Learning outcomes

• Get an overview of the indications and technical specificities of minimally invasive surgery
• Understand the principles of specific training

The idea of looking inside the body is not new but the development of surgical laparoscopy really happened in 1987 after Mouret and Dubois successfully performed the first laparoscopic cholecystectomy. The advantages of mini-invasive surgery have been described and sustained by several evidence-based studies. They usually comprise:

• Smaller incisions
• Better visions
• Less post-operative pain
• Shorter hospital stay

Since mini-invasive surgery requires specific training and specific material and as the operating costs and durations can be higher and carry specific anesthetic constraints, one can really ask the question: Laparoscopy, is it for the practitioner or why and how should I start with it?

Mini-invasive surgery requires a specific material: a tiltable surgical table, a complete video setting with 0–30° laparoscopes, a mono or three CCD camera and recording material. In the abdominal cavity, an insufflator will also be used. An electrosurgical unit with uni- and bipolar cautery for endoscopic instruments as well as irrigation and vacuum system are necessary. All types of endoscopic instruments must also be available: laparoscopic trocars, endo-graspers, suture, clipping and stapling material... In laparoscopic surgery, the working space is obtained by insufflating carbon dioxide into the abdominal cavity, creating a pneumoperitoneum. Monitoring the patient during the procedure is mandatory and requires an anesthetist (nurse or vet) and adequate monitoring: spirometer, EKG, pulse oxymetry and, moreover, capnography.

The practitioner willing to start with minimally invasive surgery shall be prepared to follow specific pathways that include:

• Training sessions on models, cadavers and anesthetized experimental animals
• Training sessions at home on models
• Preceptorship under the guidance of a course master

This new philosophy of surgery where the minimum morbidity is the rule must be acquired and for this, hours, days and weeks of specific trainings are necessary. Once this has been achieved, the surgeon can start to use minimally invasive surgery for specific indications, as for instance:

• Exploratory examination and biopsies
  The laparoscopic assessment of most tissues is superior to open surgery due to the amount of magnification. However, a full laparoscopic exploration might be difficult and time consuming. Lately, laparoscopy has also become a major help in cancer staging and is routinely called "staging laparoscopy."
  Liver, kidney, and spleen biopsies can be easily performed using a two- or a one-hole laparoscopy. Intestinal biopsies are best made by laparoscopic-assisted technique. Taking laparoscopic liver biopsies is a simple technique for it allows visual direction towards focal lesions. This together with the large tissue chunks explain why the technique consistently delivers better quality of samples compared to ultrasound-guided Tru-Cut biopsies.
• Partial or total organ ablation, drainage
  Laparoscopy offers several advantages over conventional laparotomy for elective surgeries: cryptorchiectomy, ovariectomy or ovario-hysterectomy. In several studies, postoperative behavior using behavior scales have validated the superiority of laparoscopic ovariectomy over regular ovariectomy. Besides the traditional 3 holes techniques, 2 and one-hole techniques have been described and offer great cosmetic advantages. To perform quickly coagulation and resection, several devices have been advocated including monopolar or bipolar electrocautery, laser, harmonic scalpel and vessel­sealer divider devices. In order to reduce the operation time, by reducing the exchanges of instruments, vessel-sealer divider devices are the best option.
  Intra-abdominal removal of pathologic organs have also been performed: cholecystectomy, adrenalectomy, pancreatic tumors... In the chest, thoracoscopic pericardectomy offers major advantages over traditional trans-sternal or trans-thoracic approaches.
• Mini-invasive assisted procedure
• Laparoscopic-assisted gastropexy
  Laparoscopic-assisted gastropexy represents a fast and very convenient method used in the prophylaxis of gastric dilatation volvulus. It could be done as a standalone procedure or concomitantly with others (e.g., laparoscopic gonadectomy). One can choose between single-incision-multiple-port, single-incision-single-port or multiple-incisions-multiple port variation of laparoscopic­assisted techniques. No matter which technique is used, they all have in common that the gastric wall is grasped in the area of pyloric antrum by a laparoscopic grasper and brought to the right abdominal wall just caudal to the last rib while the abdomen is being deflated. The original incision of the abdominal wall is usually extended, the serosa and the muscular layer of the stomach are also incised and the muscular layers are appositionally sutured to each other from outside of the abdominal wall.
• Laparoscopic-assisted cystotomy
  This technique is usually used for uroliths removal and biopsy of the urinary bladder as well as removal of intraluminal masses. Urinary bladder is brought to the abdominal wall by means of laparoscopy. An incision is created directly over the bladder and the bladder is temporarily sutured there. A trocar could be placed into the bladder and it will be explored and treated endoscopically.
• Laparoscopic-assisted entero-/enterectomy and/or intestinal anastomosis
  After proper laparoscopic examination of the abdominal cavity, the affected intestinal loop is grasped and brought outside of the abdominal cavity where the contaminated part of the procedure is performed and the intestinal segment is cleaned, flushed and returned into the abdomen.
• Other laparoscopic and video-assisted procedures
  Many other video-assisted procedures have been published in the veterinary literature:
  Laparoscopic-assisted placement of gastrointestinal feeding tube, laparoscopic-assisted placement of peritoneal dialysis catheter and cholecystostomy tube, laparoscopic-assisted placement of gastrointestinal feeding tube, laparoscopic-assisted splenectomy, laparoscopic-assisted treatment of pyometras. In the chest, partial or total lung lobectomies, PDA closure, ligamentum arteriosum removal, thymomas removal have been performed.

Finally, these questions are to be answered in order to understand why and how one shall start

• Does mini-invasive surgery present any advantage to the patient?
  On many elective surgeries (ovariectomy, ovario­hysterectomy, cryptorchiectomy) as well as on some specific procedures (pericardiectomy, adrenalectomy), pain scores and behavior scores have been shown to be in favor of mini-invasive approach.
• What are the advantages for the owners?
  The idea of mini-invasive surgery as well as the idea of offering the “state-of-the art technology" pushes the owners to ask for mini-invasive surgeries. They easily compare human surgery with veterinary surgery and expect for their pet what they want for themselves.
• Can the practitioner benefit from it?
  Placing a scope into a cavity has brought over the years a tremendous amount of information. The practitioner willing to start with mini-invasive surgery should start with rigid endoscopic examination: urethro-cystoscopy, otoscopy, rhinoscopy, laryngo-pharyngoscopy, bronchoscopy. Then, further progresses can be achieved by performing intra-abdominal biopsies: liver, lymph node, pancreas...Once this has been done, elective surgeries can be offered: ovariectomy, cryptorchiectomy.

Over the past twenty years mini-invasive surgery has represented a major progress in diagnosis and treatment of surgical diseases. In small animal surgery, practitioners shall benefit of it and shall offer it to their clients. Going step by step, getting trained in training centers, not being too ambitious when getting started are the keys for efficient progresses and successes.

References

1.  Monnet E, Twedt DC. Laparoscopy. Vet Clin North Am Small Anim Pract. 2003;33(5):1147–1163.

2.  Barnes RF, Greenfield CL, Schaeffer DJ, Landolfi J, Andrews J. Comparison of biopsy samples obtained using standard endoscopic instruments and the harmonic scalpel during laparoscopic and laparoscopic-assisted surgery in normal dogs. Vet Surg. 2006;35(3):243–251.

3.  Dupré G, Fiorbianco V, Skalicky M, Gültiken N, Ay SS, Findik M. Laparoscopic ovariectomy in dogs: comparison between single portal and two­portal access. Vet Surg. 2009;38:818–824.

4.  Fiorbianco V, Skalicky M, Doerner J, Findik M, Dupré G. Right intercostal insertion of a Veress needle for laparoscopy in dogs. Vet Surg. 2012;41(3):367–373.

5.  Dupré G, Fiorbianco V. In: Griffon D, Hamaide A, eds. Complications in Small Animal Surgery. ISBN: 978-0-470-95962-6; 2016.

6.  Pelaez MJ, Bouvy BM, Dupré G. Laparoscopic adrenalectomy for treatment of unilateral adrenocortical carcinomas: technique, complications, and results in seven dogs. Vet Surg. 2008;37:444–453.

7.  Buote NJ, Kovak-McClaran JR, Schold JD. Conversion from diagnostic laparoscopy to laparotomy: risk factors and occurrence. Vet Surg. 2011;40(1):106–114.

8.  Dupré G, Coudek K. Laparoscopic-assisted placement of a peritoneal dialysis catheter with partial omentectomy and omentopexy in dogs: an experimental study. Vet Surg. 2013.

9.  Petre SL, McClaran JK, Bergman PJ, Monette S. Safety and efficacy of laparoscopic hepatic biopsy in dogs: 80 cases (2004–2009). J Am Vet Med Assoc. 2012;240(2):181–185.

10.  McDevitt HL, Mayhew PD, Giuffrida MA, Brown DC, Culp WT, Runge JJ. Short-term dinical outcome of laparoscopic liver biopsy in dogs: 106 cases (2003–2013). J Am Vet Med Assoc. 2016;248(1):83–90.

11.  Becher-Deichsel A, Aurich JE, Schrammel N, Dupré G. A surgical glove port technique for laparoscopic-assisted ovariohysterectomy for pyometra in the bitch. Theriogenology. 2016;86(2):619–25. doi: 10.1016/j.theriogenology 2016.

12.  Katic N, Dupré G. Advances in endoscopic surgery for small animal reproduction. Reprod Dom Anim. 2016;51(Suppl. 1):25–30.