Laparoscopic cryptorchidectomy using electrosurgical instrumentation in standing horses

Development and application of a spray tip that enables electrocoagulation of a variety of tissues

BACKGROUND

Spray hemostasis is possible using a high-frequency power source from the tip of an electric scalpel; however, the difficulties regarding the uniformity and rapidity of the hemostasis surface remain. This study reports the development of a novel electrocoagulation device tip that can be used in endoscopic and robotic surgeries and can quickly coagulate and hemostat and easily adjust the extent of cauterization and hemostasis while minimizing the depth of thermal injury.

METHODS

The safety and efficacy of the hemostatic device were verified in a porcine model. A liver surface transection was conducted in vivo and the rapidity of the hemostatic effect of the device was observed. An extracted stomach, kidney, and liver were cauterized ex vivo by three operators with different surgical skills and the effects were analyzed pathologically. In addition, a sacrificed pig cadaver was used to achieve hemostasis at a renal transection site using the multi-spray endoscope tip.

RESULTS

An increase in the number of tip terminals expanded the cauterization surface and shortened the cauterization time. In parenchymatous organs, uniform cauterization was possible without increasing the depth of thermal injury. The cauterization depth did not depend on the operator's skill, and the spray coagulation was safe. The variable spray tip allowed for simple hemostasis during open and laparoscopic surgeries.

CONCLUSIONS

This novel electrocoagulation device tip can be developed as a forceps that can change the spray range and can be used during laparoscopic and robotic surgeries.

Current Use of Equine Laparoscopy in Urogenital Disorders: A Scoping Review of the Literature from 2000 to 2021

(1) Background: Laparoscopic surgery replaced traditional invasive techniques for the treatment of common urogenital disorders in equids. The aim of this review is to evaluate applications and the development of urogenital laparoscopy from 2001 to 2021. (2) Methods: A scoping review of literature was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for scoping reviews on three databases (NCBI-PubMed, Web of Science-Thompson Reuters, and SciVerse Scopus). (3) Results: A total of 452 papers were identified. After duplicate removal and title screening, 181 papers underwent abstract screening. Of these, 160 + 10 papers (cited by others) were assessed for eligibility according to the PICOs. A total of 132 papers were considered eligible. Most of the research was focused on ovaries and testes, followed by urinary bladder and general articles about laparoscopy in horses. We identified 43 original studies (33%, RCT, NoRCT, and experimental trials), 39 case series/retrospective studies (29%), 37 case reports (28%), and 13 reviews (10%, narrative or systematic). (4) Conclusions: Gonadal disorders were the most investigated. Hand-Assisted Laparoscopic Surgery (HALS) and laparoscopic-assisted surgery represent valuable options for more challenging conditions (uterine and urinary bladder disorders).

Recovery after General Anaesthesia in Adult Horses: A Structured Summary of the Literature

Simple Summary

Recovery is the most dangerous phase of general anaesthesia in horses. Numerous publications have reported about this phase, but structured reviews that try to reduce the risk of bias of narrative reviews/expert opinions, focussing on the topic are missing. Therefore, the aim of the present article was to publish the first structured review as a summary of the literature focussing on the recovery phase after general anaesthesia in horses. The objective was to summarise the available literature, taking into account the scientific evidence of the individual studies. A structured approach was followed with two experts in the field independently deciding on article inclusion and its level of scientific evidence. A total number of 444 articles, sorted by topics and classified based on their levels of evidence, were finally included into the present summary. The most important findings were summarised and discussed. The present structured review can be used as a compilation of the publications that, to date, focus on the recovery phase after general anaesthesia in adult horses. This type of review tries to minimise the risk of bias inherent to narrative reviews/expert opinions.

Abstract

Recovery remains the most dangerous phase of general anaesthesia in horses. The objective of this publication was to perform a structured literature review including levels of evidence (LoE) of each study with the keywords “recovery anaesthesia horse”, entered at once, in the search browsers PubMed and Web of Science. The two authors independently evaluated each candidate article. A final list with 444 articles was obtained on 5 April 2021, classified as: 41 “narrative reviews/expert opinions”, 16 “retrospective outcome studies”, 5 “surveys”, 59 “premedication/sedation and induction drugs”, 27 “maintenance with inhalant agents”, 55 “maintenance with total intravenous anaesthesia (TIVA)”, 3 “TIVA versus inhalants”, 56 “maintenance with partial intravenous anaesthesia (PIVA)”, 27 “other drugs used during maintenance”, 18 “drugs before/during recovery”, 18 “recovery systems”, 21 “respiratory system in recovery”, 41 “other factors”, 51 “case series/reports” and 6 “systems to score recoveries”. Of them, 167 were LoE 1, 36 LoE 2, 33 LoE 3, 110 LoE 4, 90 LoE 5 and 8 could not be classified based on the available abstract. This review can be used as an up-to-date compilation of the literature about recovery after general anaesthesia in adult horses that tried to minimise the bias inherent to narrative reviews.

A Retrospective Study of Cryptorchidectomy in Horses: Diagnosis, Treatment, Outcome and Complications in 70 Cases

Simple Summary

Cryptorchidism is the failure of one or both testes to descend into the scrotum and is considered to be one of the most common developmental disorders in horses. The aim of the study was to review medical records of horses referred for uni- or bilateral cryptorchidism. It was observed that the Western Riding horse breeds were the most affected, and that left abdominal and right inguinal retentions were the most frequent. Transabdominal ultrasound was the most reliable diagnostic tool to localize the retained testis. Standing laparoscopic and open inguinal cryptorchidectomy were elected as the surgical treatment of choice, in case of abdominal retention and inguinal retention respectively. For incomplete abdominal retention, laparoscopy was the preferred treatment, even though an open inguinal approach was a viable option for the concurrent removal of the descended testis.

Abstract

The aim of the study was to investigate the breed predisposition and the diagnostic and surgical management of horses referred for cryptorchidism. The breed, localization of retained testis, diagnosis, type of surgical treatment and complications were analyzed. Seventy horses were included in the study; the Western Riding horse breeds were the most affected (Quarter Horse 34/70, 48.5%; Appaloosa 9/70, 12.8%). In unilateral cryptorchids (65/70, 92.8%) the most common location for a retained testis was the left abdomen (28/65, 43%), while in bilateral cryptorchids (5/70, 7.1%), bilateral abdominal retention was the most frequent (3/5, 6%). Information about testis localization was achieved through transabdominal ultrasound (30/49 cases, 61.2%), through per rectum palpation (21/49 cases, 42.9%) and through inguinal palpation (14/49 cases, 28.9%). Cryptorchidectomy was achieved with standing laparoscopy (44/70 cases, 62.8%), or with open inguinal orchiectomy in general anesthesia (26/70 cases, 37.2%). Complications during laparoscopy were spleen puncture (1/44, 2.2%), a self-limiting bleeding from the spermatic cord (10/44 cases, 22.7%), hyperthermia (3/44 cases, 6.8%), and emphysema (15/44, 34%). During inguinal open cryptorchidectomy difficulties with identifying the inguinal testis during surgery (8/26 cases, 30.8%) and a moderate and self-limiting swelling of the inguinal region after surgery (17/26, 65.4%) were observed. For orchiectomy, a standing laparoscopy was confirmed as the preferred procedure for an abdominally retained testis with almost no complications.

Wound Retractor Laparoscopic Port System for Standing Laparoscopic Cryptorchidectomy in the Horse: A Case Report

Cryptorchidectomy is the most commonly performed laparoscopic procedure in horses. However, its use for the extraction of an abdominal testis has disadvantages such as loss of a resected testis from grasp and fragmentation of the specimen because of the excessive tension required for extraction through a thick body wall. The ring wound retractor laparoscopic port system was recently used in human and small animal surgery to perform laparoscopic-assisted procedures and retrieve large specimens from the abdomen. In the present case, the wound retractor was placed as the ventral port in the right flank through a minilaparotomy. Thereafter, the cap with the gas inlet and instrument port was connected. The other two ports were placed dorsally using 10-mm stainless steel cannulas. Grasping forcep was introduced through the ventral port, and the laparoscope and vessel-sealing devices were introduced through the dorsal ports. After the testis was resected, it was retrieved from the abdomen through the retractor without the grasping forceps jaw being released. This is the first case report describing the use of the wound retractor laparoscopic port system for standing cryptorchidectomy in a horse. This system can be a feasible and safe option for flank laparoscopy in horses, and it facilitates specimen retrieval from the abdominal cavity, but further studies should confirm this preliminary report.

Vessel sealer and divider instrument temperature during laparoscopic ovariectomy in horses

OBJECTIVE

To determine the temperature of a vessel sealer and divider device during unilateral paralumbar laparoscopic ovariectomy in standing, sedated mares.

STUDY DESIGN

Prospective study.

ANIMALS

Fifteen healthy research mares.

METHODS

Healthy mares with normal ovarian palpation and ultrasonographic appearance were enrolled. Horses were restrained in standing stocks and sedated. A right or left paralumbar ovariectomy was performed with a laparoscopic portal and 2 instrument portals. Ovaries were excised with traumatic forceps and a blunt tip vessel sealer and divider. Temperatures of the vessel sealer and divider were recorded with a thermocouple device adhered to the tip of the instrument. Variables were reported as median and interquartile range (IQR).

RESULTS

Surgical time was 30 minutes (IQR, 25-32) including use of the vessel sealer and the divider for 4.1 minutes (IQR, 3.2-5.8). The tip of the instrument reached temperatures of 77°C (IQR, 72-85) during activation and 64°C (IQR, 61-67) at end cycle. The median increase in end-cycle instrument tip temperature per activation cycle was 2°C (IQR, -1-6). All mares returned to their intended use.

CONCLUSION

Despite the instrument temperatures observed during unilateral laparoscopic ovariectomy, surgical complications were minimal. The clinical relevance of the increase in instrument tip temperature of the vessel sealer and divider is presently unclear, but surgeons should use the instrument with caution, especially in close proximity to viscera. The increase in temperature observed at the tip of the vessel sealer and divider during unilateral ovariectomy could be associated with morbidity. The clinical relevance of instrument tip heating during other procedures, such as adhesiolysis and intestinal resection, is unknown and should be evaluated.

Experimental laparoscopic pyloromyotomy in pigs

The objective of this study was to evaluate and compare laparoscopic pyloromyotomy methods involving the laparoscopic scalpel and the harmonic scalpel in pigs. The experiment was conducted on 4 subgroups of 12 animals subjected to laparoscopic-assisted pyloromyotomy with a surgical scalpel and the harmonic scalpel, as well as laparoscopic pyloromyotomy with Berci's laparoscopic scalpel and the harmonic scalpel. No postsurgical complications were observed. Four weeks after the surgery, the animals were sacrificed and autopsy was performed. In one animal peritoneal adhesions between the intestines and the mini-laparotomy incision were found. Laparoscopic pyloromyotomy and laparoscopic-assisted pyloromyotomy performed in pigs enabled the selection of laparoscopic entry sites, instruments for pyloromyotomy and evaluation of the applied surgical procedures in animals. The results of this study indicate that the methods applied can be safely used in clinical practice in dogs and cats due to minimal post-operative complications and fast healing of laparoscopic incisions in comparison with classical surgical wounds, and that the harmonic scalpel is a safe surgical instru- ment.

Laparoscopic cryptorchidectomy in standing bulls

Laparoscopic cryptorchidectomy without insufflation was applied in 10 standing bulls aged 3 to 15 months. Nine bulls were preoperatively pointed out intra-abdominal testes by computed tomography. Preoperative fasting for a minimum of 24 hr provided laparoscopic visualization of intra-abdominal area from the kidney to the inguinal region. Surgical procedure was interrupted by intra-abdominal fat and testis size. It took 0.6 to 1.5 hr in 4 animals weighing 98 to 139 kg, 0.8 to 2.8 hr in 4 animals weighing 170 to 187 kg, and 3 and 4 hr in 2 animals weighing 244 and 300 kg to complete the cryptorchidectomy. In conclusion, standing gasless laparoscopic cryptorchidectomy seems to be most suitable for bulls weighing from 100 to 180 kg.

Standing male equine urogenital surgery

The advantages of performing standing male urogenital surgeries are numerous when compared with performing the same surgery in the anesthetized animal. Some traditional standing male urogenital surgeries, such as castrations, may be faster and cheaper to perform. Laparoscopic standing male urogenital surgeries may allow for improved visualization of the surgical field, decreased hemorrhage, and decreased morbidity and convalescence. Limitations of standing procedures may include increased danger to the surgeon because of fractious behavior of the patient, and increased expense and training associated with instrumentation for specialized procedures such as laparoscopy.

Advances in laparoscopic techniques and instrumentation in standing equine surgery

Equine standing surgery and laparoscopy are becoming increasingly important aspects of equine surgery. Laparoscopic advancements lag behind the human medical field, mainly due to decreased access to appropriate training and instrumentation. It is nearly impossible to cover the topic of equine standing surgery without discussing advances in laparoscopy, because without such advances, equine standing surgery lacks potential for forward progress. Although novel standing techniques continue to be published, the addition of minimally invasive laparoscopic techniques adds an entirely new dimension and provides a plethora of procedures to surgeons practicing equine standing surgery.

A review of equine laparoscopy

Minimally invasive surgery in the human was first identified in mid 900's. The procedure as is more commonly practiced now was first reported in 1912. There have been many advances and new techniques developed in the past 100 years. Equine laparoscopy, was first reported in the 1970's, and similarly has undergone much transformation in the last 40 years. It is now considered the standard of care in many surgical techniques such as cryptorchidectomy, ovariectomy, nephrosplenic space ablation, standing abdominal exploratory, and many other reproductive surgeries. This manuscript describes the history of minimally invasive surgery, and highlights many of the techniques that are currently performed in equine surgery. Special attention is given to instrumentation, ligating techniques, and the surgical principles of equine minimally invasive surgery.

Laparoscopic cryptorchidectomy and ovariectomy in standing horses using the EnSeal® tissue-sealing device

In the present series of cases, 8 laparoscopic cryptorchidectomies and 4 laparoscopic ovariectomies were carried out in sedated standing horses. Sedation involved a lesser anaesthesiological risk than does general anaesthesia. As compared to laparotomic exposure, the minimally invasive laparoscopic intervention provided better visualisation, shorter operative time and faster recovery. The blood vessels supplying the testes and ovaries and the suspensory ligaments of the organs were sealed and cut with EnSeal®, an adaptive bipolar electrosurgical blood vessel- and tissue-sealing device. The clinical use of the blood vessel- and tissue-sealing device proved to be successful in all cases. Gradual separation of the intact tissue from the treated, compacted, dehydrated and homogenised tissue areas and occlusion of the lumen of blood vessels treated with the device could be observed in all histological sections. To the best of our knowledge, this is the first report on the use of EnSeal® for laparoscopic cryptorchidectomy and ovariectomy in horses.

Laparoscopic cryptorchidectomy and ovariectomy in horses

Laparoscopic surgery has become commonplace in the field of equine urogenital surgery. As with most surgical procedures, the limiting factors in developing new surgical techniques are limited to the patient size and demeanor, the skills of the surgeon, and the available equipment. Some of the greatest benefits of laparoscopic surgery in the horse include better visualization of the important structures; tension-free amputation of the testes or ovaries,which generally leads to less postoperative pain; and the ability to evaluate the transected stump carefully to make sure there is no hemorrhage. This article is limited to the use of laparoscopy for cryptorchidectomy and ovariectomy.

Laparoscopic Ovariectomy in Mares Using a Polyamide Tie-Rap

OBJECTIVE

To describe use of a polyamide tie-rap to ligate the mesovarium during standing laparoscopic ovariectomy in mares.

STUDY DESIGN

Prospective study.

ANIMALS

Ten mares.

METHODS

Bilateral ovariectomy was performed in 10 mares. Standing laparoscopic ovariectomy was performed using 3 portals in the paralumbar fossa. A commercial polyamide tie-rap was prepared as a loop and marked with 4 colored lines close to the buckle, to enable us to check whether the loop was tightened securely. The ovary was grasped with forceps and after the mesovarium was minimally transected cranially and caudally, the loop of the tie-rap was inserted in the abdomen and placed around the mesovarium. It was firmly tightened, until at least 3 of the 4 marks were visible, then the end of the tie-rap was cut. The ovary was transected and removed through an enlarged 3rd portal. The contralateral ovary was removed similarly through the opposite paralumbar fossa. Repeat laparoscopy was performed in 8 mares, 2, 3, 4, and 12 weeks later.

RESULTS

None of the mares had postoperative discomfort. On repeat laparoscopy, there was complete encapsulation of the stump and tie-rap after 3-4 weeks. In 2 mares, an adhesion between the left stump and the mesentery of the descending colon was observed.

CONCLUSION

Ligation of the mesovarium can be easily and safely performed using a polyamide tie-rap during standing laparoscopic ovariectomy in mares.

CLINICAL RELEVANCE

Standing laparoscopic ovariectomy using a polyamide tie-rap is a safe, technically easy and reliable surgical procedure in the mare.

Recent advances in equine abdominal surgery

Laparoscopy is a minimally invasive procedure that has applications as a diagnostic, therapeutic and prognostic technique. Specialized equipment is necessary to perform equine laparoscopy, and there is a large range of instruments, both disposable and non-disposable available. Laparoscopic procedures described include ovariectomy, cryptorchidectomy, adhesiolysis and herniorrhaphy. Laparoscopy can be performed in a standing or dorsally recumbent position, depending on surgeon preference, patient status and the procedure to be performed. Stapling equipment is frequently used in gastrointestinal surgery in horses. Advantages include decreased surgical time and a decrease in the risk of contamination. Stapling equipment is often used in creating anastomoses, both in the large and small intestines, as well as in vessel ligation. New surgical techniques intended to decrease adhesion formation include the use of carboxymethylcellulose and bioresorbable patches. Indwelling abdominal drains can be used for peritoneal lavage following surgery and also appear to decrease the risk of adhesion formation. Improvements in post-operative care, including the treatment of post-operative ileus and endotoxaemia can significantly improve the outcome of horses that have undergone surgery for abdominal disorders. Recommendations for the use of prokinetic agents in horses with ileus vary widely. Prokinetic agents include local anaesthetics, macrolide antimicrobials, cholinergic agonists and dopamine antagonists. Endotoxaemia is common in horses following surgery for gastrointestinal disorders. The antibiotic polymyxin B binds to the circulating endotoxin molecule, decreasing its half-life in the intra-vascular space and reducing associated inflammation. This drug appears to be an effective and affordable treatment option for horses with endotoxaemia. The use of specific cyclooxygenase inhibitors in veterinary medicine have been studied recently. Selective cyclooxygenase-2 inhibitors may provide comparable anti-inflammatory and analgesic properties to the non-selective non-steroidal anti-inflammatory drugs. These drugs appear to have similar clinical effectiveness and will hopefully minimize deleterious side effects. The optimal healing of ventral midline incisions in horses is related to many factors including appropriate suture patterns and bite size, in addition to appropriate post-operative exercise recommendations. Recent advances in surgical techniques and post-operative care should decrease the morbidity and mortality associated with abdominal surgery. This article provides an overview of some of these advances.

Laparoscopic Sterilization of Sardinia Donkeys Using an Endoscopic Stapler

OBJECTIVE

To describe a laparoscopic technique for sterilization of the male donkey using an endoscopic linear stapler (ELS).

STUDY DESIGN

Clinical report.

ANIMALS

Male Sardinia donkeys (n=6), aged 24-36 months.

METHODS

Laparoscopic sterilization was performed under standing sedation or recumbent under general anesthesia. An endoscopic linear stapler was used to transect, and control hemorrhage of, the spermatic cord. Serum testosterone concentrations were measured preoperatively and at 3, 6, and 12 months after sterilization. One testis from each of 2 donkeys was collected at 12 months for histologic examination.

RESULTS

Sterilization was successfully achieved. The only minor intraoperative complication experienced was hemorrhage from 1 spermatic cord stump, which was re-stapled. No other major short- or long-term complications occurred. Serum testosterone concentrations were < 15 ng/dL at 3, 6, and 12 months after surgery in all donkeys. Testicular atrophy without evidence of revascularization was observed in the 2 testes examined histologically.

CONCLUSIONS

Sterilization of descended testes by intraabdominal laparoscopic transection of the spermatic cord is a simple practical method, with minimal intraoperative or postoperative complications. Testicular revascularization did not occur.

CLINICAL RELEVANCE

Laparoscopic sterilization in donkey can be performed using an endoscopic linear stapler as an alternative to scrotal castration.