Cats

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Minimally Invasive Surgery – Laparoscopy

View of the liver and diaphragm laparoscopically

View of the right ovary during a standard laparoscopic spay.

Abdominal view of a laparoscopic gastropexy.

What is laparoscopy? This is an advanced surgical technique that utilizes cameras and instruments that are introduced into the abdomen via small incisions (portals). This type of surgical procedure is becoming more and more common in human medicine. It is not uncommon to hear about gallbladder removals, “lap band” procedures and many other operations being performed this way. It is really becoming the standard of care – so why not for our pets? Certainly the technology is there! The more and more we get comfortable with these techniques, the more we will be able to do.

The basic concept of laparoscopy is to make portals that allow the introduction of a camera and instruments. The actual surgical work is done within the abdomen by visualizing it on a video monitor. Before attempting laparoscopic surgeries, the surgeon needs to be comfortable with performing the surgery in an open approach, because there are times, when laparoscopy is not the best approach and the surgery needs to be converted.

What are the benefits of laparoscopy? The most notable benefits are patient comfort, soft tissue damage (termed morbidity), excellent visualization (images are magnified), shorter hospital stays. All these combined form a convincing argument for laparoscopic surgery.

One of the most common procedures performed is the ovariohysterectomy (spay). This can be performed from 0.5 cm and 1.0 cm incisions. This is a very quick procedure and allows the surgeon complete access and visualization of the ovaries and uterus. Specialized sealing devices allow the surgeon to remove the full uterus and ovaries with minimal bleeding and incisions. Another benefit is that with the small size of the incisions, there is low risk of herniation of abdominal contents, and the patient can return to activity in about a week.

The spay is many times combined with a prophylactic gastropexy in the larger breed dogs. This is a procedure that allows the stomach to be attached to the body wall to prevent deadly twisting of the stomach. This is a very effective procedure. For more information, please visit the previous blogs entitled GDV.

Other more complex procedures include multiple biopsies, adrenalectomy, gallbladder removal, liver mass resection, cryptorchid testicle removal, etc. As more experience is gained with laparoscopy the more we can do. If you have questions about laparoscopy feel free to comment or ask your veterinarian and veterinary surgeon.

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Minimally Invasive Surgery – 1

I hope everyone is having a great weekend! The next series of topics is join got focus on minimally invasive procedures. This is of particular interest of mine. There are multiple implications of this terms, I am going to focus on laparascopy, thoracoscopy and arthroscopy.

As medicine advances in both the human and veterinary world, we are starting to do more with less. What I mean is that through smaller incisions and better technology we address more and more surgical problems. The benefit of this is shorter hospital stays, decreased complication rte, decreased infection rates, and decreased soft tissue trauma and post-surgical pain. We are very lucky to have all this new technology available to us.

Here is a definition of the terms:

Laparascopy: Abdominal surgery being performed with a scope/camera via a small portal incision. Multiple other portals are made to introduce instruments. All procedures are performed within the abdominal cavity. Laparoscopic-assisted means that part of the procedure is done with cameras within the body cavity and part is done via small incisions outside of the abdomen.

Thoracoscopy: Same definition as above, however this pertains to the chest or thorax. This is a very useful modality and is used to treat various cardiac, pulmonary (lung) and esophageal problems.

Arthroscopy: Same definition as above, however this is performed on the joints. This is a very common use in veterinary medicine and is thought to be the gold standard in joint evaluation. The most common joints evaluated through this are the elbows, shoulders and knees, however the wrists (carpi), ankles (hocks/tarsi), and hips can be evaluated. Just think, if you have an ACL injury, it is very common for you to have your knee scoped, why not your best friend?

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ACL Injuries in Dogs – Diagnosis

Typically a diagnosis of an ACL tear in a dog can be made based on physical exam. The findings of forward movement of the tibia (cranial drawer) generally allows the surgeon to go directly to surgery. Other ways to evaluate the knee are as follows:

Radiographs: Classic radiographic findings are joint swelling, arthritic change and subluxation (forward movement) of the tibia in relation to the femoral. Classic areas of arthritic development are the patella, fabella, tibial plateau and femoral condylar ridges. I recommend the radiograph (x-ray) be taken with the knee and hock in 90 degree flexion. Please note the differences of the normal and affected knee in the radiographs attached. The benefit of radiographs for me is to see mild changes to confirm the diagnosis and to derive my measurements for either the tibial plateau leveling osteotomy (TPLO) or tibial tuberosity advancement (TTA) procedures.

MRI: While this is a very sensitive diagnostic test to run, generally it isn’t performed in veterinary medicine for this issue, unless the more common tests don’t reveal the answer and the patient is still lame. Unfortunately, a MRI will increase costs and not provide a treatment.

Arthroscopy: I am a big proponent of this method. This is performed at the same surgeory as the corrective procedures, prior to them. Fortunately, arthroscopy is a minimally invasive technique of evaluating the joint and gives us the ability to debride (clean-up) the joint. Between 30-50% of dogs will also injure the medial (inside) meniscus and arthroscopy will allow us to address that issue too. This is far less invasive than an open arthrotomy (opening the joint), which is the mainstay of treatment. Also, immediate recovery is a little quicker to, due to the increased nerve endings present in the joint capsule and muscle disruption.

Open Arthrotomy: This is performed by making a large incision into the joint and moving over the patella (knee cap) to visualize the ACL ligament and menisci. While this is the mainstay approach it is the most aggressive. This allows the surgeon to address the ACL and any meniscal tears.

As you have probably noticed, I am biased towards the knee arthroscopy to evaluate the joint as this is the most minimally invasive approach and allow excellent evaluation of the important structures of the joint. When one is proficient at this approach there really is not an increase in surgery/anesthesia time, making it safe and effective.

X-ray of stifle with a ruptured ACL

X-ray of stifle with a ruptured ACL

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ACL injuries in dogs

ACL injuries are the most common orthopedic injuries seen in the dog. You may also here them referred to as a cranial cruciate ligament rupture (this is the anatomically correct description, but we will call it the ACL since most are familiar with this). When I talk to owners, I try to reference it to what people experience to make it a little easier to understand.

The ACL, while small, is a very major player in stability of the knee. If this is ruptured (partial or complete) this will cause instability to a varying degree which will cause inflammation, arthritis and cartilage wear in the knee.

There are three big forces that the ACL counteracts: knee hyperextension, tibial(shin bone) internal rotation (twisting inward) and cranial (anterior) shear force. When you think about how we rupture our ACL it is usually by hyperextending the knee and a large force (like a linebacker) impacting the knee or by planting your foot and turning abruptly (internal rotation). Most of the time we rupture our ACL by strenuous activity. The third force (cranial shear force) is greater in the dog than you or I. With us, the top of our tibial (tibial plateau) is relatively flat with only a very small angle of inclination. When the top of our tibial meets the rounded femur (thigh bone) there is very little push forward. In the dog, due to the way the dog stands (4 legs) and develops (much higher angle of inclination of the tibia (normally between 20-40 degrees) this push forward is much greater as the tibia meets the femur. Think of a wheel on a hill model – the steeper the hill the more the wheel will roll down it (the hill is the tibial and the wheel is the femur). The ACL runs from the front part of the tibia to the back of the femur and counteracts the above force. When it is torn there is no holding the tibial back as the dog steps and walks on the injured dog.

So this is a little about what a ruptured ACL is, next we will talk about the signs. Have a great Monday and be sure to check back!!!

X-ray of a normal knee

X-ray of a normal knee

 

Please look like at the following video: arthroscopic evaluation of the canine stifle joint.