Page 377 - ONLINE PROCEEDING BOOK WSAVA 2017
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WSVA7-0569
MEDICAL ONCOLOGY
MINIMALLY INVASIVE SURGERY: LATEST INFORMATION
J. Kirpensteijn1
1Hill’s Pet Nutrition, Global Prof Affairs, Lawrence, USA
Common endoscopic oncologic procedures
Many laparoscopic procedures have been described in human surgery and are performed on a regular basis. Small animal laparoscopy is slowly developing and is often stuck in an experimental phase. However, several veterinary institutions have advocated laparoscopic surgery in the last decade and now few private practitioners and surgical specialists are using this innovative technique in stead of the old fashioned laparotomy
Abdominal exploratory
The procedure of an abdominal exploratory is relatively easy and minimally invasive. A thorough super cial evaluation is possible of most organs and requires minimal instrumentation. The use of retractors and gripping instruments will also allow visualisation of the more dorsally located organs (kidneys, adrenals, etc.)
It is extremely important to use a  xed order in which you explore the abdomen. During the exploratory, you should always start at the left side and proceed from cranial to caudal (i.e. diaphragm, liver, chest wall, stomach, spleen, abdominal wall etc.). After the left side, you use the same order for the right side. This will prevent that you skip essential organs or abdominal areas. Not all organs can be visualised properly through a median approach. Adrenal glands, kidneys and other dorsally located organs can often better be approached through a lateral approach. Abdominal wall haemorrhage is more likely
in a lateral approach compared to a midline approach. Visualisation of deeper (more dorsally located) organs can also be improved by tilting the patient (use gravity) and by using retracting forceps.
In cases of severe ascites, the  uid should be removed before exploring the abdomen. Inserting the trocar
of the scope can be done blindly (the chance of puncturing an essential organ is minimal because of the amount of  uid). Some of the  uid is aspirated using and endoscopic suction device. Then the abdomen is in ated and the rest of the  uid is removed under direct visualization.
Endoscopic biopsy
To obtain a biopsy using laparoscopy is relatively easy. The location of the organ often dictates the entry ports of the laparoscope and instruments. If the location is
unknown a median entry of the laparoscope, just behind the umbilicus is preferred. The falciform ligament is avoided and the whole abdomen can be visualized easily. There are two methods of obtaining a biopsy specimen that are propagated.
• using cutting or coagulating instruments through separate entry ports.
• using speci c biopsy instruments (Tru-cut, sure cut) without a separate entry port.
Almost any organ can be biopsied using one of these techniques. Haemorrhage caused by the biopsy instrument can be stopped using coagulation, suture material or application of thrombin-impregnated gelatine. An excisional biopsy can be performed in selected cases. For instance, an abnormal lymph node may be obtained through careful dissection and coagulation of the afferent and efferent vessels.
Laparoscopic adrenalectomy
Amongst advanced laparoscopic procedures in human medicine, laparoscopic adrenalectomy has become a standard of care procedure for resection of most primary adrenal tumors. There is now gathering evidence that laparoscopic adrenalectomy may represent a very reasonable option for resection of non-invasive adrenal tumors in small animal patients.
The author prefers a sternal approach: In a full sternal position the dog is placed on its sternum with a cushion between its hind legs lifting the pelvis of the table.
The two hind legs are placed besides the cushion in a splayed leg position. The purpose of this recumbency
is to lift the abdomen as far from the table as possible, preferably in a hanging position. This often requires taping the dog especially on the nonsurgical site to handles of the table to increase stability. The sternal position makes the organs ‘suspend’ in the abdomen and eliminates the need for pushing organs away during the procedure. The visibility of the adrenal gland is much improved during this position technique. If the kidney is closely associated with the adrenal gland, cutting the retroperitoneal attachment cranially or over the full length of the kidney will also increase visibility. In this way you create an open retroperitoneal approach.
For LA in sternal recumbency ports are placed in a semicircular line starting halfway the ribcage and ending at the middle of the ilial wing. The circle is pointing upwards. The  rst trocar inserted is the camera port on the highest point of the circle, 1-2 cm under the epaxial abdominal muscles and preferably before the left kidney (if palpable). The authors prefer to use an open approach using a turn trocar under endoscopic visualization. As soon as the abdomen is entered, CO2 is insuf ated and
An Urban Experience
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