Page 66 - WSAVA2017
P. 66

An Urban Experience
G. Dupré1
1Dipl. ECVS, Dipl. Human thoracoscopy and interventional pneumology, Clinic for Small animal Surgery, Veterinary Medicine University of Vienna, Veterinaerplatz 1, 1210 Vienna
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 trocards, 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, post-operative 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 vessel- sealer 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.
or intra-thoracic diseases can also be facilitated using a scope and a video monitor.

   64   65   66   67   68