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Laparoscopic ovariectomy in standing donkeys by using a new instrument
Animal Reproduction Science 107 (2008) 107–114
Laparoscopic ovariectomy in standing donkeys by using a new instrument D.M. Aziz ∗ , M.S. Al-Badrany, M.B. Taha Department of Surgery and Obstetrics, College of Veterinary Medicine, University of Mosul, Mosul, Iraq Received 2 April 2007; received in revised form 21 May 2007; accepted 1 June 2007 Available online 15 June 2007
Abstract Bilateral laparoscopic ovariectomy was performed in six female donkeys. Laparoscopic ovariectomy was performed in standing position by using a new laparoscopic instrument which was developed by the authors. We used the instrument for isolation, coagulation and cutting of mesovarium. One laparoscope portal and two instrument portals were located in each paralumbar fossa. The ovary was removed through an enlarged second portal. The contralateral ovary was removed through the opposite paralumbar fossa. Hemostasis, coagulation and cutting of the mesovarium were achieved successfully using the new laparoscopic instrument. The time required for removal of each ovary was between 2 and 4 min (average 2.8 min). While the total time of unilateral ovariectomy was between 10 and 15 min (average 12 min). No additional ligature was required in all operations. There was no complication, hemorrhage or oozing of blood from the mesovarium during or after the operations. In conclusion, laparoscopic ovariectomy in donkeys by using this new instrument was safe and effective. The new instrument reduced the time of operation and provided a viable hemostasis and coagulation for blood vessels within the mesovarium. Also cutting of the mesovarium was very easy. © 2007 Elsevier B.V. All rights reserved. Keywords: Ovariectomy; Standing donkey; Laparoscopy; New instrument
1. Introduction Ovariectomy is a surgical procedure performed to remove one or both ovaries. In the equine, bilateral ovariectomy is done as an elective surgery used to prevent estrus associated behaviour, manage colic associated with estrus and to prevent pregnancy (Trotter and Embertson, 1992; ∗ Corresponding author at: Department of Surgery and Obstetrics, College of Veterinary Medicine, University of Mosul, P.O. Box 11141, Mosul, Iraq. Tel.: +964 770 209 3321. E-mail address: [email protected] (D.M. Aziz).
0378-4320/$ – see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.anireprosci.2007.06.011
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Hooper et al., 1993). It is also done to remove the ovaries in some pathologic conditions such as ovarian hematoma, teratoma and granulosa cell tumor (Carson-Dunkerley and Hanson, 1997; Palmer, 2002; Catone et al., 2004). Various methods can be used for ovariectomy; these include colpotomy (Colbern and Reagan, 1987), ventral midline approaches (Ragle, 2002), paramedian approaches (Moll et al., 1987), and laparoscopic techniques (Hanson and Galuppo, 1999; Rodgerson et al., 2001). Laparoscopic ovariectomy provides good visualization of the ovary and mesovarium and allows tensionless manipulation of the mesovarium during pedicle transection, visual assessment of hemostasis and smaller body wall incisions (Palmer, 1993; Ragle and Schneider, 1995; Boure et al., 1997; Hanson and Galuppo, 1999; Rodgerson et al., 2001). This technique has been developed for mares in the standing (Hanson and Galuppo, 1999; Rodgerson et al., 2001) and dorsal recumbent positions (Ragle and Schneider, 1995; Santschi and Troedsson, 2001). Standing laparoscopic ovariectomy has advantages over dorsal recumbent technique because it eliminates the risk of general anesthesia (Hanson and Galuppo, 1999), and it provides excellent visualization to locate and manipulate the ovaries (Boure et al., 1997; Al-Badrany, 2007). The main challenge with laparoscopic ovariectomy technique is finding the best way to ligate the ovarian pedicle and provide hemostasis. Therefore, numerous methods are used for hemostasis of the mesovarium and the associated ovarian vessels which include electrocoagulation (Rodgerson et al., 2001; Hand et al., 2002), ligature application (Boure et al., 1997), laser techniques (Palmer, 1993), stapling instruments (Doran et al., 1998), vascular clips (Rodgerson et al., 1998), ultrasonic shears (Alldredge and Hendrickson, 2004), and Harmonic Scalpel (D¨usterdieck et al., 2003). These methods of hemostasis are time consuming and have some other disadvantages, which include difficulty in applying the hemostatic devices, ligature slippage and the cost of device. The aim of the present study was to develop a bilateral ovariectomy procedure in female donkeys using a new laparoscopic instrument which has been developed by the authors. We used this instrument for isolation, coagulation and cutting of mesovarium. 2. Materials and methods 2.1. Laparoscopic equipment In addition to the standard laparoscopic instruments; cannulas, telescope, insufflator, Veress needle and forceps (Karl Storz, Germany), a new laparoscopic instrument, designed and manufactured by the authors, were used in this study. The new instrument has an outer body (metallic tube with an outer diameter of 10 mm), internal movable part with two movable arms (length of each one is 7 cm) for holding the thermal wire, a thermal wire (0.5 mm in diameter and 8 cm long), on/off switch and a source of continuous electrical current (12 V, 12 A) (Fig. 1). In the abdominal cavity, the instrument is opened by pushing its internal part toward the cavity of abdomen; the two instrument arms and the thermal wire form a loop (the major axis of loop is 10 cm, the minor axis is 5 cm, the circumference of loop is 22 cm and the area of the inside of loop is 25 cm2 ). The thermal wire was used to isolate, coagulate, and for cutting of mesovarium. 2.2. Animals Six adult female donkeys (age, 3–5 years and weight, 120–150 kg) were used in this study. The animals were donated to the Clinic of College of Veterinary Medicine, University of Mosul for
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Fig. 1. The new laparoscopic instrument. 1, Thermal wire; 2, the two movable arms (length, 7 cm) for holding of thermal wire; 3, outer body (metallic tube with an outer diameter 10 mm); 4, rubber valve to prevent gas escape; 5, internal movable part. 6, on/off switch; 7, source of continuous electrical current (12 V, 12 A).
euthanasia due to the existence of problems that did not require urgent care and were unrelated to the reproductive tract. The animals were housed together in a large paddock in the animal house of College of Veterinary Medicine, University of Mosul, and had free access to feed and water. 2.3. Presurgical preparation The animals were fasted for 12 h to reduce the volume of intestinal contents and to improve the working area within the abdomen. Both paralumbar fossae were clipped and prepared using routine aseptic technique. 2.4. Sedation and anesthesia The donkeys were sedated with xylazine hydrochloride (Pantex, Holland) (1 mg/kg, b.w., i.v.) prior to being restrained in stocks. Local anesthesia was achieved by direct infiltration of the laparoscopic portal sites with approximately 20 ml of 2% lidocaine (Laborate Pharmaceutical, India). 2.5. Surgical procedure Pneumoperitoneum was achieved by introducing the Veress needle into the abdominal cavity through a 1–1.5 cm skin incision, which was made in the paralumber fossa at the level of the tuber coxae, midway between the caudal aspect of the last rib and the tuber coxae. The presence of the needle within the abdomen was confirmed by the sound of air entering the abdomen and the loss of negative intra-abdominal pressure. The needle was then connected to the insufflator and the abdomen was insufflated to a pressure of 16 mmHg with carbon dioxide. Three instrument portals were made. The primary portal was located at the site of Veress needle, the Veress needle was removed and 10 mm trocar–cannula unit was inserted. The trocar was removed, and a 10 mm, 30◦ angle laparoscope was inserted to locate the ovary. The second portal was placed 2 cm caudal to the last rib and 7–8 cm cranioventral to the primary portal. A 1 cm
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Fig. 2. (a) Insertion of instruments to the abdominal cavity. (b and c) The developed instrument was opened, and the ovary was pulled by the Babcock forceps through the loop of this instrument. (d) The internal part of the instrument was pulled back and the two instrument arms were closed to surround the mesovarium by the thermal wire.
skin incision was performed and also 10 mm trocar–cannula unit was inserted. The skin incision for the third portal was made 7–8 cm caudoventral to the first portal and 14–15 cm ventral to the second portal, 5 mm trocar–cannula unit was inserted in this portal. The laparoscope was removed from the primary portal and inserted through the second portal. Then our new instrument was inserted through the first portal, while a laparoscopic Babcock forceps was inserted through the third portal. After insertion of instruments to the abdominal cavity, the developed instrument was opened, and the ovary was pulled by the Babcock forceps through the loop of this instrument. Thereafter, the internal part of the instrument was pulled back and the two instrument arms were closed to surround the mesovarium by the thermal wire. The thermal wire was tightened to tourniquet the mesovarium, and then the switch was turned on to begin the function of the thermal wire (Fig. 2). For coagulation of the mesovarium, numerous pulsations of power (4–5 s) were given. The mesovarium was monitored until the tissue at the site of thermal wire turned white, indicating adequate coagulation. After that, the power was given continuously for about 1 min to cut the mesovarium. The site of cutting was closely observed for any hemorrhage (Fig. 3). To remove the ovary, the thermal instrument was removed from the second portal and replaced with tissue extractor forceps. The free ovary was released from the Babcock forceps in the third portal, after it was grasped by the tissue extractor forceps in the second portal. Then, the second portal was enlarged (5–6 cm) to assist in extracting the ovary through the abdominal wall (Fig. 4). After removing of the ovary, the mesovarium was inspected again for any hemorrhage before removing of the telescope. The laparoscope was removed, and the pneumoperitoneum was relieved
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Fig. 3. (a) Start coagulation of the mesovarium by numerous pulsations of power (4–5 s). (b) The mesovarium tissue at the site of thermal wire was turned white. (c and d) Cutting the mesovarium.
by opening the valves of the cannulas. The remaining cannulas were removed also. The incisions in the abdominal wall were closed with catgut No. 0, and the skin incisions were closed with silk No. 2. The contralateral ovary was removed in a similar fashion through the opposite paralumbar fossa. 2.6. Postoperative care After operation, the animals were given penicillin–streptomycin (10,000 IU/kg penicillin and 10 mg/kg streptomycin, intramuscularly) (Combi-Kel 20 + 20, Kela Laboratoria, Belgium), daily for 4 days. The skin sutures were removed after 1 week of operation. After close observation for 24 h post surgery, the animals were clinically examined daily for 1 month. 3. Results Bilateral laparoscopic ovariectomy was performed successfully in six female donkeys in standing position through three laparoscopic portals in each paralumbar fossa. The arrangement of the laparoscopic instruments provided excellent visibility for the ovary and the mesovarium. Hemostasis, coagulation and cutting of the mesovarium were achieved with high degree of success by using the new laparoscopic instrument, whereas the time required to isolate, coagulate and cut of each ovary was between 2 and 4 min with an average of 2.8 min. The total time of unilateral ovariec-
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Fig. 4. (a) Ovary was removed. (b and c) The free ovary was released from the Babcock forceps in third portal, after it was grasped by the tissue extractor forceps in second portal. (d) The site of cutting was closely observed for hemorrhage.
tomy was between 10 and 15 min with an average of 12 min. No additional ligature was required in all operations. The removed ovaries were kidney-shaped and measured about 3.5–5.5 cm in length, 2–3.5 cm in width and 2–3 cm in thickness. There was no complication, no hemorrhage or oozing of blood from the mesovarium during or after the operations. Also, no major complication was recorded postoperatively, except a mild inflammation in the skin incision of one donkey. All animals were acting normally after 1–2 days of surgery. 4. Discussion Through our routine bilateral laparoscopic ovariectomy at the Clinic of College of Veterinary Medicine, University of Mosul, we found it is time consuming and have other problems, these include; the difficulty associated with isolating of mesovarium and applying of the hemostatic devices, bleeding, and the cost of hemostatic device. Some of these problems were reported in previous studies (Hanson and Galuppo, 1999; Rodgerson and Hanson, 2000; Alldredge and Hendrickson, 2004). Therefore, we developed a new instrument to resolve these problems. Numerous methods were used for coagulation of mesovarium which included the applications of electrocoagulation, laser techniques, ultrasonic shears and Harmonic Scalpel (Palmer, 1993; Rodgerson et al., 2001; D¨usterdieck et al., 2003; Alldredge and Hendrickson, 2004). However, in spite of the fact that these devices are working by different ways, they have a similar outcome, that is increasing of tissue temperature then forming of the coagulum. Similarly, our instrument
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increases the temperature of mesovarium tissue to induce coagulation. It depends on heat generated by electrical current in the thermal wire. Results of the present study indicate that the mesovarium was isolated quickly and easily by using our new instrument, where the arms of instrument simplified the application of the thermal wire around the mesovarium. Also, this instrument provided adequate coagulation for the mesovarium. The thermal wire act as a tourniquet for the mesovarium and its blood vessels, as the heat causes denaturing of the protein and forming the coagulum; therefore the mesovarium blood vessels were closed and coagulated by the effect of tourniquet and heat, respectively. The time that required for coagulation and cutting of each ovary was very short (2.8 ± 0.8 min) in comparison with our routine laparoscopic ovariectomy in donkeys and traditional laparoscopic ovariectomy in female donkeys and mares (Al-Badrany, 2007; Shoemaker et al., 2004). In this study, the hemostatic and coagulation device was applied on the mesovarium in one place, and there was no requirement to change the place of the thermal wire on the mesovarium, while in other laparoscopic ovariectomy (Alldredge and Hendrickson, 2004; Shoemaker et al., 2004), the surgeon must apply the hemostatic device multi times to produce adequate hemostasis and coagulation for the mesovarium. Also our new instrument achieved three functions; isolation, coagulation and cutting of the mesovarium, but in the subordinated laparoscopic ovariectomy two or more instruments were required to achieve these aims (Hanson and Galuppo, 1999; Rodgerson and Hanson, 2000; Shoemaker et al., 2004; Cokelaere et al., 2005). During the application of the electrocoagulation device, notable amount of smoke was produced; therefore, a laparoscopic smoke filtration system was developed to evacuate the smoke during the operation. In our study and in all operations, there was no smoke production during coagulation and cutting of the mesovarium. The circumference and the area of the inside of loop of the new instrument were suitable for the donkey ovaries. The size of removed ovaries was relatively smaller (about half) in comparison with that of the mare ovaries. However, the instrument can be modified to be suitable for larger ovaries by increasing the loop circumference and area, and this can be done by increasing the length of thermal wire and the two arms of the instrument. Further, the procedure can be modified to be suitable for closing the larger blood vessels within the mesovarium by increasing the time of coagulation. These modifications can be validated in future studies. Finally, the usage of the new instrument for ovariectomy was economically in comparison with recently used devices (D¨usterdieck et al., 2003; Alldredge and Hendrickson, 2004). This is because the instrument was produced from cheap and simple materials, and no high technology was necessary for its function. Also, the new instrument is simple and can be easily manufactured. 5. Conclusion Using the new thermal laparoscopic instrument was an effective technique for paralumbar fossa laparoscopic ovariectomy in female donkeys, where the new instrument reduced the time of operation and provided a viable hemostasis and coagulation for the mesovarium, also the mesovarium cutting was very easy. Acknowledgements The authors would like to acknowledge the valuable assistance of Drs. Laith M. Al-Katan and Fouad M. Mohammed during the surgical operations.
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Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.anireprosci.2007.06.011. References Al-Badrany, M.S., 2007. Laparoscopic ovariectomy in standing donkeys by titanium clips and monopolar electrocautary. J. Anim. Vet. Adv. 6, 663–667. Alldredge, J.G., Hendrickson, D.A., 2004. Use of high-power ultrasonic shears for laparoscopic ovariectomy in mares. J. Am. Vet. Med. Assoc. 225, 1578–1580. Boure, L., Marcoux, M., Laverty, S., 1997. Paralumbar fossa laparoscopic ovariectomy in horses with use of endoloop ligatures. Vet. Surg. 26, 478–483. Carson-Dunkerley, S.A., Hanson, R.R., 1997. Ovariectomy of granulosa cell tumors in mares by use of the diagonal paramedian approach: 12 cases. J. Am. Vet. Med. Assoc. 211, 204–206. Catone, G., Marino, G., Mancuso, R., Zanghi, A., 2004. Clinicopathological features of an equine ovarian teratoma. Reprod. Domest. Anim. 39, 65–69. Cokelaere, S.M., Martens, A.M., Wiemer, P., 2005. Laparoscopic ovariectomy in mares using a polyamide tie-rap. Vet. Surg. 34, 651–656. Colbern, G.T., Reagan, W.J., 1987. Ovariectomy by colpotomy in mares. Comp. Contin. Educ. Pract. Vet. 9, 1035–1038. Doran, R., Allen, D., Gordon, B., 1998. Use of stapling instruments to aid in the removal of ovarian tumours in mares. Equine Vet. J. 20, 37–40. D¨usterdieck, K.F., Pleasant, R.S., Lanz, O.I., Saunders, G., Howard, R.D., 2003. Evaluation of the Harmonic Scalpel for laparoscopic bilateral ovariectomy in standing horses. Vet. Surg. 32, 242–250. Hand, R., Rakestraw, P., Taylor, T., 2002. Evaluation of a vessel-sealing device for use in laparoscopic ovariectomy in mares. Vet. Surg. 31, 240–244. Hanson, C.A., Galuppo, L.D., 1999. Bilateral laparoscopic ovariectomy in standing mares: 22 cases. Vet. Surg. 28, 106–112. Hooper, R.N., Taylor, T.S., Varner, D.D., Blanchard, T.L., 1993. Effects of bilateral ovariectomy via colpotomy in mares: 23 cases (1984–1990). J. Am. Vet. Med. Assoc. 203, 1043–1046. Moll, H.D., Slone, D.E., Juzwiak, J.S., Garrett, P.D., 1987. Diagonal paramedian approach for removal of ovarian tumors in mares. Vet. Surg. 16, 456–458. Palmer, S.E., 1993. Standing laparoscopic laser technique for ovariectomy in five mares. J. Am. Vet. Med. Assoc. 203, 279–284. Palmer, S.E., 2002. Laparoscopic ovariectomy in the standing horse. In: Fischer, A.T. (Ed.), Equine Diagnostic and Surgical Laparoscopy. W.B. Saunders Co., USA, pp. 189–195. Ragle, C.A., 2002. Ventral abdominal approach for bilateral laparoscopic ovariectomy. In: Fischer, A.T. (Ed.), Equine Diagnostic and surgical laparoscopy. W B Saunders Co., USA, pp. 181–188. Ragle, C.A., Schneider, R.K., 1995. Ventral abdominal approach for laparoscopic ovariectomy in horses. Vet. Surg. 24, 492–497. Rodgerson, D.H., Baird, A.N., Lin, H.C., Pugh, D.G., 1998. Ventral abdominal approach for laparoscopic ovariectomy in llamas. Vet. Surg. 27, 331–336. Rodgerson, D.H., Belknap, J.K., Wilson, D.A., 2001. Laparoscopic ovariectomy using sequential electrocoagulation and sharp transection of the equine mesovarium. Vet. Surg. 30, 572–579. Rodgerson, D.H., Hanson, R.R., 2000. Ligature slippage during standing laparoscopic ovariectomy in a mare. Can. Vet. J. 41, 395–397. Santschi, E.M., Troedsson, M.H.T., 2001. How to perform bilateral ovariectomy in the mare through two paramedian incisions. A.A.E.P. Proceedings 47, 420–422. Shoemaker, R.W., Read, E.K., Duke, T., Wilson, D.G., 2004. In situ coagulation and transection of the ovarian pedicle: an alternative to laparoscopic ovariectomy in juvenile horses. Can. J. Vet. Res. 68, 27–32. Trotter, G.W., Embertson, R.M., 1992. Surgical diseases of the cranial reproductive tract. In: Auer, J.A. (Ed.), Equine Surgery, second ed. WB Saunders, Philadelphia, pp. 750–761.
Laparoscopic ovariectomy in standing donkeys by using a new instrument D.M. Aziz ∗ , M.S. Al-Badrany, M.B. Taha Department of Surgery and Obstetrics, College of Veterinary Medicine, University of Mosul, Mosul, Iraq Received 2 April 2007; received in revised form 21 May 2007; accepted 1 June 2007 Available online 15 June 2007
Abstract Bilateral laparoscopic ovariectomy was performed in six female donkeys. Laparoscopic ovariectomy was performed in standing position by using a new laparoscopic instrument which was developed by the authors. We used the instrument for isolation, coagulation and cutting of mesovarium. One laparoscope portal and two instrument portals were located in each paralumbar fossa. The ovary was removed through an enlarged second portal. The contralateral ovary was removed through the opposite paralumbar fossa. Hemostasis, coagulation and cutting of the mesovarium were achieved successfully using the new laparoscopic instrument. The time required for removal of each ovary was between 2 and 4 min (average 2.8 min). While the total time of unilateral ovariectomy was between 10 and 15 min (average 12 min). No additional ligature was required in all operations. There was no complication, hemorrhage or oozing of blood from the mesovarium during or after the operations. In conclusion, laparoscopic ovariectomy in donkeys by using this new instrument was safe and effective. The new instrument reduced the time of operation and provided a viable hemostasis and coagulation for blood vessels within the mesovarium. Also cutting of the mesovarium was very easy. © 2007 Elsevier B.V. All rights reserved. Keywords: Ovariectomy; Standing donkey; Laparoscopy; New instrument
1. Introduction Ovariectomy is a surgical procedure performed to remove one or both ovaries. In the equine, bilateral ovariectomy is done as an elective surgery used to prevent estrus associated behaviour, manage colic associated with estrus and to prevent pregnancy (Trotter and Embertson, 1992; ∗ Corresponding author at: Department of Surgery and Obstetrics, College of Veterinary Medicine, University of Mosul, P.O. Box 11141, Mosul, Iraq. Tel.: +964 770 209 3321. E-mail address: [email protected] (D.M. Aziz).
0378-4320/$ – see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.anireprosci.2007.06.011
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Hooper et al., 1993). It is also done to remove the ovaries in some pathologic conditions such as ovarian hematoma, teratoma and granulosa cell tumor (Carson-Dunkerley and Hanson, 1997; Palmer, 2002; Catone et al., 2004). Various methods can be used for ovariectomy; these include colpotomy (Colbern and Reagan, 1987), ventral midline approaches (Ragle, 2002), paramedian approaches (Moll et al., 1987), and laparoscopic techniques (Hanson and Galuppo, 1999; Rodgerson et al., 2001). Laparoscopic ovariectomy provides good visualization of the ovary and mesovarium and allows tensionless manipulation of the mesovarium during pedicle transection, visual assessment of hemostasis and smaller body wall incisions (Palmer, 1993; Ragle and Schneider, 1995; Boure et al., 1997; Hanson and Galuppo, 1999; Rodgerson et al., 2001). This technique has been developed for mares in the standing (Hanson and Galuppo, 1999; Rodgerson et al., 2001) and dorsal recumbent positions (Ragle and Schneider, 1995; Santschi and Troedsson, 2001). Standing laparoscopic ovariectomy has advantages over dorsal recumbent technique because it eliminates the risk of general anesthesia (Hanson and Galuppo, 1999), and it provides excellent visualization to locate and manipulate the ovaries (Boure et al., 1997; Al-Badrany, 2007). The main challenge with laparoscopic ovariectomy technique is finding the best way to ligate the ovarian pedicle and provide hemostasis. Therefore, numerous methods are used for hemostasis of the mesovarium and the associated ovarian vessels which include electrocoagulation (Rodgerson et al., 2001; Hand et al., 2002), ligature application (Boure et al., 1997), laser techniques (Palmer, 1993), stapling instruments (Doran et al., 1998), vascular clips (Rodgerson et al., 1998), ultrasonic shears (Alldredge and Hendrickson, 2004), and Harmonic Scalpel (D¨usterdieck et al., 2003). These methods of hemostasis are time consuming and have some other disadvantages, which include difficulty in applying the hemostatic devices, ligature slippage and the cost of device. The aim of the present study was to develop a bilateral ovariectomy procedure in female donkeys using a new laparoscopic instrument which has been developed by the authors. We used this instrument for isolation, coagulation and cutting of mesovarium. 2. Materials and methods 2.1. Laparoscopic equipment In addition to the standard laparoscopic instruments; cannulas, telescope, insufflator, Veress needle and forceps (Karl Storz, Germany), a new laparoscopic instrument, designed and manufactured by the authors, were used in this study. The new instrument has an outer body (metallic tube with an outer diameter of 10 mm), internal movable part with two movable arms (length of each one is 7 cm) for holding the thermal wire, a thermal wire (0.5 mm in diameter and 8 cm long), on/off switch and a source of continuous electrical current (12 V, 12 A) (Fig. 1). In the abdominal cavity, the instrument is opened by pushing its internal part toward the cavity of abdomen; the two instrument arms and the thermal wire form a loop (the major axis of loop is 10 cm, the minor axis is 5 cm, the circumference of loop is 22 cm and the area of the inside of loop is 25 cm2 ). The thermal wire was used to isolate, coagulate, and for cutting of mesovarium. 2.2. Animals Six adult female donkeys (age, 3–5 years and weight, 120–150 kg) were used in this study. The animals were donated to the Clinic of College of Veterinary Medicine, University of Mosul for
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Fig. 1. The new laparoscopic instrument. 1, Thermal wire; 2, the two movable arms (length, 7 cm) for holding of thermal wire; 3, outer body (metallic tube with an outer diameter 10 mm); 4, rubber valve to prevent gas escape; 5, internal movable part. 6, on/off switch; 7, source of continuous electrical current (12 V, 12 A).
euthanasia due to the existence of problems that did not require urgent care and were unrelated to the reproductive tract. The animals were housed together in a large paddock in the animal house of College of Veterinary Medicine, University of Mosul, and had free access to feed and water. 2.3. Presurgical preparation The animals were fasted for 12 h to reduce the volume of intestinal contents and to improve the working area within the abdomen. Both paralumbar fossae were clipped and prepared using routine aseptic technique. 2.4. Sedation and anesthesia The donkeys were sedated with xylazine hydrochloride (Pantex, Holland) (1 mg/kg, b.w., i.v.) prior to being restrained in stocks. Local anesthesia was achieved by direct infiltration of the laparoscopic portal sites with approximately 20 ml of 2% lidocaine (Laborate Pharmaceutical, India). 2.5. Surgical procedure Pneumoperitoneum was achieved by introducing the Veress needle into the abdominal cavity through a 1–1.5 cm skin incision, which was made in the paralumber fossa at the level of the tuber coxae, midway between the caudal aspect of the last rib and the tuber coxae. The presence of the needle within the abdomen was confirmed by the sound of air entering the abdomen and the loss of negative intra-abdominal pressure. The needle was then connected to the insufflator and the abdomen was insufflated to a pressure of 16 mmHg with carbon dioxide. Three instrument portals were made. The primary portal was located at the site of Veress needle, the Veress needle was removed and 10 mm trocar–cannula unit was inserted. The trocar was removed, and a 10 mm, 30◦ angle laparoscope was inserted to locate the ovary. The second portal was placed 2 cm caudal to the last rib and 7–8 cm cranioventral to the primary portal. A 1 cm
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Fig. 2. (a) Insertion of instruments to the abdominal cavity. (b and c) The developed instrument was opened, and the ovary was pulled by the Babcock forceps through the loop of this instrument. (d) The internal part of the instrument was pulled back and the two instrument arms were closed to surround the mesovarium by the thermal wire.
skin incision was performed and also 10 mm trocar–cannula unit was inserted. The skin incision for the third portal was made 7–8 cm caudoventral to the first portal and 14–15 cm ventral to the second portal, 5 mm trocar–cannula unit was inserted in this portal. The laparoscope was removed from the primary portal and inserted through the second portal. Then our new instrument was inserted through the first portal, while a laparoscopic Babcock forceps was inserted through the third portal. After insertion of instruments to the abdominal cavity, the developed instrument was opened, and the ovary was pulled by the Babcock forceps through the loop of this instrument. Thereafter, the internal part of the instrument was pulled back and the two instrument arms were closed to surround the mesovarium by the thermal wire. The thermal wire was tightened to tourniquet the mesovarium, and then the switch was turned on to begin the function of the thermal wire (Fig. 2). For coagulation of the mesovarium, numerous pulsations of power (4–5 s) were given. The mesovarium was monitored until the tissue at the site of thermal wire turned white, indicating adequate coagulation. After that, the power was given continuously for about 1 min to cut the mesovarium. The site of cutting was closely observed for any hemorrhage (Fig. 3). To remove the ovary, the thermal instrument was removed from the second portal and replaced with tissue extractor forceps. The free ovary was released from the Babcock forceps in the third portal, after it was grasped by the tissue extractor forceps in the second portal. Then, the second portal was enlarged (5–6 cm) to assist in extracting the ovary through the abdominal wall (Fig. 4). After removing of the ovary, the mesovarium was inspected again for any hemorrhage before removing of the telescope. The laparoscope was removed, and the pneumoperitoneum was relieved
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Fig. 3. (a) Start coagulation of the mesovarium by numerous pulsations of power (4–5 s). (b) The mesovarium tissue at the site of thermal wire was turned white. (c and d) Cutting the mesovarium.
by opening the valves of the cannulas. The remaining cannulas were removed also. The incisions in the abdominal wall were closed with catgut No. 0, and the skin incisions were closed with silk No. 2. The contralateral ovary was removed in a similar fashion through the opposite paralumbar fossa. 2.6. Postoperative care After operation, the animals were given penicillin–streptomycin (10,000 IU/kg penicillin and 10 mg/kg streptomycin, intramuscularly) (Combi-Kel 20 + 20, Kela Laboratoria, Belgium), daily for 4 days. The skin sutures were removed after 1 week of operation. After close observation for 24 h post surgery, the animals were clinically examined daily for 1 month. 3. Results Bilateral laparoscopic ovariectomy was performed successfully in six female donkeys in standing position through three laparoscopic portals in each paralumbar fossa. The arrangement of the laparoscopic instruments provided excellent visibility for the ovary and the mesovarium. Hemostasis, coagulation and cutting of the mesovarium were achieved with high degree of success by using the new laparoscopic instrument, whereas the time required to isolate, coagulate and cut of each ovary was between 2 and 4 min with an average of 2.8 min. The total time of unilateral ovariec-
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Fig. 4. (a) Ovary was removed. (b and c) The free ovary was released from the Babcock forceps in third portal, after it was grasped by the tissue extractor forceps in second portal. (d) The site of cutting was closely observed for hemorrhage.
tomy was between 10 and 15 min with an average of 12 min. No additional ligature was required in all operations. The removed ovaries were kidney-shaped and measured about 3.5–5.5 cm in length, 2–3.5 cm in width and 2–3 cm in thickness. There was no complication, no hemorrhage or oozing of blood from the mesovarium during or after the operations. Also, no major complication was recorded postoperatively, except a mild inflammation in the skin incision of one donkey. All animals were acting normally after 1–2 days of surgery. 4. Discussion Through our routine bilateral laparoscopic ovariectomy at the Clinic of College of Veterinary Medicine, University of Mosul, we found it is time consuming and have other problems, these include; the difficulty associated with isolating of mesovarium and applying of the hemostatic devices, bleeding, and the cost of hemostatic device. Some of these problems were reported in previous studies (Hanson and Galuppo, 1999; Rodgerson and Hanson, 2000; Alldredge and Hendrickson, 2004). Therefore, we developed a new instrument to resolve these problems. Numerous methods were used for coagulation of mesovarium which included the applications of electrocoagulation, laser techniques, ultrasonic shears and Harmonic Scalpel (Palmer, 1993; Rodgerson et al., 2001; D¨usterdieck et al., 2003; Alldredge and Hendrickson, 2004). However, in spite of the fact that these devices are working by different ways, they have a similar outcome, that is increasing of tissue temperature then forming of the coagulum. Similarly, our instrument
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increases the temperature of mesovarium tissue to induce coagulation. It depends on heat generated by electrical current in the thermal wire. Results of the present study indicate that the mesovarium was isolated quickly and easily by using our new instrument, where the arms of instrument simplified the application of the thermal wire around the mesovarium. Also, this instrument provided adequate coagulation for the mesovarium. The thermal wire act as a tourniquet for the mesovarium and its blood vessels, as the heat causes denaturing of the protein and forming the coagulum; therefore the mesovarium blood vessels were closed and coagulated by the effect of tourniquet and heat, respectively. The time that required for coagulation and cutting of each ovary was very short (2.8 ± 0.8 min) in comparison with our routine laparoscopic ovariectomy in donkeys and traditional laparoscopic ovariectomy in female donkeys and mares (Al-Badrany, 2007; Shoemaker et al., 2004). In this study, the hemostatic and coagulation device was applied on the mesovarium in one place, and there was no requirement to change the place of the thermal wire on the mesovarium, while in other laparoscopic ovariectomy (Alldredge and Hendrickson, 2004; Shoemaker et al., 2004), the surgeon must apply the hemostatic device multi times to produce adequate hemostasis and coagulation for the mesovarium. Also our new instrument achieved three functions; isolation, coagulation and cutting of the mesovarium, but in the subordinated laparoscopic ovariectomy two or more instruments were required to achieve these aims (Hanson and Galuppo, 1999; Rodgerson and Hanson, 2000; Shoemaker et al., 2004; Cokelaere et al., 2005). During the application of the electrocoagulation device, notable amount of smoke was produced; therefore, a laparoscopic smoke filtration system was developed to evacuate the smoke during the operation. In our study and in all operations, there was no smoke production during coagulation and cutting of the mesovarium. The circumference and the area of the inside of loop of the new instrument were suitable for the donkey ovaries. The size of removed ovaries was relatively smaller (about half) in comparison with that of the mare ovaries. However, the instrument can be modified to be suitable for larger ovaries by increasing the loop circumference and area, and this can be done by increasing the length of thermal wire and the two arms of the instrument. Further, the procedure can be modified to be suitable for closing the larger blood vessels within the mesovarium by increasing the time of coagulation. These modifications can be validated in future studies. Finally, the usage of the new instrument for ovariectomy was economically in comparison with recently used devices (D¨usterdieck et al., 2003; Alldredge and Hendrickson, 2004). This is because the instrument was produced from cheap and simple materials, and no high technology was necessary for its function. Also, the new instrument is simple and can be easily manufactured. 5. Conclusion Using the new thermal laparoscopic instrument was an effective technique for paralumbar fossa laparoscopic ovariectomy in female donkeys, where the new instrument reduced the time of operation and provided a viable hemostasis and coagulation for the mesovarium, also the mesovarium cutting was very easy. Acknowledgements The authors would like to acknowledge the valuable assistance of Drs. Laith M. Al-Katan and Fouad M. Mohammed during the surgical operations.
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