- Email: [email protected]
Laparoscopic Anatomy of the Abdomen and Laparoscopic Ligating Loops, Electrocoagulation, and a Novel Modified Electroligation Ovariectomy in Standing Mare
Journal of Equine Veterinary Science 33 (2013) 912-923
Journal of Equine Veterinary Science journal homepage: www.j-evs.com
Original Research
Laparoscopic Anatomy of the Abdomen and Laparoscopic Ligating Loops, Electrocoagulation, and a Novel Modified Electroligation Ovariectomy in Standing Mare Mohamed A.M. Alsafy a , Mahmoud H. El-Kammar b, Mostafa M. Kassem b, Samir A.A. El-Gendy a, Ahmad N. EL-Khamary c a b c
Department of Anatomy and Embryology, Faculty of Veterinary Medicine, Alexandria University, Egypt Department of Surgery, Faculty of Veterinary Medicine, Alexandria University, Egypt Department of Surgery, Faculty of Veterinary Medicine, Damanhur University, Egypt
a r t i c l e i n f o
a b s t r a c t
Article history: Received 7 November 2012 Received in revised form 25 December 2012 Accepted 10 January 2013 Available online 28 February 2013
The purpose of this study was to provide a detailed laparoscopic anatomy of the caudal abdominal region of mare in a standing position and to evaluate and modify a technique for standing laparoscopic ovariectomy using combination between hand-tied ligating loop and electrocoagulation techniques, as the ligating loops, electrocoagulation, and modified electroligation laparoscopic ovariectomy were applied using nine adult mares. Laparoscopy was practical and effective for direct visual examination of internal abdominal organs in the mare. Ventral dislocation of abdominal viscera after pneumoperitoneum was established with the mare in standing position, which provided an excellent inspection of the dorsal and ventral structures in the peritoneal cavity on the right and left sides. Standing laparoscopic ovariectomy using an electroligation modified method was considered a safe and effective method for hemostasis of the mesovarium, technically easy, time saving, and economical. The mean surgical time for bilateral ovariectomy was 40 7.63, 60 5.25, and 85 6.43 minutes for electroligationmodified technique, ligating loops technique, and electrocoagulation technique, respectively. Ó 2013 Elsevier Inc. All rights reserved.
Keywords: Laparoscopy Anatomy Abdomen Ovariectomy Mare
1. Introduction Laparoscopy is a minimally invasive technique for viewing the internal organs of the abdominal cavity. The equipment used during laparoscopy provides a live picture of the insides of the abdominal cavity [15]. Laparoscopy has many diagnostic, therapeutic, and prognostic applications [5,8,16,18,35]. Insufflation by CO2 into the peritoneal cavity to create pneumoperitoneum is a routine technique for abdominal exposure, which improves visualization and Corresponding author at: Mohamed A.M. Alsafy, Department of Anatomy and Embryology, Faculty of Veterinary Medicine, Edfina, Behera, Egypt, Postbox 22785. E-mail address: [email protected] (M.A.M. Alsafy). 0737-0806/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jevs.2013.01.007
facilitates instrumental and visceral manipulation during laparoscopic surgery [15,25]. Equine ovariectomy was performed for various reasons, mainly to prepare a mount mare for semen collection, eliminate estrous behavior and colic signs, sterilize the mare for registration purposes, and to prepare recipient mares for embryo transfer, removing pathologically abnormal ovaries [7]. Different surgical techniques have been developed to remove equine ovaries. Horses can be operated on in a standing or dorsally recumbent position. The standing technique can be performed using sedation and local anesthesia [10], whereas general anesthesia is indicated for large thecal tumor [4,20]. In standing mares, ovariectomy can be done by flank laparotomy [32]. The flank approach is favorable because visibility is improved, but it involves large abdominal
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
incisions, at least 20-30 cm long, and may result in incisional complications such as hematomas or abscesses, prolonged postoperative convalescence from several weeks to months, poor operative visibility, and difficulty in recognizing and treating hemorrhage from the mesovarium [9,32,29]. Consequently, standing laparoscopic ovariectomy has become a more common technique to remove ovaries in mares [26]. Reported advantages of laparoscopic techniques compared with ovariectomy via laparotomy include reduction of complications through full observation of the operative field, minimal invasiveness, secure hemostasis, short convalescent time, fewer postsurgical complications, and tension-free ligation of vessels in the mesovarium [9,14,30]. The main challenge with laparoscopic ovariectomy technique is finding the best way to ligate the ovarian pedicle and provide hemostasis. Therefore, numerous methods have been used for hemostasis of the mesovarium and the associated ovarian vessels, which include stapling instruments [12], laser techniques [27], ligature application [6], vascular clips, electrocoagulation [30,31], vessel sealing device [19], and ultrasonic shears [2]; these methods of hemostasis are time consuming, difficult to apply hemostatic devices, are prone to ligature slippage, smoke generation, and cost of device. 2. Materials and Methods 2.1. Animals The present study was carried out with nine adult nonpregnant apparently healthy mares weighing 250-300 kg and 7-9 years old. Six mares were used for laparoscopic anatomy evaluation first, and then all nine mares were subdivided into three groups, each group included three mares for laparoscopic ovariectomy by ligating loop, electrocautery, and electroligation techniques. 2.2. Laparoscopic Equipments and Instrumentation Standard laparoscopic instruments, cannulas, telescope, insufflator, Veress needle, and forceps (Endoservice optical instruments GmbH, Germany), Sutroon 400 Electrosurgical Generator, 5-mm spatula monopolar electrode, and 5-mm reusable bipolar electrocautery forceps was used in this study. Operating instruments were available in 45-cm length and 10-mm diameter and compatible with monopolarity (Fig. 1). 2.3. Animal Preparation Food but not water was withhold for 24-36 hours. A single dose of 3000 IU of tetanus antitoxin prophylaxis, 10,000 IU/kg Procaine penicillin G plus 10 mg of streptomycin/kg (Combi-Kel, Kela Laboratoria, Belgium), and 1.1 mg/kg non-steriodal anti-inflammatory flunixin meglumine (Finadyne, Intervet Shering-Plough Animal Health) were administered before laparoscopic procedures. Both paralumbar fossae were shaved and aseptically prepared. All mares were sedated with detomidine hydrochloride, 20 mg/L in a saline intravenous infusion [21]. Local anesthesia was achieved with 20 ml of 2% lidocaine hydrochloride (Fig. 2B and C).
913
2.4. Flank Approach in Standing Mare 2.4.1. Establishment of Pneumoperitoneum Establishment of pneumoperitoneum was provided by adequate amounts of CO2 available for the procedure. 2.4.2. Laparoscopic Anatomy of the Abdomen The abdomen of the standing mare was divided into two main regions: left caudal and right caudal. These regions were subdivided into their respective dorsal and ventral aspects [17,18]. The laparoscope was positioned in the left caudal region between the spleen and lateral body wall. The laparoscope was positioned in the right caudal region of the abdomen by withdrawing it to the caudal edge of the cecal base and then arching the tip of the laparoscope caudally toward the pelvic inlet. 2.5. Standing Laparoscopic Ovariectomy Techniques Three instrumental portals were made. The first portal was placed at the level of the base of the tubercoxae midway between the tubercoxae and the last rib. The second portal was made just cranial and 10 cm proximal to the first cannula, and the third portal was made 5-10 cm ventral to the first cannula. The laparoscope was removed from the primary portal and inserted through the second portal. Laparoscopic claw grasping forceps was inserted through one instrument portal to provide traction on the ovary when the mesovarium was infiltrated with 20 ml of 2% lidocaine solution at different places by using 16-gauge spinal needles through the abdominal wall [6,13]. 2.5.1. Ligating Loops Technique The technique was achieved in three mares. The laparoscopic claw grasping forceps was inserted through the dorsal instrumental portal to grasp the mesosalpinx and place it under tension. The laparoscopic scissors were introduced through the ventral instrumental portal to divide the mesosalpnix and oviduct (Fig. 3A). The grasping forceps were placed on the surface of the ovary to provide tension while the proper ligament was divided (Fig. 3B). A 5-mm reducer was applied on the dorsal instrumental portal through which the knot pusher containing endoloop ligature polyglactin 910 no. 2 was tied in a modified Roeder knot. The ovary was grasped with forceps through the ligature loop and then manipulated to tease the loop around the newly created ovarian pedicle (Fig. 3C). Once the pedicle was snared, the loop was tightened by advancing the knot pusher while pulling the tail end of the ligature. The knot pusher was exchanged for scissors, and the tail of the ligature was cut and removed; this step was repeated for the second endoloop (Fig. 3D). The laparoscopic scissors was used to transect the ovarian pedicle between the ovaries and ligature (Fig. 3E). The ovarian stump was checked for bleeding (Fig. 3F) [26,28]. 2.5.2. Electrocoagulation Technique The electrocoagulation technique was achieved in three mares. The laparoscopic claw grasping forceps were inserted through the ventral instrumental portal to provide traction on the ovary. The bipolar electrosurgical instrument was inserted through the dorsal instrumental portal.
914
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
Fig. 1. Laparoscopic equipments and instrumentation. (A) Laparoscopic tower from top to bottom; video monitor, camera control unit, xenon light source, insufflator, suction and irrigation machine. (B) Optical system. (B1) Zero degree laparoscope. (B2) Light cable. (B3) Video camera. (C1) Disposable drapes. (C2) from left, 11-mm disposal cannula, 11-mm reusable cannula, 11-mm reusable cannula with clip on reducer and blunt tip trocar. (C3, from left) Debocaine 2% (lidocaine hydrochloride 2%) and Detomo Vet (detomidine hydrochloride 10 mg̸ ml) sedative drug. (C4) Two ampules of 1 polydioxanone (PDS) suture. (C5, from top) Laparoscopic scissors, claw grasping forceps, Maryland forces, insert of Babcock forceps, knot pusher, hook and spatula monopolar electrode and bipolar.
The bipolar forceps were placed across the cranial aspect of the mesovarium, approximately 1 cm proximal to the ovary (Fig. 4A). The cranial mesovarium was coagulated until blanching and shrinkage. The laparoscopic claw grasping forceps were removed, and the laparoscopic scissors were inserted through the ventral instrumental portal to transect the mesovarium distal to the coagulated site (Fig. 4B and C). Coagulation and transection were repeated sequentially in a caudal direction until the ovary was suspended only by the tubal membrane, oviduct, and proper ligament of the ovary. The bipolar electrosurgical instrument was replaced with the monopolar electrosurgical instrument to transect the remaining tubal membrane, oviduct and proper ligament of the ovary while the laparoscopic claw grasping forceps was used to grasp the ovary (Fig. 4D). The bipolar electrosurgical instrument was inserted through the dorsal instrumental portal to control any point of hemorrhage (Fig. 4E and F) [31]. 2.5.3. Modified Electroligation Technique The laparoscopic Babcock grasping forceps was inserted through the ventral instrumental portal to provide traction on the mesovarium. A monopolar hook electrode was inserted through the dorsal instrumental portal to create
a window in the mesovarium just caudal to ovarian blood vessels, which were identified from the medial aspect of mesovarium (Fig. 5B-E). Two extracorporeal 4S modified Roeder knots of 1 polydioxanone (Demetech Corp) was applied to the ovarian pedicle through the dorsal instrumental portal by using Maryland forceps and a knot pusher (Figs. 6, 7A and B). A third extracorporeal loop ligature was secured to the ovary before complete division of the ovarian pedicle. A monopolar spatula electrode was inserted through the dorsal instrumental portal to coagulate and transect the tubal membrane, oviduct, and proper ligament of the ovary from the ventral margin toward the dorsal aspect (Fig. 7C). The ovarian pedicle was sharply sectioned using laparoscopic spatula leaving two knots on the ovarian pedicle and one on the transected ovary while the laparoscopic claw grasping forceps used to grasp the ovary. Exteriorizing the ovary from the abdominal cavity was accomplished by widening the ventral portal in case of small ovary or by connecting the two ventral incisions to create a single skin incision approximately 5-10 cm in length in case of large ovary. The subcutaneous tissues and external abdominal oblique muscle fibers were sharply dissected, and the internal and transverse abdominal oblique muscles were separated along the axis of their
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
915
Fig. 2. Routine laparoscopic examination in standing mare. (A) Sedation of standing mare with intravenous infusion (yellow arrow) of detomidine HCl. (B) Local infiltration analgesia of laparoscopic portal site with lidocaine HCl. (C) Location o first laparoscopic port (green circle) at the level of the base of tubercoxae, midway between the tubercoxae (yellow points) and the Last rib (red points). (D) The 10-12 mm stab incision of skin and external abdominal oblique muscle. (E) Advancing of 11-mm diameter, 15 cm long cannula with a blunt trocar through the abdominal wall in the direction of the opposite stiffle joint. (F) Replacement of the trocar by laparoscope to confirm intra-abdominal position.
fibers to create a small grid incision in the abdominal cavity. The laparoscopic grasping forceps was used to draw the ovary carefully through the body wall. When the ovary was presented to the skin surface, two Allis tissue forceps were used to grasp the ovary to provide additional security for
extraction of the ovary through the body wall (Fig. 8E). Large follicles were aspirated to reduce the size of the ovary to facilitate removal through the small incision. The second ovary was removed by performing the same procedure through the opposite flank. Only the skin was closed using
Fig. 3. Laparoscopic ovariectomy using ligation loop technique. (A) Section of the uterine tube (UT) and mesosalpnix (MS). (B) Section of the proper ovarian ligament (PL). Note cut edges of the uterine tube and mesosalpnix. (C and D) Application of the first pretied loop (yellow arrow) around newly created ovarian pedicle. (E) Transection of ovarian pedicle between the ovary (OV) and ligature (red arrow) with laparoscopic scissors (S). (F) Showing transected ovarian stump (green arrow) after amputation of right ovary. Note no hemorrhage from ovarian stump. MA, Maryland forceps. KP, knot pusher. RL, round ligament of the uterus. CL, claw grasping forceps.
916
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
Fig. 4. Laparoscopic ovariectomy using electrocoagulation technique. (AeC) Multiple coagulation and transaction cycle is created in a caudal direction until the ovary is only suspended by tubal membrane, oviduct and proper ligament of the ovary. (D and E) Coagulation and transaction of the remaining mesosalpnix (MS). Uterine tube (UT) and proper ligament of the ovary using spatula monopolar electrode (SP). (E) Application bipolar forceps (BF) to control any point of bleeding. (F) Coagulated mesovarium after laparoscopic ovariectomy (yellow arrow). S, saparoscopic scissors. M, mesentery of the descending colon.
small incisions and 0 nylon in a cruciate pattern. The external abdominal oblique muscle and fascia were closed in the single enlarged incision using 0 polyglactin 910 (Unicryl, Unimed, Kingdom of Saudi Arabia) in a simple continuous pattern and 0 nylon in the skin in simple
interrupted pattern (Fig. 8F). Operative time, hemorrhage and method of hemostasis as well as complications during and after surgery were recorded. Operative time was defined as the time from the skin incision till completion of skin closure.
Fig. 5. Laparoscopic ovariectomy using electroligation technique (step1). (A) Vertical arrangement of the laparoscopic port in the left flank. (A1) dorsal laparoscopic port. (A2) middle instrumental port for monopolar electrode and (A3) ventral instrument for grasping forceps. Note front position of laparoscopic tower on the other side of the horse (green arrow). (B) Infiltration of the mesovarium (MO) at different place with 20 ml of lidocaine HCl, using 16-gauge/20-cm anesthetic needle (AN). (CeE) Creating the window in the mesovarium just caudal to ovarian blood vessels (yellow arrow) by hook monopolar electrode (H). OV, ovary. BC, Babcock grasping forceps. UT, uterine tube and (blue arrow) newly created window.
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
917
Fig. 6. Laparoscopic ovariectomy using electroligation technique (step 2). (AeF) Application of the first extracorporeal 4S modified Roeder knot around the newly created ovarian pedicle (OP), through the second instrumental portal (red arrow), using knot pusher (KP). BC, Babcock grasping forceps. MO, mesovarium. OV, ovary. UT, uterine tube. S, laparoscopic scissors. M, mesentery of the descending colon. Blue arrow, first 4S modified Roeder knot.
3. Results 3.1. Laparoscopic Anatomy Laparoscopy provided a comprehensive description of the normal anatomy of the caudal region of abdomen in standing mares. Flank access provided adequate visualization of the most abdominal structures. The ventral dislocation of abdominal viscera after pneumoperitoneum with the mare in standing position provided an excellent inspection of the dorsally and ventrally situated structures in the peritoneal cavity and on the right and left sides of the dorsal aspects of the abdomen. 3.1.1. Left Caudodorsal Region The mesorectum and rectum were occasionally identified in this region, but they were more consistently seen in the right caudodorsal region (Fig. 9). The left kidney was visualized retroperitoneally dorsal and axial to the spleen (Fig. 9A). Caudal and medial to the left kidney, the mesocolon of the descending colon and mesojejunum was observed and obscured direct visualization of the right abdomen. Mesocolon was seen originating cranially from the left side of the root of the mesentery at the junction of the duodenocolic ligament to extend caudally toward the pelvic inlet (Fig. 9A). The mesovarium and mesometrium were identified with the left ovary and the left uterine horn lateral to the mesocolon and caudal to the kidney. The round ligament of the uterus was seen from the lateral portion of the broad ligament to the dorsolateral uterine body (Fig. 9B). The ovarian and uterine vascular anatomy were not identified. The urinary bladder was consistently visualized extending cranially from the floor of the pelvic cavity, lying caudal and ventral to the uterine body. The lateral ligament of the
bladder was seen craniodorsal to the pelvic inlet. The prepubic tendon, body of the uterus and cervix were seen within the pelvic cavity with the empty bladder. 3.1.2. Left Caudoventral Region The examination was enhanced by catheterizing and emptying the urinary bladder. The ventral edge of the spleen was observed by directing the tip of the laparoscope directly ventral to its insertion site (Fig. 9C). Random intestinal segments were observed medial and caudal to the spleen and lateral to the mesocolon of the descending colon. The jejunum was identified by its smooth serosal surface, its lack of tenia and its propensity to have increased peristaltic activity compared to the descending and ascending colons. The descending colon was identified by its characteristic deep sacculations and antimesentric band and the presence of fecal matters within its lumen (Fig. 9D). The left dorsal colon and pelvic flexure were identified by their size sacculations and by the presence or lack of anti mesenteric bands (Fig. 9E). The caudal aspect of the transverse fascia and the rectus abdominal muscle were seen as they converged to form the vaginal ring. The pudendoepigastric vessels were seen entering the vaginal ring (Fig. 9F). Branches of the caudal mesenteric and cranial rectal arteries were identified within the descending mesocolon extending from the dorsal abdominal wall to the mesenteric border of the descending colon (Fig. 9D). The lateral ligament of the bladder was identified extending from the dorsolateral aspect of the pelvic inlet to the apex of the bladder (Fig. 9F). 3.1.3. Right Caudodorsal Region The ventral surface of the right kidney was identified retroperitoneally more readily when there was less
918
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
Fig. 7. Laparoscopic ovariectomy using electroligation technique (step 3). (A and B) Application of the second extracorporeal 4S modified Roeder knot (green arrow) around newly ovarian pedicle using Maryland forceps (MA) and knot pusher (KP). (C) Coagulation and transection of uterine tube (UT), mesosalpnix (MS), and proper ligament of the ovary (PL) from the ventral margin toward the dorsal aspect using spatula monopolar electrode (SP). (D) Application of the third extracorporeal 4S modified Roeder knot (red arrow), which acts as a good guide in case dropping of the ovary in the abdomen occurs and as good prevention of retrograde hemorrhage from ovary (OV). UH, uterine horn and (blue arrow) first knot.
perirenal fat (Fig. 10A). The mesocolon of the descending colon was seen and continued caudally toward the pelvic canal. Caudal to the base of the cecum, the right ovary
was observed suspended from the dorsal abdominal wall by the mesovarium (Fig. 10C). The mesovarium extended cranially toward the caudal pole of the right kidney.
Fig. 8. Laparoscopic ovariectomy using electroligation technique (step 4). (A-D) Section of ovarian pedicle using spatula monopolar electrode (SP) between second loop (green arrow). CL, laparoscopic claw grasping forceps was used to grasp the ovary. Note no hemorrhage from ovarian stump (ST), and third loop (yellow arrow) acts as a tether. (E) Extraction of ovary through ventral skin incision (back arrow) using two Allis tissue forceps. (F) Ports closure in interrupted manner using 0 nylon.
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
919
Fig. 9. Laparoscopic images of the left caudal region of the abdomen of standing mare. (A and B) laparoscopic images as viewed with the laparoscope located in the dorsal aspect of the left caudal region of the abdomen. (C-F) laparoscopic images as viewed with the laparoscope located in the ventral aspect of the left caudal region of the abdomen. SPL, spleen. RS, renosplenic ligament. LK, left kidney. (M, Mesocolon of descending colon. MO, mesovarium. OV, left ovary. MO, mesovarium. UT, Uterine tube. MM, mesometrium. UH, uterine horn. RL, round ligament of uterus. DEC, descending colon. UB, urinary bladder. VSPL, ventral edge of spleen. J, jejunum. LDC, left dorsal colon. LVC, left ventral colon. AMC, ascending mesocolon. P, pudendoepigastric vessels. T, transverse fascia. I, internal abdominal muscle. PT, prepubic tendon. Green arrow, lateral bladder ligament. Black arrow, vaginal ring. MA, Maryland forceps.
3.1.4. Right Caudoventral Region The base of the cecum was identified by its characteristic ventral band and sacculations and was observed extending ventrally from the dorsal abdominal wall (Fig. 10E). A greater proportion of jejunum and a lesser proportion of descending colon were visible in the right caudoventral region compared with that in the left caudoventral region (Fig. 10E). The pelvic flexure of the ascending colon was observed caudal to the base of the cecum and adjacent to the right lateral abdominal wall (Fig. 10F). The vaginal ring of all cases was easily seen when food was withhold for 36 hours. The urinary bladder and the cranial aspect of the pubis were equally visualized (Fig. 10F). 3.2. Laparoscopic Ovariectomy 3.2.1. Ligating Loop Technique Ligating loop technique was technically difficult in two cases. Excised ovaries ranged from 8-12 mm in diameter and 4-6 mm in thickness. Ligature slippage occurred in one case and resulted in immediate hemorrhage from three to four branches of the ovarian artery. Hemorrhage was managed immediately with additional ligating loop (Fig. 11A-C). 3.2.2. Electrocautery Technique In electrocautery technique, the sequential coagulation and transection were considered the rate-limiting step of the surgical procedure. Coagulation of tissue at one time was roughly 5 mm; on average, 6-10 coagulation and transection cycles were required per equine ovarian
pedicle. Smoke generation occurred during the coagulation and impaired the surgeon’s visualization and required intermittent opening of the CO2 insufflation valve on the laparoscope cannula to improve the laparoscopic visual field. Intraoperative hemorrhage from mesovarium occurred in two cases after transection of ovarian pedicles without appropriate coagulation. Three times of coagulation was required for hemostasis of ovarian pedicles (Fig. 11D-F). Intraoperative hemorrhage from the mesovarium obscured envisioning the operative site. 3.2.3. Electroligation Modified Method Standing laparoscopic ovariectomy using the electroligation-modified method was considered a secure, safe, and effective method for hemostasis of the mesovarium and technically easy, time saving, and economical. The mean surgical times for bilateral ovariectomy were 40 7.63, 60 5.25, and 85 6.43 minutes for electroligation modified technique, ligating loops technique, and electrocoagulation technique, respectively. Ligation of the mesovarium with 4S modified Roeder extracorporeal knot was considered technically easy, reliable, and efficient to avoid hemorrhage and prevented reverse slippage in all cases. Creation of a window in the mesovarium caudal to the ovarian blood vessels allowed secure loop fixation. Using a monopolar electrocautery to shatter, coagulate, and cut the mesosalpinx, the proper ligament of the ovary and the mesovarium approximately 1 cm distal to the ligature appeared effective for hemostasis, easily accomplished and reduced time-consuming coagulation of the mesovarium superfluous.
920
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
Fig. 10. Laparoscopic images of the right caudal region of the abdomen of standing mare. (A-D) laparoscopic images as viewed with the laparoscope located in the dorsal aspect of the right caudal region of the abdomen. (E and F) laparoscopic images as viewed with the laparoscope located in the ventral aspect of the right caudal region of the abdomen. RK, right kidney. MD, mesoduodenum. D, duodenum. HR, hepatorenal ligament. rTL, right triangular ligament. R, Right lobe of the liver. C, Caudate process of liver. M, mesocolon of descending colon. J, jejunum. CD, caudal duodenal flexure. CC, base of the cecum black arrow, ventral cecal band. OV, right ovary. MS, mesosalpnix. UT, uterine tube. UH, uterine horn. DEC, descending colon. R, rectum. RAC, right dorsal colon. UB, urinary bladder. U, uterus. PF, pelvic flexure of ascending colon. P, pudendoepigastric vessels. MA, Maryland forceps.
Electrocoagulation was tolerated very well by the mares, and mild smoke accumulation and image interference hardly complicated the procedure. Opening the CO2
valve on the laparoscopic cannula helped decrease the smoke accumulation within the visual field. The third extracorporeal loop ligature that was secured to the ovary
Fig. 11. Intraoperative hemorrhage from transected ovarian stump as a complication of ligating loop and electrocautery laparoscopic ovariectomy techniques and method of hemostasis. (A-C) Intraoperative hemorrhage from transected ovarian stump (ST) and hemostasis by application of additional ligating loop in ligating loop technique. MA, Maryland forceps. KP, knot pusher and (green arrow) pretied loop. (D-F) intraoperative hemorrhage from ovarian blood vessels and hemorrhage control by grasping the cut end of the vessels with bipolar forceps (BF) and then cauterizing the vessels. MO, mesovarium.
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
before complete division of the ovarian pedicle appeared effective to prevent retrograde hemorrhage from ovary and as a good guide in case of dropping ovary in the abdomen which occurred in two cases. Applying a pair of Allis tissue forceps and exteriorizing the ovary slowly prevented the ovary from slipping in the abdomen while pulling it through the abdominal wall. All mares recovered in an uncomplicated fashion. Postoperative temporary subcutaneous emphysema developed in two cases and gradually resolved in 3-5 days. Mild signs of colic occurred in one mare postoperatively but resolved after administration of a single dose of flunixin meglumine (1.1 mg/kg, intravenous). Incisional cosmesis was considered good (Fig. 12A). In a repeated laparoscopic examination, no visible complications or adhesions related to laparoscopic ovariectomy were observed in all mares (Fig. 12B).
4. Discussion In the present investigation, the main anatomical structures of diagnostic importance that could be consistently observed in the left caudal region were the left kidney, the mesocolon of the descending colon, the left portion of reproductive tract and its supporting structures, the urinary bladder, the left lateral ligament of the bladder, the pelvic inlet, the area of prepubic tendon attachment, the caudal edge of the spleen, random segments of the jejunum and of the descending and ascending colons, the left vaginal ring, and the lateral abdominal wall. In the present study, standing laparoscopy was generally performed using sedation and local infiltration in the
Fig. 12. Incisional cosmesis 7 days after surgery. (A) Appearance of the ovarian pedicle 7 days postoperatively during laparoscopic examination. (B) Ovarian pedicle (blue arrow), remnants of oviduct (green arrow), and uterine horn (UH).
921
flank at the portal sites and in the mesovarium. This was sufficient to control pain and did not require any repeated doses during surgery and avoided the risk and expense of general anesthesia while providing easier access to the ovaries because of the location of the reproductive anatomy [10,22]. The left flank was recommended to avoid cecum penetration by right flank approach [26,36]. Our findings suggested that an open technique for initial cannula insertion with no prior abdominal insufflation for laparoscopy was effective in all cases, without any complications [11,14,20]. In the present investigation, presurgical fasting was mandatory before any laparoscopic procedure [18,26]. Concerns and limitations associated with laparoscopic techniques include the necessity and cost of specialized equipment and technical difficulty of the procedures and requires training to conduct them and the fact that a lack of familiarity with procedures can dramatically increase operating time [10,23]. In this study, limits of the ligating loop technique included the fact that the placement of loops became increasingly difficult as the size of the ovary increased and that the equine ovary was larger in diameter than commercially available suture loops [20]. Ligature slippage occurred in one case in this study and resulted in immediate hemorrhage from three to four branches of the ovarian artery and the hemorrhage was managed immediately with additional ligating loop. Therefore, the ligating loops for normal sized ovaries are recommended [26]. In this work, disadvantages of electrocautery method were roughly 5 mm of tissue could be coagulated at one time; on average, 6 to 10 coagulation and transection cycles were required per equine ovarian pedicle. Sequential coagulation and transection were considered the ratelimiting steps of the surgical procedure. Smoke generation occurred during coagulation, impairing the surgeon’s visualization and required intermittent opening of the CO2 insufflation valve on the laparoscope cannula to improve the laparoscopic visual field. Intraoperative hemorrhage from mesovarium occurred in two cases after transection of ovarian pedicles without appropriate coagulation. Repeated coagulation was required less than three times for all ovarian pedicles [32,34]. Our findings suggested that the electroligationmodified technique appeared to be secure, safe, and effective method for hemostasis of mesovarium through application of two extracorporeal 4S modified Roeder slipping knot applied on small ovarian pedicle. Vessels in the pedicle of even a normal equine ovary are estimated to be up to 10 mm diameter and are, therefore, potentially larger in cases of enlarged ovaries [19,24,30]. The 4S modified Roeder was significantly and consistently stronger than other slipknots [30,33]. In contrast, the conventional bipolar electrosurgical forceps was limited for coagulation of vessels of 3 mm in diameter or less [32], and the vessel sealing device can be used confidently in vessels up to 7 mm only [21]. On the other hand, excessive bleeding was encountered in 50% of pedicles after using ultrasonic shears for standing laparoscopic removal of normal equine ovaries [2]. The electroligation hemostatic method avoided all causes of ligature slippage through small ovarian pedicle after creation of a window caudal to ovarian blood supply,
922
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
using monopolar and blunt dissection by Maryland forceps, proximal placement of knot, applying two knot instead one, and transection of the ovarian pedicle one cm distal to the suture ligature [31]. The electroligation-modified technique was considered technically easy and time-saving in comparison with ligating loop and electrocoagulation techniques. The electroligation-modified technique depended on 4S modified Roeder extracorporeal slipping knot that was easily tightened in every case in addition to application of a monopolar electrocautery that used in easy and fast manner to shatter, coagulate and cut the mesosalpnix, the proper ligament of the ovary and the mesovarium. The modified technique dealt with ovarian blood vessels, not the ovary itself, so it was not influenced with ovarian size as with the ligating loop technique [1]. While, the ligating loop placement was time consuming and required an exacting level of expertise especially with large ovaries, 15-18 cm in diameter, because it was difficult to control such large loop in the abdomen [26]. The modified technique was economical in comparison with recently used devices because the procedure was accomplished by two polydioxanone sutures, 150 cm in length, and monopolar electrocautery that overcame the disadvantages of bipolar electrocautery methods, which are time consuming procedures; these results agree with those described previously [30,31,34]. On the other hand, Palmer [27] used laser techniques, Hand et al. [19] used the vessel sealing device, and Alldredge et al. [2] used ultrasonic shears; these methods of hemostasis are expensive, and the blades were designed for single use. In standing equine laparoscopy, the laparoscope portal was routinely placed dorsal to the crus of the internal abdominal oblique muscle, equidistant from the tuber coxae and last rib [10]. In the present study using the vertical placement of the instrument portals provided good visibility for the ovary and the mesovarium, suitable with smaller mares with limited width of the paralumbar fossa and comfortable for positioning of cameraman and surgeon [3,32].
6. Conclusions It could be concluded that laparoscopy is a practical and effective tool for direct visual examination of internal abdominal organs. Standing laparoscopic surgery provided a valuable alternative approach for traditional reproductive surgery in mares. Laparoscopic ovariectomy using the electroligation-modified technique as a novel technique provided a secure, safe, and effective method for hemostasis of the mesovarium and was technically easy, time saving, and a more economical technique than ligating loops and electrocoagulation methods.
References [1] Al-Badrany MS. Laparoscopic ovariectomy in standing donkeys by titanium clips and monopolar electrocautery. J Anim Vet Adv 2007;6(5):663-7. [2] Alldredge JG, Hendrickson DA. Use of high-power ultrasonic shears for laparoscopic ovariectomy in mares. J Am Vet Med Assoc 2004;225:1578-80.
[3] Babkine M, Desrochers A. Laparoscopic surgery in adult cattle. Vet Clin Food Anim 2005;21:251-79. [4] Bidwell LA, Bramlage LR, Rood WA. Equine perioperative fatalities associated with general anesthesia in a private practicea retrospective case series. Vet Anaesth Analg 2007;34:23-30. [5] Boure L, Marcoux M, Laverty S. Paralumbar fossa laparoscopic ovariectomy in horses with use of endoloop ligature. Vet Surg 1997;26:478-83. [6] Boure LP, Pearce SG, Kerr CL. Evaluation of laparoscopic adhesiolysis for the treatment of experimentally induced adhesions in pony foals. Am J Vet Res 2002;63:289-94. [7] Catone G, Marino G, Mancuso R, Zanghi A. Clinicopathological features of an equine ovarian teratoma. Reprod Domest Anim 2004;39:65-9. [8] Chamness CJ. Nondisposable instrumentation for equine laparoscopy. In: Fisher AT, editor. Equine diagnostic and surgical laparoscopy. Philadelphia: WB Saunders; 2002. p. 37-49. [9] Colbern GT. Ovariectomy. In: Mckinnon AO, Voss JL, editors. Equine reproduction. Philadelphia: Lea & Febiger; 1993. p. 450-5. [10] Dechant JE, Hendrickson DA. Standing female equine urogenital endoscopic surgery. Vet Clin North Am Equine Pract 2000;16:301-15. [11] Desmaizieres LM, Martinot S, Lepage OM, Bareiss E, Cadore JL. Complications associated with cannula insertion techniques used for laparoscopy in standing horses. Vet Surg 2003;32:501-6. [12] Doran R, Allen D, Gordon B. Use of stapling instruments to aid in the removal of ovarian tumors in mares. Equine Vet J 1988;20:37-40. [13] Farstvedt E, Hendrickson DA. Intraoperative pain responses following intraovarian versus mesovarian injection of lidocaine in mares undergoing laparoscopic ovariectomy. J Am Vet Med Assoc 2005;227:593-6. [14] Fischer AT. Standing laparoscopic surgery. Vet Clin North Am Equine Pract 1991;7:641-7. [15] Freeman LG. Operating room set up, equipment, and instrumentation. In: Veterinary endosurgery. St. Louis: Mosby; 1999. p. 3e23. [16] Fulton IC, Brown CM, Yamini B. Adenocarcinoma of intestinal origin in a horse: diagnosis by abdominocentesis and laparoscopy. Equine Vet J 1990;22:447-8. [17] Galuppo LD, Snyder JR, Pascoe JR. Laparoscopic anatomy of the equine abdomen. Am J Vet Res 1995;56:518-31. [18] Galuppo LD. Laparoscopic anatomy. In: Fisher AT, editor. Equine diagnostic and surgical laparoscopy. Philadelphia: WB Saunders Company; 2002. p. 7-27. [19] Hand R, Rakestraw P, Taylor T. Evaluation of a vessel-sealing device for use in laparoscopic ovariectomy in mares. Vet Surg 2002;31:240-4. [20] Hanson CA, Galuppo LD. Bilateral laparoscopic ovariectomy in standing mares: 22 cases. Vet Surg 1999;28:106-12. [21] Harold KL, Pollinger H, Matthews BD, Kercher KW, Sing RF, Heniford BT. Comparison of ultrasonic energy, bipolar thermal energy and vascular clips for the hemostasis of small, medium and large-sized arteries. Surg Endosc 2003;17:1228-30. [22] Hendrickson DA, Wilson DG. Instrumentation and techniques for laparoscopic and thoracoscopic surgery in the horse. Vet Clin North Am Equine Pract 1996;12:235-51. [23] Hendrickson DA. Complications of laparoscopic surgery. Vet Clin Equine 2009;24:557-71. [24] Hubert JD, Burba DJ, Moore RM. Evaluation of a vessel-sealing device for laparoscopic granulose cell tumor removal in standing mares. Vet Surg 2006;35:324-9. [25] Latimer FG, Eades SC, Pettifer G, Tetens J, Hosgood G, Moore RM. Cardiopulmonary, blood and peritoneal fluid alterations associated with abdominal insufflation of carbon dioxide in standing horses. Equine Vet J 2003;35:283-90. [26] Lee M, Hendrickson DA. A review of equine standing laparoscopic ovariectomy. J Equine Vet Sci 2008;28:105-11. [27] Palmer SE. Laparoscopic ovariectomy in the standing horse. In: Fisher AT, editor. Equine diagnostic and surgical laparoscopy. Philadephia: WB Saunders; 2002. p. 189-95. [28] Palmer SE. Standing laparoscopic laser technique for ovariectomy in five mares. J Am Vet Med Assoc 1993;203:279-83. [29] Ragle CA, Southwood LL, Galuppo LD, Howlett MR. Laparoscopic diagnosis of ischemic necrosis of the descending colon after rectal prolapse and rupture of the mesocolon in two postpartum mares. J Am Vet Med Assoc 1997;210:1646-8. [30] Rocken M, Doz D, Mosel G, Seyrek-Intas K, Seyrek-Intas D, Litzke F, Verver J, Rijkenhuizen AM. unilateral and bilateral laparoscopic ovariectomy in 157 mares: a retrospective multicenter study. Veterinary Surgery 2011;40:1009-14.
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923 [31] Rodgerson DH, Belknap JK, Wilson DA. Laparoscopic ovariectomy using sequential electrocoagulation and sharp transection of the equine mesovarium. Vet Surg 2001;30:572-9. [32] Rodgerson DH, Hanson RR. Ligature slippage during standing laparoscopic ovariectomy in a mare. Can Vet J 2000;41:395-7. [33] Schettko DL, Hendrickson DA. Education and the laparoscope: uses of laparoscopy in teaching. J Equine Vet Sci 2008;28:51-3.
923
[34] Shoemaker RW, Read EK, Duke T, Wilson DG. In situ coagulation and transection of the ovarian pedicle: An alternative to laparoscopic ovariectomy in juvenile. Can J Vet Res 2004;68:27-32. [35] Silva LC, Zoppa AL, Hendrickson DA. Equine diagnostic laparoscopy. J Equine Vet Sci 2008;28:247-54. [36] Walmsley JP. Review of equine laparoscopy and an analysis of 158 laparoscopies in the horse. Equine Vet J 1999;31:456-64.
Journal of Equine Veterinary Science journal homepage: www.j-evs.com
Original Research
Laparoscopic Anatomy of the Abdomen and Laparoscopic Ligating Loops, Electrocoagulation, and a Novel Modified Electroligation Ovariectomy in Standing Mare Mohamed A.M. Alsafy a , Mahmoud H. El-Kammar b, Mostafa M. Kassem b, Samir A.A. El-Gendy a, Ahmad N. EL-Khamary c a b c
Department of Anatomy and Embryology, Faculty of Veterinary Medicine, Alexandria University, Egypt Department of Surgery, Faculty of Veterinary Medicine, Alexandria University, Egypt Department of Surgery, Faculty of Veterinary Medicine, Damanhur University, Egypt
a r t i c l e i n f o
a b s t r a c t
Article history: Received 7 November 2012 Received in revised form 25 December 2012 Accepted 10 January 2013 Available online 28 February 2013
The purpose of this study was to provide a detailed laparoscopic anatomy of the caudal abdominal region of mare in a standing position and to evaluate and modify a technique for standing laparoscopic ovariectomy using combination between hand-tied ligating loop and electrocoagulation techniques, as the ligating loops, electrocoagulation, and modified electroligation laparoscopic ovariectomy were applied using nine adult mares. Laparoscopy was practical and effective for direct visual examination of internal abdominal organs in the mare. Ventral dislocation of abdominal viscera after pneumoperitoneum was established with the mare in standing position, which provided an excellent inspection of the dorsal and ventral structures in the peritoneal cavity on the right and left sides. Standing laparoscopic ovariectomy using an electroligation modified method was considered a safe and effective method for hemostasis of the mesovarium, technically easy, time saving, and economical. The mean surgical time for bilateral ovariectomy was 40 7.63, 60 5.25, and 85 6.43 minutes for electroligationmodified technique, ligating loops technique, and electrocoagulation technique, respectively. Ó 2013 Elsevier Inc. All rights reserved.
Keywords: Laparoscopy Anatomy Abdomen Ovariectomy Mare
1. Introduction Laparoscopy is a minimally invasive technique for viewing the internal organs of the abdominal cavity. The equipment used during laparoscopy provides a live picture of the insides of the abdominal cavity [15]. Laparoscopy has many diagnostic, therapeutic, and prognostic applications [5,8,16,18,35]. Insufflation by CO2 into the peritoneal cavity to create pneumoperitoneum is a routine technique for abdominal exposure, which improves visualization and Corresponding author at: Mohamed A.M. Alsafy, Department of Anatomy and Embryology, Faculty of Veterinary Medicine, Edfina, Behera, Egypt, Postbox 22785. E-mail address: [email protected] (M.A.M. Alsafy). 0737-0806/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jevs.2013.01.007
facilitates instrumental and visceral manipulation during laparoscopic surgery [15,25]. Equine ovariectomy was performed for various reasons, mainly to prepare a mount mare for semen collection, eliminate estrous behavior and colic signs, sterilize the mare for registration purposes, and to prepare recipient mares for embryo transfer, removing pathologically abnormal ovaries [7]. Different surgical techniques have been developed to remove equine ovaries. Horses can be operated on in a standing or dorsally recumbent position. The standing technique can be performed using sedation and local anesthesia [10], whereas general anesthesia is indicated for large thecal tumor [4,20]. In standing mares, ovariectomy can be done by flank laparotomy [32]. The flank approach is favorable because visibility is improved, but it involves large abdominal
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
incisions, at least 20-30 cm long, and may result in incisional complications such as hematomas or abscesses, prolonged postoperative convalescence from several weeks to months, poor operative visibility, and difficulty in recognizing and treating hemorrhage from the mesovarium [9,32,29]. Consequently, standing laparoscopic ovariectomy has become a more common technique to remove ovaries in mares [26]. Reported advantages of laparoscopic techniques compared with ovariectomy via laparotomy include reduction of complications through full observation of the operative field, minimal invasiveness, secure hemostasis, short convalescent time, fewer postsurgical complications, and tension-free ligation of vessels in the mesovarium [9,14,30]. The main challenge with laparoscopic ovariectomy technique is finding the best way to ligate the ovarian pedicle and provide hemostasis. Therefore, numerous methods have been used for hemostasis of the mesovarium and the associated ovarian vessels, which include stapling instruments [12], laser techniques [27], ligature application [6], vascular clips, electrocoagulation [30,31], vessel sealing device [19], and ultrasonic shears [2]; these methods of hemostasis are time consuming, difficult to apply hemostatic devices, are prone to ligature slippage, smoke generation, and cost of device. 2. Materials and Methods 2.1. Animals The present study was carried out with nine adult nonpregnant apparently healthy mares weighing 250-300 kg and 7-9 years old. Six mares were used for laparoscopic anatomy evaluation first, and then all nine mares were subdivided into three groups, each group included three mares for laparoscopic ovariectomy by ligating loop, electrocautery, and electroligation techniques. 2.2. Laparoscopic Equipments and Instrumentation Standard laparoscopic instruments, cannulas, telescope, insufflator, Veress needle, and forceps (Endoservice optical instruments GmbH, Germany), Sutroon 400 Electrosurgical Generator, 5-mm spatula monopolar electrode, and 5-mm reusable bipolar electrocautery forceps was used in this study. Operating instruments were available in 45-cm length and 10-mm diameter and compatible with monopolarity (Fig. 1). 2.3. Animal Preparation Food but not water was withhold for 24-36 hours. A single dose of 3000 IU of tetanus antitoxin prophylaxis, 10,000 IU/kg Procaine penicillin G plus 10 mg of streptomycin/kg (Combi-Kel, Kela Laboratoria, Belgium), and 1.1 mg/kg non-steriodal anti-inflammatory flunixin meglumine (Finadyne, Intervet Shering-Plough Animal Health) were administered before laparoscopic procedures. Both paralumbar fossae were shaved and aseptically prepared. All mares were sedated with detomidine hydrochloride, 20 mg/L in a saline intravenous infusion [21]. Local anesthesia was achieved with 20 ml of 2% lidocaine hydrochloride (Fig. 2B and C).
913
2.4. Flank Approach in Standing Mare 2.4.1. Establishment of Pneumoperitoneum Establishment of pneumoperitoneum was provided by adequate amounts of CO2 available for the procedure. 2.4.2. Laparoscopic Anatomy of the Abdomen The abdomen of the standing mare was divided into two main regions: left caudal and right caudal. These regions were subdivided into their respective dorsal and ventral aspects [17,18]. The laparoscope was positioned in the left caudal region between the spleen and lateral body wall. The laparoscope was positioned in the right caudal region of the abdomen by withdrawing it to the caudal edge of the cecal base and then arching the tip of the laparoscope caudally toward the pelvic inlet. 2.5. Standing Laparoscopic Ovariectomy Techniques Three instrumental portals were made. The first portal was placed at the level of the base of the tubercoxae midway between the tubercoxae and the last rib. The second portal was made just cranial and 10 cm proximal to the first cannula, and the third portal was made 5-10 cm ventral to the first cannula. The laparoscope was removed from the primary portal and inserted through the second portal. Laparoscopic claw grasping forceps was inserted through one instrument portal to provide traction on the ovary when the mesovarium was infiltrated with 20 ml of 2% lidocaine solution at different places by using 16-gauge spinal needles through the abdominal wall [6,13]. 2.5.1. Ligating Loops Technique The technique was achieved in three mares. The laparoscopic claw grasping forceps was inserted through the dorsal instrumental portal to grasp the mesosalpinx and place it under tension. The laparoscopic scissors were introduced through the ventral instrumental portal to divide the mesosalpnix and oviduct (Fig. 3A). The grasping forceps were placed on the surface of the ovary to provide tension while the proper ligament was divided (Fig. 3B). A 5-mm reducer was applied on the dorsal instrumental portal through which the knot pusher containing endoloop ligature polyglactin 910 no. 2 was tied in a modified Roeder knot. The ovary was grasped with forceps through the ligature loop and then manipulated to tease the loop around the newly created ovarian pedicle (Fig. 3C). Once the pedicle was snared, the loop was tightened by advancing the knot pusher while pulling the tail end of the ligature. The knot pusher was exchanged for scissors, and the tail of the ligature was cut and removed; this step was repeated for the second endoloop (Fig. 3D). The laparoscopic scissors was used to transect the ovarian pedicle between the ovaries and ligature (Fig. 3E). The ovarian stump was checked for bleeding (Fig. 3F) [26,28]. 2.5.2. Electrocoagulation Technique The electrocoagulation technique was achieved in three mares. The laparoscopic claw grasping forceps were inserted through the ventral instrumental portal to provide traction on the ovary. The bipolar electrosurgical instrument was inserted through the dorsal instrumental portal.
914
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
Fig. 1. Laparoscopic equipments and instrumentation. (A) Laparoscopic tower from top to bottom; video monitor, camera control unit, xenon light source, insufflator, suction and irrigation machine. (B) Optical system. (B1) Zero degree laparoscope. (B2) Light cable. (B3) Video camera. (C1) Disposable drapes. (C2) from left, 11-mm disposal cannula, 11-mm reusable cannula, 11-mm reusable cannula with clip on reducer and blunt tip trocar. (C3, from left) Debocaine 2% (lidocaine hydrochloride 2%) and Detomo Vet (detomidine hydrochloride 10 mg̸ ml) sedative drug. (C4) Two ampules of 1 polydioxanone (PDS) suture. (C5, from top) Laparoscopic scissors, claw grasping forceps, Maryland forces, insert of Babcock forceps, knot pusher, hook and spatula monopolar electrode and bipolar.
The bipolar forceps were placed across the cranial aspect of the mesovarium, approximately 1 cm proximal to the ovary (Fig. 4A). The cranial mesovarium was coagulated until blanching and shrinkage. The laparoscopic claw grasping forceps were removed, and the laparoscopic scissors were inserted through the ventral instrumental portal to transect the mesovarium distal to the coagulated site (Fig. 4B and C). Coagulation and transection were repeated sequentially in a caudal direction until the ovary was suspended only by the tubal membrane, oviduct, and proper ligament of the ovary. The bipolar electrosurgical instrument was replaced with the monopolar electrosurgical instrument to transect the remaining tubal membrane, oviduct and proper ligament of the ovary while the laparoscopic claw grasping forceps was used to grasp the ovary (Fig. 4D). The bipolar electrosurgical instrument was inserted through the dorsal instrumental portal to control any point of hemorrhage (Fig. 4E and F) [31]. 2.5.3. Modified Electroligation Technique The laparoscopic Babcock grasping forceps was inserted through the ventral instrumental portal to provide traction on the mesovarium. A monopolar hook electrode was inserted through the dorsal instrumental portal to create
a window in the mesovarium just caudal to ovarian blood vessels, which were identified from the medial aspect of mesovarium (Fig. 5B-E). Two extracorporeal 4S modified Roeder knots of 1 polydioxanone (Demetech Corp) was applied to the ovarian pedicle through the dorsal instrumental portal by using Maryland forceps and a knot pusher (Figs. 6, 7A and B). A third extracorporeal loop ligature was secured to the ovary before complete division of the ovarian pedicle. A monopolar spatula electrode was inserted through the dorsal instrumental portal to coagulate and transect the tubal membrane, oviduct, and proper ligament of the ovary from the ventral margin toward the dorsal aspect (Fig. 7C). The ovarian pedicle was sharply sectioned using laparoscopic spatula leaving two knots on the ovarian pedicle and one on the transected ovary while the laparoscopic claw grasping forceps used to grasp the ovary. Exteriorizing the ovary from the abdominal cavity was accomplished by widening the ventral portal in case of small ovary or by connecting the two ventral incisions to create a single skin incision approximately 5-10 cm in length in case of large ovary. The subcutaneous tissues and external abdominal oblique muscle fibers were sharply dissected, and the internal and transverse abdominal oblique muscles were separated along the axis of their
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
915
Fig. 2. Routine laparoscopic examination in standing mare. (A) Sedation of standing mare with intravenous infusion (yellow arrow) of detomidine HCl. (B) Local infiltration analgesia of laparoscopic portal site with lidocaine HCl. (C) Location o first laparoscopic port (green circle) at the level of the base of tubercoxae, midway between the tubercoxae (yellow points) and the Last rib (red points). (D) The 10-12 mm stab incision of skin and external abdominal oblique muscle. (E) Advancing of 11-mm diameter, 15 cm long cannula with a blunt trocar through the abdominal wall in the direction of the opposite stiffle joint. (F) Replacement of the trocar by laparoscope to confirm intra-abdominal position.
fibers to create a small grid incision in the abdominal cavity. The laparoscopic grasping forceps was used to draw the ovary carefully through the body wall. When the ovary was presented to the skin surface, two Allis tissue forceps were used to grasp the ovary to provide additional security for
extraction of the ovary through the body wall (Fig. 8E). Large follicles were aspirated to reduce the size of the ovary to facilitate removal through the small incision. The second ovary was removed by performing the same procedure through the opposite flank. Only the skin was closed using
Fig. 3. Laparoscopic ovariectomy using ligation loop technique. (A) Section of the uterine tube (UT) and mesosalpnix (MS). (B) Section of the proper ovarian ligament (PL). Note cut edges of the uterine tube and mesosalpnix. (C and D) Application of the first pretied loop (yellow arrow) around newly created ovarian pedicle. (E) Transection of ovarian pedicle between the ovary (OV) and ligature (red arrow) with laparoscopic scissors (S). (F) Showing transected ovarian stump (green arrow) after amputation of right ovary. Note no hemorrhage from ovarian stump. MA, Maryland forceps. KP, knot pusher. RL, round ligament of the uterus. CL, claw grasping forceps.
916
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
Fig. 4. Laparoscopic ovariectomy using electrocoagulation technique. (AeC) Multiple coagulation and transaction cycle is created in a caudal direction until the ovary is only suspended by tubal membrane, oviduct and proper ligament of the ovary. (D and E) Coagulation and transaction of the remaining mesosalpnix (MS). Uterine tube (UT) and proper ligament of the ovary using spatula monopolar electrode (SP). (E) Application bipolar forceps (BF) to control any point of bleeding. (F) Coagulated mesovarium after laparoscopic ovariectomy (yellow arrow). S, saparoscopic scissors. M, mesentery of the descending colon.
small incisions and 0 nylon in a cruciate pattern. The external abdominal oblique muscle and fascia were closed in the single enlarged incision using 0 polyglactin 910 (Unicryl, Unimed, Kingdom of Saudi Arabia) in a simple continuous pattern and 0 nylon in the skin in simple
interrupted pattern (Fig. 8F). Operative time, hemorrhage and method of hemostasis as well as complications during and after surgery were recorded. Operative time was defined as the time from the skin incision till completion of skin closure.
Fig. 5. Laparoscopic ovariectomy using electroligation technique (step1). (A) Vertical arrangement of the laparoscopic port in the left flank. (A1) dorsal laparoscopic port. (A2) middle instrumental port for monopolar electrode and (A3) ventral instrument for grasping forceps. Note front position of laparoscopic tower on the other side of the horse (green arrow). (B) Infiltration of the mesovarium (MO) at different place with 20 ml of lidocaine HCl, using 16-gauge/20-cm anesthetic needle (AN). (CeE) Creating the window in the mesovarium just caudal to ovarian blood vessels (yellow arrow) by hook monopolar electrode (H). OV, ovary. BC, Babcock grasping forceps. UT, uterine tube and (blue arrow) newly created window.
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
917
Fig. 6. Laparoscopic ovariectomy using electroligation technique (step 2). (AeF) Application of the first extracorporeal 4S modified Roeder knot around the newly created ovarian pedicle (OP), through the second instrumental portal (red arrow), using knot pusher (KP). BC, Babcock grasping forceps. MO, mesovarium. OV, ovary. UT, uterine tube. S, laparoscopic scissors. M, mesentery of the descending colon. Blue arrow, first 4S modified Roeder knot.
3. Results 3.1. Laparoscopic Anatomy Laparoscopy provided a comprehensive description of the normal anatomy of the caudal region of abdomen in standing mares. Flank access provided adequate visualization of the most abdominal structures. The ventral dislocation of abdominal viscera after pneumoperitoneum with the mare in standing position provided an excellent inspection of the dorsally and ventrally situated structures in the peritoneal cavity and on the right and left sides of the dorsal aspects of the abdomen. 3.1.1. Left Caudodorsal Region The mesorectum and rectum were occasionally identified in this region, but they were more consistently seen in the right caudodorsal region (Fig. 9). The left kidney was visualized retroperitoneally dorsal and axial to the spleen (Fig. 9A). Caudal and medial to the left kidney, the mesocolon of the descending colon and mesojejunum was observed and obscured direct visualization of the right abdomen. Mesocolon was seen originating cranially from the left side of the root of the mesentery at the junction of the duodenocolic ligament to extend caudally toward the pelvic inlet (Fig. 9A). The mesovarium and mesometrium were identified with the left ovary and the left uterine horn lateral to the mesocolon and caudal to the kidney. The round ligament of the uterus was seen from the lateral portion of the broad ligament to the dorsolateral uterine body (Fig. 9B). The ovarian and uterine vascular anatomy were not identified. The urinary bladder was consistently visualized extending cranially from the floor of the pelvic cavity, lying caudal and ventral to the uterine body. The lateral ligament of the
bladder was seen craniodorsal to the pelvic inlet. The prepubic tendon, body of the uterus and cervix were seen within the pelvic cavity with the empty bladder. 3.1.2. Left Caudoventral Region The examination was enhanced by catheterizing and emptying the urinary bladder. The ventral edge of the spleen was observed by directing the tip of the laparoscope directly ventral to its insertion site (Fig. 9C). Random intestinal segments were observed medial and caudal to the spleen and lateral to the mesocolon of the descending colon. The jejunum was identified by its smooth serosal surface, its lack of tenia and its propensity to have increased peristaltic activity compared to the descending and ascending colons. The descending colon was identified by its characteristic deep sacculations and antimesentric band and the presence of fecal matters within its lumen (Fig. 9D). The left dorsal colon and pelvic flexure were identified by their size sacculations and by the presence or lack of anti mesenteric bands (Fig. 9E). The caudal aspect of the transverse fascia and the rectus abdominal muscle were seen as they converged to form the vaginal ring. The pudendoepigastric vessels were seen entering the vaginal ring (Fig. 9F). Branches of the caudal mesenteric and cranial rectal arteries were identified within the descending mesocolon extending from the dorsal abdominal wall to the mesenteric border of the descending colon (Fig. 9D). The lateral ligament of the bladder was identified extending from the dorsolateral aspect of the pelvic inlet to the apex of the bladder (Fig. 9F). 3.1.3. Right Caudodorsal Region The ventral surface of the right kidney was identified retroperitoneally more readily when there was less
918
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
Fig. 7. Laparoscopic ovariectomy using electroligation technique (step 3). (A and B) Application of the second extracorporeal 4S modified Roeder knot (green arrow) around newly ovarian pedicle using Maryland forceps (MA) and knot pusher (KP). (C) Coagulation and transection of uterine tube (UT), mesosalpnix (MS), and proper ligament of the ovary (PL) from the ventral margin toward the dorsal aspect using spatula monopolar electrode (SP). (D) Application of the third extracorporeal 4S modified Roeder knot (red arrow), which acts as a good guide in case dropping of the ovary in the abdomen occurs and as good prevention of retrograde hemorrhage from ovary (OV). UH, uterine horn and (blue arrow) first knot.
perirenal fat (Fig. 10A). The mesocolon of the descending colon was seen and continued caudally toward the pelvic canal. Caudal to the base of the cecum, the right ovary
was observed suspended from the dorsal abdominal wall by the mesovarium (Fig. 10C). The mesovarium extended cranially toward the caudal pole of the right kidney.
Fig. 8. Laparoscopic ovariectomy using electroligation technique (step 4). (A-D) Section of ovarian pedicle using spatula monopolar electrode (SP) between second loop (green arrow). CL, laparoscopic claw grasping forceps was used to grasp the ovary. Note no hemorrhage from ovarian stump (ST), and third loop (yellow arrow) acts as a tether. (E) Extraction of ovary through ventral skin incision (back arrow) using two Allis tissue forceps. (F) Ports closure in interrupted manner using 0 nylon.
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
919
Fig. 9. Laparoscopic images of the left caudal region of the abdomen of standing mare. (A and B) laparoscopic images as viewed with the laparoscope located in the dorsal aspect of the left caudal region of the abdomen. (C-F) laparoscopic images as viewed with the laparoscope located in the ventral aspect of the left caudal region of the abdomen. SPL, spleen. RS, renosplenic ligament. LK, left kidney. (M, Mesocolon of descending colon. MO, mesovarium. OV, left ovary. MO, mesovarium. UT, Uterine tube. MM, mesometrium. UH, uterine horn. RL, round ligament of uterus. DEC, descending colon. UB, urinary bladder. VSPL, ventral edge of spleen. J, jejunum. LDC, left dorsal colon. LVC, left ventral colon. AMC, ascending mesocolon. P, pudendoepigastric vessels. T, transverse fascia. I, internal abdominal muscle. PT, prepubic tendon. Green arrow, lateral bladder ligament. Black arrow, vaginal ring. MA, Maryland forceps.
3.1.4. Right Caudoventral Region The base of the cecum was identified by its characteristic ventral band and sacculations and was observed extending ventrally from the dorsal abdominal wall (Fig. 10E). A greater proportion of jejunum and a lesser proportion of descending colon were visible in the right caudoventral region compared with that in the left caudoventral region (Fig. 10E). The pelvic flexure of the ascending colon was observed caudal to the base of the cecum and adjacent to the right lateral abdominal wall (Fig. 10F). The vaginal ring of all cases was easily seen when food was withhold for 36 hours. The urinary bladder and the cranial aspect of the pubis were equally visualized (Fig. 10F). 3.2. Laparoscopic Ovariectomy 3.2.1. Ligating Loop Technique Ligating loop technique was technically difficult in two cases. Excised ovaries ranged from 8-12 mm in diameter and 4-6 mm in thickness. Ligature slippage occurred in one case and resulted in immediate hemorrhage from three to four branches of the ovarian artery. Hemorrhage was managed immediately with additional ligating loop (Fig. 11A-C). 3.2.2. Electrocautery Technique In electrocautery technique, the sequential coagulation and transection were considered the rate-limiting step of the surgical procedure. Coagulation of tissue at one time was roughly 5 mm; on average, 6-10 coagulation and transection cycles were required per equine ovarian
pedicle. Smoke generation occurred during the coagulation and impaired the surgeon’s visualization and required intermittent opening of the CO2 insufflation valve on the laparoscope cannula to improve the laparoscopic visual field. Intraoperative hemorrhage from mesovarium occurred in two cases after transection of ovarian pedicles without appropriate coagulation. Three times of coagulation was required for hemostasis of ovarian pedicles (Fig. 11D-F). Intraoperative hemorrhage from the mesovarium obscured envisioning the operative site. 3.2.3. Electroligation Modified Method Standing laparoscopic ovariectomy using the electroligation-modified method was considered a secure, safe, and effective method for hemostasis of the mesovarium and technically easy, time saving, and economical. The mean surgical times for bilateral ovariectomy were 40 7.63, 60 5.25, and 85 6.43 minutes for electroligation modified technique, ligating loops technique, and electrocoagulation technique, respectively. Ligation of the mesovarium with 4S modified Roeder extracorporeal knot was considered technically easy, reliable, and efficient to avoid hemorrhage and prevented reverse slippage in all cases. Creation of a window in the mesovarium caudal to the ovarian blood vessels allowed secure loop fixation. Using a monopolar electrocautery to shatter, coagulate, and cut the mesosalpinx, the proper ligament of the ovary and the mesovarium approximately 1 cm distal to the ligature appeared effective for hemostasis, easily accomplished and reduced time-consuming coagulation of the mesovarium superfluous.
920
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
Fig. 10. Laparoscopic images of the right caudal region of the abdomen of standing mare. (A-D) laparoscopic images as viewed with the laparoscope located in the dorsal aspect of the right caudal region of the abdomen. (E and F) laparoscopic images as viewed with the laparoscope located in the ventral aspect of the right caudal region of the abdomen. RK, right kidney. MD, mesoduodenum. D, duodenum. HR, hepatorenal ligament. rTL, right triangular ligament. R, Right lobe of the liver. C, Caudate process of liver. M, mesocolon of descending colon. J, jejunum. CD, caudal duodenal flexure. CC, base of the cecum black arrow, ventral cecal band. OV, right ovary. MS, mesosalpnix. UT, uterine tube. UH, uterine horn. DEC, descending colon. R, rectum. RAC, right dorsal colon. UB, urinary bladder. U, uterus. PF, pelvic flexure of ascending colon. P, pudendoepigastric vessels. MA, Maryland forceps.
Electrocoagulation was tolerated very well by the mares, and mild smoke accumulation and image interference hardly complicated the procedure. Opening the CO2
valve on the laparoscopic cannula helped decrease the smoke accumulation within the visual field. The third extracorporeal loop ligature that was secured to the ovary
Fig. 11. Intraoperative hemorrhage from transected ovarian stump as a complication of ligating loop and electrocautery laparoscopic ovariectomy techniques and method of hemostasis. (A-C) Intraoperative hemorrhage from transected ovarian stump (ST) and hemostasis by application of additional ligating loop in ligating loop technique. MA, Maryland forceps. KP, knot pusher and (green arrow) pretied loop. (D-F) intraoperative hemorrhage from ovarian blood vessels and hemorrhage control by grasping the cut end of the vessels with bipolar forceps (BF) and then cauterizing the vessels. MO, mesovarium.
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
before complete division of the ovarian pedicle appeared effective to prevent retrograde hemorrhage from ovary and as a good guide in case of dropping ovary in the abdomen which occurred in two cases. Applying a pair of Allis tissue forceps and exteriorizing the ovary slowly prevented the ovary from slipping in the abdomen while pulling it through the abdominal wall. All mares recovered in an uncomplicated fashion. Postoperative temporary subcutaneous emphysema developed in two cases and gradually resolved in 3-5 days. Mild signs of colic occurred in one mare postoperatively but resolved after administration of a single dose of flunixin meglumine (1.1 mg/kg, intravenous). Incisional cosmesis was considered good (Fig. 12A). In a repeated laparoscopic examination, no visible complications or adhesions related to laparoscopic ovariectomy were observed in all mares (Fig. 12B).
4. Discussion In the present investigation, the main anatomical structures of diagnostic importance that could be consistently observed in the left caudal region were the left kidney, the mesocolon of the descending colon, the left portion of reproductive tract and its supporting structures, the urinary bladder, the left lateral ligament of the bladder, the pelvic inlet, the area of prepubic tendon attachment, the caudal edge of the spleen, random segments of the jejunum and of the descending and ascending colons, the left vaginal ring, and the lateral abdominal wall. In the present study, standing laparoscopy was generally performed using sedation and local infiltration in the
Fig. 12. Incisional cosmesis 7 days after surgery. (A) Appearance of the ovarian pedicle 7 days postoperatively during laparoscopic examination. (B) Ovarian pedicle (blue arrow), remnants of oviduct (green arrow), and uterine horn (UH).
921
flank at the portal sites and in the mesovarium. This was sufficient to control pain and did not require any repeated doses during surgery and avoided the risk and expense of general anesthesia while providing easier access to the ovaries because of the location of the reproductive anatomy [10,22]. The left flank was recommended to avoid cecum penetration by right flank approach [26,36]. Our findings suggested that an open technique for initial cannula insertion with no prior abdominal insufflation for laparoscopy was effective in all cases, without any complications [11,14,20]. In the present investigation, presurgical fasting was mandatory before any laparoscopic procedure [18,26]. Concerns and limitations associated with laparoscopic techniques include the necessity and cost of specialized equipment and technical difficulty of the procedures and requires training to conduct them and the fact that a lack of familiarity with procedures can dramatically increase operating time [10,23]. In this study, limits of the ligating loop technique included the fact that the placement of loops became increasingly difficult as the size of the ovary increased and that the equine ovary was larger in diameter than commercially available suture loops [20]. Ligature slippage occurred in one case in this study and resulted in immediate hemorrhage from three to four branches of the ovarian artery and the hemorrhage was managed immediately with additional ligating loop. Therefore, the ligating loops for normal sized ovaries are recommended [26]. In this work, disadvantages of electrocautery method were roughly 5 mm of tissue could be coagulated at one time; on average, 6 to 10 coagulation and transection cycles were required per equine ovarian pedicle. Sequential coagulation and transection were considered the ratelimiting steps of the surgical procedure. Smoke generation occurred during coagulation, impairing the surgeon’s visualization and required intermittent opening of the CO2 insufflation valve on the laparoscope cannula to improve the laparoscopic visual field. Intraoperative hemorrhage from mesovarium occurred in two cases after transection of ovarian pedicles without appropriate coagulation. Repeated coagulation was required less than three times for all ovarian pedicles [32,34]. Our findings suggested that the electroligationmodified technique appeared to be secure, safe, and effective method for hemostasis of mesovarium through application of two extracorporeal 4S modified Roeder slipping knot applied on small ovarian pedicle. Vessels in the pedicle of even a normal equine ovary are estimated to be up to 10 mm diameter and are, therefore, potentially larger in cases of enlarged ovaries [19,24,30]. The 4S modified Roeder was significantly and consistently stronger than other slipknots [30,33]. In contrast, the conventional bipolar electrosurgical forceps was limited for coagulation of vessels of 3 mm in diameter or less [32], and the vessel sealing device can be used confidently in vessels up to 7 mm only [21]. On the other hand, excessive bleeding was encountered in 50% of pedicles after using ultrasonic shears for standing laparoscopic removal of normal equine ovaries [2]. The electroligation hemostatic method avoided all causes of ligature slippage through small ovarian pedicle after creation of a window caudal to ovarian blood supply,
922
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923
using monopolar and blunt dissection by Maryland forceps, proximal placement of knot, applying two knot instead one, and transection of the ovarian pedicle one cm distal to the suture ligature [31]. The electroligation-modified technique was considered technically easy and time-saving in comparison with ligating loop and electrocoagulation techniques. The electroligation-modified technique depended on 4S modified Roeder extracorporeal slipping knot that was easily tightened in every case in addition to application of a monopolar electrocautery that used in easy and fast manner to shatter, coagulate and cut the mesosalpnix, the proper ligament of the ovary and the mesovarium. The modified technique dealt with ovarian blood vessels, not the ovary itself, so it was not influenced with ovarian size as with the ligating loop technique [1]. While, the ligating loop placement was time consuming and required an exacting level of expertise especially with large ovaries, 15-18 cm in diameter, because it was difficult to control such large loop in the abdomen [26]. The modified technique was economical in comparison with recently used devices because the procedure was accomplished by two polydioxanone sutures, 150 cm in length, and monopolar electrocautery that overcame the disadvantages of bipolar electrocautery methods, which are time consuming procedures; these results agree with those described previously [30,31,34]. On the other hand, Palmer [27] used laser techniques, Hand et al. [19] used the vessel sealing device, and Alldredge et al. [2] used ultrasonic shears; these methods of hemostasis are expensive, and the blades were designed for single use. In standing equine laparoscopy, the laparoscope portal was routinely placed dorsal to the crus of the internal abdominal oblique muscle, equidistant from the tuber coxae and last rib [10]. In the present study using the vertical placement of the instrument portals provided good visibility for the ovary and the mesovarium, suitable with smaller mares with limited width of the paralumbar fossa and comfortable for positioning of cameraman and surgeon [3,32].
6. Conclusions It could be concluded that laparoscopy is a practical and effective tool for direct visual examination of internal abdominal organs. Standing laparoscopic surgery provided a valuable alternative approach for traditional reproductive surgery in mares. Laparoscopic ovariectomy using the electroligation-modified technique as a novel technique provided a secure, safe, and effective method for hemostasis of the mesovarium and was technically easy, time saving, and a more economical technique than ligating loops and electrocoagulation methods.
References [1] Al-Badrany MS. Laparoscopic ovariectomy in standing donkeys by titanium clips and monopolar electrocautery. J Anim Vet Adv 2007;6(5):663-7. [2] Alldredge JG, Hendrickson DA. Use of high-power ultrasonic shears for laparoscopic ovariectomy in mares. J Am Vet Med Assoc 2004;225:1578-80.
[3] Babkine M, Desrochers A. Laparoscopic surgery in adult cattle. Vet Clin Food Anim 2005;21:251-79. [4] Bidwell LA, Bramlage LR, Rood WA. Equine perioperative fatalities associated with general anesthesia in a private practicea retrospective case series. Vet Anaesth Analg 2007;34:23-30. [5] Boure L, Marcoux M, Laverty S. Paralumbar fossa laparoscopic ovariectomy in horses with use of endoloop ligature. Vet Surg 1997;26:478-83. [6] Boure LP, Pearce SG, Kerr CL. Evaluation of laparoscopic adhesiolysis for the treatment of experimentally induced adhesions in pony foals. Am J Vet Res 2002;63:289-94. [7] Catone G, Marino G, Mancuso R, Zanghi A. Clinicopathological features of an equine ovarian teratoma. Reprod Domest Anim 2004;39:65-9. [8] Chamness CJ. Nondisposable instrumentation for equine laparoscopy. In: Fisher AT, editor. Equine diagnostic and surgical laparoscopy. Philadelphia: WB Saunders; 2002. p. 37-49. [9] Colbern GT. Ovariectomy. In: Mckinnon AO, Voss JL, editors. Equine reproduction. Philadelphia: Lea & Febiger; 1993. p. 450-5. [10] Dechant JE, Hendrickson DA. Standing female equine urogenital endoscopic surgery. Vet Clin North Am Equine Pract 2000;16:301-15. [11] Desmaizieres LM, Martinot S, Lepage OM, Bareiss E, Cadore JL. Complications associated with cannula insertion techniques used for laparoscopy in standing horses. Vet Surg 2003;32:501-6. [12] Doran R, Allen D, Gordon B. Use of stapling instruments to aid in the removal of ovarian tumors in mares. Equine Vet J 1988;20:37-40. [13] Farstvedt E, Hendrickson DA. Intraoperative pain responses following intraovarian versus mesovarian injection of lidocaine in mares undergoing laparoscopic ovariectomy. J Am Vet Med Assoc 2005;227:593-6. [14] Fischer AT. Standing laparoscopic surgery. Vet Clin North Am Equine Pract 1991;7:641-7. [15] Freeman LG. Operating room set up, equipment, and instrumentation. In: Veterinary endosurgery. St. Louis: Mosby; 1999. p. 3e23. [16] Fulton IC, Brown CM, Yamini B. Adenocarcinoma of intestinal origin in a horse: diagnosis by abdominocentesis and laparoscopy. Equine Vet J 1990;22:447-8. [17] Galuppo LD, Snyder JR, Pascoe JR. Laparoscopic anatomy of the equine abdomen. Am J Vet Res 1995;56:518-31. [18] Galuppo LD. Laparoscopic anatomy. In: Fisher AT, editor. Equine diagnostic and surgical laparoscopy. Philadelphia: WB Saunders Company; 2002. p. 7-27. [19] Hand R, Rakestraw P, Taylor T. Evaluation of a vessel-sealing device for use in laparoscopic ovariectomy in mares. Vet Surg 2002;31:240-4. [20] Hanson CA, Galuppo LD. Bilateral laparoscopic ovariectomy in standing mares: 22 cases. Vet Surg 1999;28:106-12. [21] Harold KL, Pollinger H, Matthews BD, Kercher KW, Sing RF, Heniford BT. Comparison of ultrasonic energy, bipolar thermal energy and vascular clips for the hemostasis of small, medium and large-sized arteries. Surg Endosc 2003;17:1228-30. [22] Hendrickson DA, Wilson DG. Instrumentation and techniques for laparoscopic and thoracoscopic surgery in the horse. Vet Clin North Am Equine Pract 1996;12:235-51. [23] Hendrickson DA. Complications of laparoscopic surgery. Vet Clin Equine 2009;24:557-71. [24] Hubert JD, Burba DJ, Moore RM. Evaluation of a vessel-sealing device for laparoscopic granulose cell tumor removal in standing mares. Vet Surg 2006;35:324-9. [25] Latimer FG, Eades SC, Pettifer G, Tetens J, Hosgood G, Moore RM. Cardiopulmonary, blood and peritoneal fluid alterations associated with abdominal insufflation of carbon dioxide in standing horses. Equine Vet J 2003;35:283-90. [26] Lee M, Hendrickson DA. A review of equine standing laparoscopic ovariectomy. J Equine Vet Sci 2008;28:105-11. [27] Palmer SE. Laparoscopic ovariectomy in the standing horse. In: Fisher AT, editor. Equine diagnostic and surgical laparoscopy. Philadephia: WB Saunders; 2002. p. 189-95. [28] Palmer SE. Standing laparoscopic laser technique for ovariectomy in five mares. J Am Vet Med Assoc 1993;203:279-83. [29] Ragle CA, Southwood LL, Galuppo LD, Howlett MR. Laparoscopic diagnosis of ischemic necrosis of the descending colon after rectal prolapse and rupture of the mesocolon in two postpartum mares. J Am Vet Med Assoc 1997;210:1646-8. [30] Rocken M, Doz D, Mosel G, Seyrek-Intas K, Seyrek-Intas D, Litzke F, Verver J, Rijkenhuizen AM. unilateral and bilateral laparoscopic ovariectomy in 157 mares: a retrospective multicenter study. Veterinary Surgery 2011;40:1009-14.
M.A.M. Alsafy et al. / Journal of Equine Veterinary Science 33 (2013) 912-923 [31] Rodgerson DH, Belknap JK, Wilson DA. Laparoscopic ovariectomy using sequential electrocoagulation and sharp transection of the equine mesovarium. Vet Surg 2001;30:572-9. [32] Rodgerson DH, Hanson RR. Ligature slippage during standing laparoscopic ovariectomy in a mare. Can Vet J 2000;41:395-7. [33] Schettko DL, Hendrickson DA. Education and the laparoscope: uses of laparoscopy in teaching. J Equine Vet Sci 2008;28:51-3.
923
[34] Shoemaker RW, Read EK, Duke T, Wilson DG. In situ coagulation and transection of the ovarian pedicle: An alternative to laparoscopic ovariectomy in juvenile. Can J Vet Res 2004;68:27-32. [35] Silva LC, Zoppa AL, Hendrickson DA. Equine diagnostic laparoscopy. J Equine Vet Sci 2008;28:247-54. [36] Walmsley JP. Review of equine laparoscopy and an analysis of 158 laparoscopies in the horse. Equine Vet J 1999;31:456-64.