that incision is placed into the abdomen a 5mm non-threaded trocar and cannula assembly. At this point, the trocar will be connected to the high flow insufflators. For the insufflation is used CO2. The intraabdominal pressure that is preferred to be achieved is 8mmHg-10mmHg.
A 5mm 0° rigid camera, connected to a light source, is inserted into the trocar and a 360° scan is performed to control the existence of any abnormality. Afterwards the camera is orientated caudoventrally, pointing the ventral abdominal wall, as the second incision is going to take place. The direct visualization of the incision is essential to prevent any injury of the abdominal organs.
The second incision is made 3-4cm cranial to the pubis. A trocar-less threaded cannula is inserted into the abdomen. When the 5mm trocar insertion is completed, the surgical table is rotated either to the right or to the left. In this way, the abdominal organs are moved to the right or the left side and the surgeon can cosily go on search for the left ovary or for the right one.
source: from our own laparoscopic surgeries
Fig. 8 Laparoscopic operation with both trocars in position.
To help the research, it could be used the laparoscopic forceps, positioned in the caudal port. In this way, the intestines could be moved medially and the ovary may be found. (Fossum TW. et al, 2013)
On search for the left ovary, another organ that can also be manipulated to ease the view is the spleen. She should be moved to the right side. (Culp WTN. et al, 2009) Once the ovary is found, the proper ligament can be grasped with the forceps, then elevated and tacked to the body wall. At this point, a suture with a needle is passed percutaneously into the abdominal cavity, and located closely to the site of the elevated ovary. The needle pass through the mesovarium and continued through the abdominal wall again. (Culp WTN. et al, 2009)
source: from our own laparoscopic surgeries
Fig. 9 The ovary is pulled and tighten up to the ventral abdomen wall.
The two ends of the suture must be pulled and clamped tightly together with a haemostat, to keep the ovary in close contact with the ventral abdomen wall. (Culp WTN. et al, 2009)
Thus, makes it possible for the ovary to be maintained without the forceps.
Afterwards, the ovarian pedicle, proper ligament and mesovarium are cauterized and resect by a vessel sealing device that is placed at the caudal portal. The resect ovary is grasped by the haemostat that had taken the place of the vessel sealing device and pulled up to the caudal portal, after the suture that was holding it to the abdomen wall was removed. (Culp WTN. et al, 2009)
The cannula is removed when the ovary needed to be pulled out of the abdomen and is replaced into the same caudal portal as previously. So that the operation can be continued for the search of the remaining ovary.
The endoscope accompanies every step of the procedure and that’s because it is the eyes of the surgeon. Without it the surgeon is blind, the reason is obvious and is that the surgery is not an open one.
Before the termination of the procedure, the abdomen is thoroughly examined for any evidence of haemorrhage or any other complications. (Shariati E. et al, 2014)
When the control is finished, and both ovaries are removed, the remaining instrumentation must be also removed and a complete evacuation of pneumoperitoneum must be executed. (Fossum TW. et al, 2013)
The portal sites are sutured with simple interrupted layers.
source: from our own laparoscopic surgeries
2.2.2.2.1. Laparoscopic OVE: an overview of different methods
A precondition of the laparoscopic surgery is the pneumoperitoneum. For that exact reason, an insufflation of the abdominal cavity must be performed. The gas that can be used are various:
§ Carbon dioxide (CO2) § Nitrous oxide (N2O)
§ Air § Nitrogen § Helium § Xenon
§ Argon. (Fröhlich C., 2008)
Carbon dioxide is the most commonly applied insufflation gas. (Kolata RJ. and Freeman LJ., 1999)
There are three methods for establishing pneumoperitoneum (Kolata RJ. and Freeman LJ., 1999):
1. the closed technique with the Veress needle. This type of needle is inserted subumbilical and directed to the pelvis.
2. the open technique for placing a Hasson trocar. The open technique was developed to avoid intra-abdominal injury which was encountered in blind puncture.
3. optical trocar. This is an alternative to the other two methods. This technique allows controlled entry, because the tissue layers can be visualized on the video monitor during trocar insertion.
In veterinary medicine a variety of methods for laparoscopic OVE with different number of portals have been described. (Mayhew PD. and Brown DC., 2007)
In laparoscopy, the primary port is where the optical portal will be positioned. One or two secondary ports should be obtained in case to achieve an optimal access. Furthermore, the secondary port must be placed correctly, beneficial to manipulation of the instruments without interference and to avoid paradoxical movements. (Kolata RJ. and Freeman LJ., 1999)
Commonly used: one median port at the umbilicus and two secondary ports paramedian halfway between the umbilicus and pubis. (Hancock RB. et al, 2005) Another technique is the use of only two ports, one at the umbilicus and the second cranial to the pubis. (Devitt CM. et al, 2005)
A new technique and alternative to 2 or 3 portal traditional laparoscopic techniques is the single port access. This innovative technique is based on the effort to potentially reduce morbidity and hospitalization. (Curcillo PG. et al, 2009)
A 3cm incision portal is performed, in this alternative technique, at the peri-umbilical area and a single access device is placed in the abdominal wall after being lubricated. (Tapia-Araya AE. et al, 2015)
In laparoscopy, different haemostatic and dissection instruments can be used. The selection of the right one depends on vascularity, friability, extend of fat tissue and obviously from the availability of the instruments. Today, are available the instruments below (Freeman and Hendrickson, 1999):
§ mechanical-like ligatures, clips and staplers. Those in combination with electrosurgery are commonly used for vessel sealing. Suture ligation is a safe and reliable method but is difficult in handling and more time-consuming compare to the other techniques. (Mayhew and Brown, 2007)
§ electrosurgery which could be monopolar or bipolar. It can sense the electrical resistance of the tissue and deliver an appropriate amount of energy to seal the tissue by fusion of the tissue elastin and collagen. (Riegler M. and Consentini E., 2004)
Bipolar electrocoagulation compared to monopolar requires less time for the haemostatic effect and damages less the surrounding tissues. (Van Goethem BE. et al, 2006)
§ laser, it has been shown to increase the duration of the surgery compared to the bipolar electrocoagulation (Van Nimwegen SA., 2005)
§ and ultrasonic energy such as harmonic scalpel. It is better to applicate on vessel not larger than 2-3mm. The haemostasis with this instrument occurs via
ultrasonic waves. It has an accurate dissection, coagulation and transection of the tissue due to the use of less heating, only 100°. (Fröhlich C, 2008)
In some cases, a combination of different methods is required. One of those cases is, for example, when the ovarian pedicle includes a lot of fat. (Freeman and Hendrickson, 1999).
2.2.2.3 Laparotomic Versus Laparoscopic OVE
Many studies have compared laparoscopic sterilization with standard open technique in female dogs.
In 1985, the first laparoscopic sterilization of dogs was reported. (Wildt DE and Leowier DF., 1985)
The advantages of the laparoscopic technique compared to the laparotomic one, are the below:
§ excellent visualization, § less haemorrhage, § fewer trauma,
§ shorter anaesthetic period (Gower S. and Meyhew P., 2008). § less invasive (Inoue Y. et al, 2003).
§ shorter length incision (Dupré G. et al, 2009). § decreased infection rate,
§ improved patient recovery,
§ less post-operative stress and pain, § less post-operative morbidity,
§ shorter hospitalization and convalescence time (Twedt DC. and Monnet E., 2005).
§ preserved immune function,
§ decreased post-operative ileus (Amodeo A. et al, 2009).
§ rapid return to preoperative and physical activity (Culp WT. et al, 2009).
However, in the laparoscopic technique some disadvantages also exist. Disadvantages that need to be evaluated are as follows:
§ the elevate cost of the instruments
§ the surgeon’s capacity and limited precision § poor ergonomy
§ perioperative complications such as anaesthetic death, air embolism and emphysema (Monnet E. and Twedt DC., 2003)
§ incisional problems like swelling, dehiscence and redness,
§ organ laceration (Van Goethem BE. et al, 2003)
§ the time consuming
CHAPTER THREE: Material and methods 3.1. Materials
3.1.1. Patients
In this study 24 female intact dogs, of various breed, ages and weights were enrolled. All 24 bitches have arrived at the Department of Veterinary Science of Pisa University to undergo an ovariectomy. They have been used two different techniques: the one was laparotomic and the other was two-hole laparoscopic.
Based on this data the animals were divided into two groups: Group 1: Laparotomic ovariectomy (8 dogs) Group 2: Laparoscopic ovariectomy (16 dogs)
A physical examination and a standard preoperative blood parameters were performed.
All surgical procedures were performed by the same surgeon as the main surgeon. He was assisted by one of his students in the role of the second surgeon.
Anaesthesia protocol and surgical time, as well as any complications were documented.
Table 1. Patients included in the study
Patient Breed Group Weight BCS Age
1 Boston terrier 1 5 Underweight (2/5) 1 year 2 Springer spaniel 1 18,6 Ideal (3/5) 11 years 3 Golden retriever 1 37 Overweight (4/5) 12 years 4 Mixed-breed 1 17 Underweight (2/5) 10 months 5 Mixed-breed 1 20 Ideal (3/5) 11 months
6 Italian wolf 1 21 Ideal (3/5) 2 years
7 West highland W.T. 1 9,2 Overweight (4/5) 11 years
8 Mixed-breed 1 6,6 Ideal (3/5) 6,5 years
9 Miniature schnauzer 2 9,6 Overweight (4/5) 3 years 10 Labrador 2 30 Overweight (4/5) 16 months
11 Weimaraner 2 36 Ideal (3/5) 8 years
12 Labrador 2 30 Ideal (3/5) 1 years
13 Pug dog 2 9 Overweight (4/5) 3,5 years 14 Mixed-breed 2 26,4 Overweight (4/5) 12 years 15 Golden Retrievier 2 30 Overweight (4/5) 4 years
16 Mixed-breed 2 7,5 Ideal (3/5) 2,5 years
17 Barboncino 2 2,2 Underweight (2/5) 6 months 18 Australian Shepherd 2 19 Ideal (3/5) 2 years
19 Mixed-breed 2 30 Ideal (3/5) 1,5 years
20 Mixed-breed 2 21,6 Ideal (3/5) 11 months 21 Australian cattle dog 2 40 Overweight (4/5) 1,5 years 22 American Staffordshire Terrier 2 24 Underweight (2/5) 10 months 23 Mixed-breed 2 19 Underweight (2/5) 11 years
In Table 1 are listed the patients of both groups. The total number of our patient is 24. The first 8 are those who were operated with the laparotomic technique and the other 16 are those who were operated with the laparoscopic technique. In the same table, are described the breed, the weight, the body condition score (BCS) and the age of each one.
Laparotomy Laparoscopy
Tab 2. Total surgical time of every patient included in the study Case
Total surgical time (min) 9 25 10 32 11 35 12 30 13 28 14 22 15 31 16 28 17 20 18 18 19 28 20 25 21 16 22 26 23 20 24 25 Mean 25,56±2,74 Case
Total surgical time (min) 1 9 2 25 3 20 4 30 5 66 6 23 7 10 8 13 Mean 24,5+14,5
Table 3. (below) Comprehends 8 tables each one for every patient of the laparotomic ovariectomy. There are included the parameters (Heart Rate, Respiratory Rate, Systolic Blood Pressure, Diastolic Blood Pressure, Mean Blood Pressure and Temperature) taken in consideration in every important step of the operation (A few minutes before surgery, Skin incision, Stretching the 1st ligament, 1st ovary resection, Stretching the 2nd ligament, 2nd ovary resection, After skin’s suture).
GROUP 1:
Patient 1:
A few minutes
before surgery
Skin incision
HR
60
54
RR
26
26
SBP
112
138
DBP
50
81
MBP
70,67
100
Temperature
37
37,1
Stretching the 1st ligament
1
stovary resection
53
53
26
26
178
145
125
99
142,67
114,33
37,1
37,2
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
52
50
64
26
26
26
162
150
114
113
100
50
129,33
116,67
71,33
37,2
37,1
37,4
Patient 2:
A few minutes
before surgery
Skin incision
HR
109
112
RR
10
13
SBP
101
103
DBP
50
53
MBP
67
69,67
Temperature
37,8
37,7
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
93
88
114
14
18
18
135
118
109
74
62
62
94,33
80,67
77, 67
37,3
37,2
36,8
Stretching the 1st ligament
1
stovary resection
88
76
42
8
153
127
93
68
113
87,67
37,6
37,5
Patient 3:
A few minutes
before surgery
Skin incision
HR
130
115
RR
12
12
SBP
52
75
DBP
32
50
MBP
38,67
58,33
Temperature
36.6
36,6
Stretching the 1st ligament
1
stovary resection
120
98
12
12
106
99
71
63
82,67
75
36,7
36,7
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
119
115
101
12
12
15
102
99
145
67
63
68
78,67
75
93,67
36,8
36,8
37
Patient 4:
A few minutes
before surgery
Skin incision
HR
80
174
RR
14
14
SBP
110
123
DBP
50
90
MBP
70
101
Temperature
37,4
37,3
Stretching the 1st ligament
1
stovary resection
122
109
14
14
119
89
84
60
95,67
69,67
37,2
37,2
Stretching the 2nd
ligament
2
ndovary resection
After skin’s suture
113
77
83
16
16
16
112
88
113
85
59
69
94
68,67
83,67
37,2
37
37,6
Stretching the 1st ligament
1
stovary resection
80
54
10
10
126
97
59
50
81,33
65,67
36,9
37
Patient 5:
A few minutes
before surgery
Skin incision
HR
116
106
RR
19
22
SBP
130
131
DBP
45
45
MBP
73,33
73,67
Temperature
37
37
Stretching the 2nd
ligament
2
ndovary resection
After skin’s suture
115
96
81
7
7
14
110
106
127
49
51
66
69,33
69,33
86,33
37
37,3
37,4
Patient 6:
A few minutes
before surgery
Skin incision
HR
62
102
RR
14
14
SBP
98
112
DBP
49
55
MBP
65,33
74
Temperature
37,2
37,2
Stretching the 1st ligament
1
stovary resection
82
46
14
14
128
108
65
44
86
65,33
37,1
37,1
Stretching the 2nd
ligament
2
ndovary resection
After skin’s suture
59
53
33
14
20
20
134
115
182
50
45
52
Patient 7:
A few minutes
before surgery
Skin incision
HR
92
64
RR
26
28
SBP
114
155
DBP
57
66
MBP
76
95,67
Temperature
36,8
36,7
Stretching the 1st ligament
1
stovary resection
76
90
27
22
170
156
76
79
107,33
104,67
36,6
36,6
Stretching the 2nd
ligament
2
ndovary resection
After skin’s suture
86
86
95
22
27
27
154
156
141
78
68
64
103,33
97,33
89,67
36,6
36,3
35,5
Stretching the 1st ligament
1
stovary resection
122
68
23
13
134
100
87
53
102,67
68,67
36,2
36,3
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
91
79
70
13
14
17
121
124
118
75
69
90
Patient 8:
A few minutes
before surgery
skin incision
HR
77
89
RR
16
18
SBP
114
117
DBP
72
77
MBP
86
90,33
Temperature
36,6
36,6
Table 4. (below) Comprehends 16 tables each one for every patient of the laparoscopic ovariectomy. There are included the parameters (Heart Rate, Respiratory Rate, Systolic Blood Pressure, Diastolic Blood Pressure, Mean Blood Pressure and Temperature) taken in consideration in every important step of the operation (A few minutes before surgery, 1st portal, 2nd portal, Stretching the 1st ligament, 1st ovary resection, Stretching the 2nd ligament, 2nd ovary resection, After skin’s suture).
GROUP 2:
Patient 9:
A few minutes
before surgery
1st portal
2nd portal
HR
134
46
85
RR
16
11
11
SBP
114
121
131
DBP
58
61
89
MBP
76,67
81
103
Temperature
35,8
35,8
35,7
Stretching the 1st ligament
1
stovary resection
115
74
11
16
135
125
95
65
108,33
85
35,7
35,6
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
87
62
53
16
16
6
127
119
106
75
64
46
92,33
82,33
66
35,4
35,4
35,4
Patient 10:
A few minutes
before surgery
1st portal
2nd portal
HR
153
154
125
RR
12
12
12
SBP
90
125
124
DBP
53 64 71MBP
65,33
84,33
88,67
Temperature
36,4
36,3
36,2
Stretching the 1st ligament
1
stovary resection
120
115
12
12
124
150
72 8989,33
109,33
36,2
36,2
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
105
112
83
12
12
14
140
140
97
87
84
52
104,67
102,67
67
36
36
36
Patient 11:
A few minutes
before surgery
1st portal
2nd portal
HR
108
109
94
RR
14
19
19
SBP
161
172
173
DBP
72
79
75
MBP
101,67
110
107,67
Temperature
35,7
35,7
35,7
Stretching the 1st ligament
1
stovary resection
73
74
14
14
166
178
81
86
109,33
116,67
35,6
35,6
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
67
61
90
14
14
14
175
183
115
69
71
61
104,33
108,33
79
35,6
35,6
35,6
Patient 12:
A few minutes
before operation
1st portal
2nd portal
HR
84
81
84
RR
12
12
12
SBP
118
120
123
DBP
75
77
78
MBP
89,33
91,33
93
Temperature
36,7
36,7
36,7
Stretching the 1st ligament
1
stovary resection
63
68
12
12
144
162
90
104
108
123,33
36,7
36,7
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
56
61
54
15
18
20
124
151
129
74
89
67
90,67
109,67
87,67
36,8
36,8
36,8
Patient 13:
A few minutes
before operation 1st portal
2nd portal
HR
115
117
119
RR
18
18
18
SBP
112
112
118
DBP
64
65
73
MBP
80
80,67
88
Temperature
36,2
36,3
36,3
Stretching the 1st ligament
1
stovary resection
133
103
36
20
119
114
74
71
89
85,33
36,6
36,9
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
102
102
90
27
27
24
116
129
106
68
83
56
84
98,33
72,67
37,6
37,7
37,8
Stretching the 1st ligament
1
stovary resection
69
72
12
15
96
108
40
40
58,67
62,67
36,7
36,7
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
75
84
85
12
12
19
171
166
169
47
49
39
88,33
88
82,33
Patient 14:
A few minutes
before operation 1st portal
2nd portal
HR
108
111
108
RR
12
12
12
SBP
84
84
85
DBP
42
41
41
MBP
56
55,33
55,67
Temperature
36,8
36,8
36,8
Patient 15:
A few minutes
before operation 1st portal
2nd portal
HR
58
69
72
RR
16
16
16
SBP
142
179
163
DBP
93
105
103
MBP
109,33
129,67
123
Temperature
35,6
35,9
35,9
Stretching the 1st ligament
1
stovary resection
78
76
12
12
143
130
89
81
107
97,33
35,9
36
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
96
75
65
14
14
17
143
142
118
102
102
72
115,67
115,33
87,33
36
35,7
37,4
Patient 16:
A few minutes
before operation 1st portal
2nd portal
HR
49
110
126
RR
20
16
21
SBP
103
160
115
DBP
39
92
64
MBP
60,33
114,67
81
Temperature
35,6
35,5
35,4
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
107
115
92
27
26
22
137
156
112
89
101
67
105
119,33
82
35,5
35,5
35,8
Stretching the 1st ligament
1
stovary resection
150
116
25
27
136
154
79
98
98
116,67
35,5
35,5
Patient 17:
A few minutes
before operation
1st portal
2nd portal
HR
154
140
125
RR
24
20
20
SBP
110
94
103
DBP
90
66
78
MBP
96,67
75,33
86,33
Temperature
38
37,6
37,3
Stretching the 1st ligament
1
stovary resection
108
108
25
23
122
126
105
116
110,67
119,33
37,2
37,1
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
114
118
91
46
34
20
155
156
115
135
133
105
141,67
140,67
108,33
37,1
37
36,8
Patient 18:
A few minutes
before operation
1st portal
2nd portal
HR
49
49
55
RR
15
13
13
SBP
158
150
163
DBP
55
54
57
MBP
89,33
86
92,33
Temperature
37,5
37,4
37,4
Stretching the 1st ligament
1
stovary resection
80
90
16
14
189
182
90
98
123
126
37,4
37,4
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
71
67
56
14
15
15
150
147
129
70
67
52
Patient 19:
A few minutes
before operation
1st portal
2nd portal
HR
80
76
67
RR
16
16
16
SBP
108
122
128
DBP
67
64
75
MBP
80,67
83,33
92,67
Temperature
36,4
36,3
36,2
Stretching the 1st ligament
1
stovary resection
60
61
16
16
123
122
70
68
87,67
86
36,2
36,2
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
62
61
66
16
16
16
101
105
104
58
60
58
72,33
75
73,33
36,1
36,2
36,2
Patient 20:
A few minutes
before operation
1st portal
2nd portal
HR
80
78
80
RR
14
14
14
SBP
125
124
135
DBP
62
61
68
MBP
83
82
90,33
Temperature
36,8
36,8
36,8
Stretching the 1st ligament
1
stovary resection
80
84
14
14
144
156
75
94
98
114,67
36,8
36,8
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
61
60
61
14
14
14
123
117
115
56
54
52
Patient 21:
A few minutes
before operation
1st portal
2nd portal
HR
116
114
112
RR
12
12
13
SBP
100
103
109
DBP
62
65
69
MBP
74,67
77,67
82,33
Temperature
36,8
36,7
36,6
Stretching the 1st ligament
1
stovary resection
108
103
12
14
131
146
88
95
102,33
112
37,2
37,2
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
87
80
75
12
15
20
121
115
106
70
68
54
87
83,67
71,33
37,2
37,2
37
Patient 22:
A few minutes
before operation
1st portal
2nd portal
HR
114
101
98
RR
19
30
30
SBP
99
114
108
DBP
44
51
49
MBP
62,33
72
68,67
Temperature
36,6
36,5
36,4
Stretching the 1st ligament
1
stovary resection
75
70
12
12
134
129
63
62
86,67
84,33
36,5
36,5
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
80
92
77
15
8
14
116
113
103
56
55
55
Patient 23:
A few minutes
before operation
1st portal
2nd portal
HR
130
120
117
RR
18
11
11
SBP
98
110
160
DBP
52
62
88
MBP
67,33
78
112
Temperature
36,3
36,3
36,3
Stretching the 1st ligament
1
stovary resection
97
95
11
11
152
141
77
64
102
89,67
36,2
36,2
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
89
92
74
16
16
16
134
144
119
72
77
46
92,67
99,33
70,33
36,1
36
36
Patient 24:
A few minutes
before surgery
1st portal
2nd portal
HR
104
105
110
RR
12
16
16
SBP
115
135
130
DBP
56
54
46
MBP
75,67
81
74
Temperature
35,2
35,3
35,3
Stretching the 1st ligament
1
stovary resection
90
76
16
16
138
133
50
47
79,33
75,67
35,2
35,3
Stretching the 2nd
ligament
2
ndovary resection After skin’s suture
75
73
74
16
17
17
105
104
92
42
42
40
3.1.2. Equipment
3.1.2.1. Laparotomic surgery equipment
For the laparotomic procedure a surgical kit was used. This kit included:
v Backhaus towel clamp v Scalpel n.3 or n.4 v Allis tissue forceps v Surgical scissors sharp v Surgical scissors blunt v Surgical scissors sharp-blunt v Tissue forceps
v Hemostatic forceps v Needle holders
v Electrosurgical bipolar scalpel v Ovariectomy hook
v Drapes
v Surgical gauzes
Additionally, was comprehended in the surgery a Blade n.10 and Monocryl or Vicryl and Ethilon 2.0 or 3.0 suture.
3.1.2.2. Laparoscopic surgery equipment
For the laparoscopic procedure, a surgical kit was used as well. This kit included:
v Backhaus towel clamp v Scalpel n.3 or n.4 v Allis tissue forceps v Surgical scissors sharp v Surgical scissors blunt v Surgical scissors sharp-blunt v Tissue forceps
v Hemostatic forceps v Needle holders v Drapes
v Surgical gauzes
v Trocars of different sizes
v Atraumatic laparoscopic forceps for the Fallopian tubes
In additional, was comprehended in the surgery a Blade n.10, a HARMONIC ACE of 5mm (can be used for coagulation and transection of vessels up to 5 mm and handle multiple surgical jobs with precision including dissection, sealing, and transection), an optic fiber 30° Storz of 5mm and Dexon, Monocryl or Vicryl 2.0 or 3.0 suture. Another important equipment for the implementation of this type of surgery is an endoscopic tower, which incorporated:
v A monitor
v A camera system v A light source v A recording system v A CO2-insufflator
