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11 November 1996 V
Minimally
FOCAL POINT
Invasive Surgery:
★By means of enhanced
Laparoscopy and
Thoracoscopy in
illumination and magnification,
minimally invasive surgery
provides excellent visualization of
abdominal and thoracic contents.
KEY FACTS
Small Animals
■ Minimally invasive surgery
results in decreased post- University of Saskatchewan
operative pain and morbidity as Audrey M. Remedios, DVM, MVetSc
well as faster recovery times. James Ferguson, DVM, MSc, DrMedVet
■ Disadvantages of minimally
M
invasive surgery include the high inimally invasive surgery (rigid endoscopy) is an exciting discipline
cost of instrumentation and the that is transforming human and veterinary surgery. In the past, the
steep learning curve for the modality was used primarily by gynecologists to diagnose and treat
operator. pelvic disorders.1 Since the introduction of laparoscopic cholecystectomy by
Mouret in 1987, technologic advances and intense interest by general surgeons
■ Carbon dioxide, not air or nitrous have led to extensive development of minimally invasive procedures.1,2 In
oxide, is recommended for human surgery, virtually every abdominal and thoracic organ has been ap-
intraperitoneal and intrathoracic proached via rigid endoscopy. Most types of surgery that have been performed
insufflation. using conventional open techniques have also been done via minimally inva-
sive surgery.
■ Electrosurgery is essential in The modality involves placing a rigid endoscope through a cannula into the
maintaining hemostasis during abdomen (laparoscopy) or thorax (thoracoscopy). Through small incisions,
minimally invasive surgery. other ports are established to enable manipulation and dissection of abdominal
and thoracic contents. The surgical field is usually displayed on a television
monitor, and the operation is performed according to the observed images.
The effect of this high-tech surgery is to project the surgeon’s eyes and hands
into cavities that previously were accessed through large incisions.
Compared with traditional open surgery, the advantages of minimally in-
vasive techniques are well established in humans2–6 (see the box). Operating
through small incisions, there is much less trauma and stress during and after
surgery. Smaller incisions result in improved cosmesis and fewer postoperative
complications (e.g., wound infection, dehiscence, bleeding, and seroma and
hernia formation). The incidence of adhesion formation is less with lapa-
roscopy because organs are not exposed and dehydrated.7 Perhaps the most im-
Small Animal The Compendium November 1996
portant advantages are less postoperative pain, shorter than open surgery during the learning stages of each
hospital stays, and faster recovery times.4,8–10 procedure.4
In addition, minimally invasive surgery provides major Total dependence on endoscopic images creates prob-
advantages to the surgeon. The enhanced illumination lems for a surgeon. Most operative injuries (e.g., hem-
and magnification facilitate excellent visualization of ab- orrhage and inadvertent organ penetration) are caused
dominal and thoracic contents. Many surgeons believe by the introduction and withdrawal of instruments that
that the visualization is better than with standard open are not under endoscopic visualization.12 The camera
operating conditions.11 Previously inaccessible recesses in operator must learn to follow each instrument entering
the abdominal, pelvic, and thoracic cavities can be ex- and leaving the cavity. The projected images viewed on
plored and visualized by means of angled scopes. the monitor show approximately the distal 5 cm of the
The new technology has operating instruments. Electrosurgical instruments or
several disadvantages. Mini- lasers can cause tissue necrosis if a portion of the acti-
Minimally mally invasive surgery re- vated instrument is out of the viewing range and con-
Invasive quires specialized equip- tacts an organ or another instrument directly adjacent
ment and instruments. A to the tissue (direct electrical coupling).13
Surgical basic operative telescopic
Techniques setup, including video EQUIPMENT
imaging, is very expensive. A basic operative telescopic unit consists of a rigid
Advantages Many veterinary practices, endoscope, video-imaging system, light source, insuffla-
■ Excellent visualization however, already have endo- tor, and electrosurgical unit. Rigid endoscopes are com-
of abdominal and scopic or videoendoscopic posed of a series of lenses that transmit light and im-
thoracic contents equipment; the cost of ac- ages. They are available with several external diameters
■ Less perioperative and quiring additional compo- and various viewing angles.11 Generally, endoscopes
nents is less. Specialized in- with a 10-mm external diameter are used in dogs
postoperative stress
struments are necessary to weighing more than 15 kg, 5-mm endoscopes are used
■ Improved cosmesis perform minimally invasive in animals that weigh 5 to 15 kg, and 2.7-mm endo-
■ Fewer postoperative procedures. Two sets of in- scopes are used in small cats and dogs. The distal ends
complications struments are required to of rigid endoscopes are designed with viewing angles
■ Decreased incidence match the body sizes of ranging from 0˚ to 90˚. Angled endoscopes allow ex-
of adhesion formation patients: standard size for ploration of narrow cavities or recesses. Because illum-
medium and large dogs and ination is lost with greater deflection, most surgeons
■ Less postoperative
pediatric size for small dogs routinely use endoscopes with 0˚ deflection.
pain and cats. The video-imaging system consists of a camera, cam-
■ Briefer hospitalization Most veterinarians are not era head, and monitor (Figure 1). Images from the rigid
■ Faster recovery trained in minimally invasive endoscope are transmitted from the attached camera
surgery. Considerable tech- head through a fiber-optic cable to a remote camera
Disadvantages nical retraining is necessary. control unit. Recently, traditional tube cameras have
■ Need for specialized Surgeons must learn to oper- been replaced by charge-coupled semiconductor cam-
instruments and ate with a new set of visual eras (or chip cameras),14,15 which significantly improve
and tactile skills while using image quality. Quality is further enhanced by digital
equipment
a two-dimensional image video-imaging units that adjust and enhance image pa-
■ Need for technical displayed on a television rameters and by high-resolution color monitors (with
training monitor. Problems to be screen sizes of at least 19 inches), which improve
■ Longer operative time overcome include hand–eye surgeon accuracy while reducing eye and back strain.
during learning stages incoordination, reversed in- Images can be recorded and stored by videocassette
■ Injuries due to strument motion across a recorders and still photo-digitalizers.
fulcrum, absence of a wide A rigid endoscope is illuminated via a fiber-optic ca-
lack of endoscopic
visual field, lack of depth ble that is coupled to a light source. Light sources used
visualization of perception, and lack of tac- in minimally invasive surgery include mercury halide
instruments during tile sensation.5 It is not sur- (150 watts) and xenon (300 watts).11,14 These sources
introduction and prising that minimally in- provide the highest light intensity. The intensity re-
withdrawal vasive surgery is associated quired is dictated by the distance from the endoscope
with longer operative time to the surgery site and by the size of the abdominal or
interbody fusion with carbon fiber cage, iliac bone graft, plates effects of increased abdominal pressure. J Surg Res
and screws. Proc Vet Orthop Soc 22nd Annu Conf:6, 1995. 30(3):249–255, 1981.
38. Gross ME, Jones BD, Berstresser DR, et al: Effects of ab- 41. Cruz AM, Southerland LC, Duke T, et al: Intraabdominal
dominal insufflation with nitrous oxide on cardiopulmonary CO2 insufflation in the pregnant ewe: Uterine blood flow,
measurements in spontaneously breathing isoflurane-anes- intraamniotic pressure and cardiopulmonary effects. Anesthe-
thetized dogs. Am J Vet Res 54(8):1352–1358, 1993. siology, accepted for publication.
39. Ivankovich AD, Miletich DJ, Albrecht RF, et al: Cardiovas- 42. McCarthy TC, McDermid SL: Thoracoscopy. Vet Clin
cular effects of intraperitoneal insufflation with carbon diox- North Am Small Anim Pract 20(5):1341–1352, 1990.
ide and nitrous oxide in the dog. Anesthesiology 42(3): 43. Remedios AM, Walsh PJ, Ferguson JF: Thoracoscopic per-
281–287, 1975. icardectomy in dogs: Preliminary findings. Proc 3rd Int
40. Kashtan J, Green JF, Parsons EQ, et al: Hemodynamic Laparosc Course Vet, 1996.