COMPARATIVE EVALUATION OF CONVENTIONAL AND LAPAROSCOPIC-ASSISTEDT ECHNIQUE FOR INTESTINAL SURGERY IN DOGS

Eunice G. Thomas1, S.D. Tripathi2, D.U. Lokhande3, G.S. Khandekar and A.A. Datir
1M.V.Sc. Student, 2Assistant Professor, 3Associate Professor & Incharge Department of Veterinary Surgery and Radiology, Bombay Veterinary College, MAFSU, Parel, Mumbai-12.
[Received: 18.1.2018; Accepted: 06.8.2018] {DOI 10.29005/IJCP.2018.10.2.157-162}

Eight dogs with intestinal tumour (02) and intestinal intussusception (06), were diagnosed and operated by
laparoscopic-assisted technique (4cases) or conventional method (4cases) under atropine sulphate (0.02 mg/kg s/c), butorphanol tartrate (0.2 mg/kg i/v) and acepromazine maleate (0.02 mg/kg i/v) pre-medicated, propofol (4 mg/kg i/v) induction and isoflurane (2.5%) maintenance anaesthesia. No intraoperative and only minimal postoperative complications were noted in the cases of both groups in this study.
Keywords: Anastomoses, Intestinal biopsy, Intestinal resection, Intestinal tumour, Intussusception,
Laparoscopic-assisted technique.

Minimally invasive surgery is being adopted in veterinary medicine with increasing frequency, and with a wider
selection of described procedures. Laparoscopic-assisted (LA) intestinal resection and anastomosis for discrete
intestinal masses is an effective treatment option for the distal duodenum to the middescending colon (Gower and Mayhew, 2011). The minimal invasiveness of the procedure, rapid patient recovery and diagnostic accuracy make laparoscopy a preferred technique over the invasive procedures. The present clinical study was done to optimize its application in intestinal surgery in dogs.

Materials and Methods
Eight clinical cases of intestinal disorders were presented at the BSDP hospital for animals affiliated to Bombay
Veterinary College, Parel Mumbai, for diagnosis and management of the condition (table 1 and 2).

Anamnesis was recorded and dogs were subjected to physical examination. Blood was collected and sent for haemato-biochemical analysis. After physical examination, surgical intervention seemed necessary in all the
cases. However, most of the cases posed high anesthetic risk due to their moribund and critical state. All the cases were administered with parenteral fluid therapy prior to surgery.
The following criteria was followed to operate the case by Laparoscopic-assisted (LA) or conventional method:

a. If the dog was in a critical condition and diagnosis seemed unclear, laparoscopic technique was used to perform exploratory laparoscopy for confirmatory diagnosis followed by a LA surgery if possible (case no. E1).

b. In unstable cases suspected for abdominal tumors, exploratory laparoscopy was performed for diagnosis followed by a biopsy of the tumour either by total laparoscopic or LA method (case no. B1).

c. In unstable cases suspected for
intussusception, laparoscopy was used for confirmatory diagnosis followed by LA surgical intervention (case no. D1, E1, F1).

d. In critical or stable cases, when the diagnosis was obvious by anamnesis, abdominal palpation and diagnostic imaging modalities like plain or contrast radiography and abdominal ultrasound, the conventional

e. approach was attempted. (case no. B2, D2, E2 and F2)

All the dogs were pre-medicated with Atropine Sulphate (0.02mg/kg body weight) s/c 15 minutes before the induction of anaesthesia. Butorphanol Tartrate (0.2mg/kg body weight) was injected i/v followed by
Acepromazine maleate (0.02mg/kg body weight). Ten minutes after the administration of premedicants. Anaesthesia was induced with Propofol (4mg/kg body weight) i/v. Anaesthesia was maintained by inhalation
anaesthesia using Isoflurane- Oxygen mixture.

Procedure for Laparoscopic-assisted
intestinal surgery

The animal was positioned in dorsal recumbancy. The ventral abdomen was prepared aseptically.Veress needle was
introduced near the umbilicus through a skin incision. Flexible tubing was used to connect the Veress needle to the insufflator and insufflation done with CO2 to establish pneumoperitoneum. A laparoscopic portal (6
mm or 11 mm) was placed on the midline between the xyphoid and the umbilicus as per the requirement. The laparoscope was placed through this trocar to enable visualization of the abdominal organs. Additional ports were
placed as per requirement. The abdominal contents were examined laparoscopically. A magnetic blunt probe was used to examine the abdominal contents. The diseased portion of the gastro-intestinal tract (GIT) was
identified and a 5 mm laparoscopic grasping forceps was inserted through one of the additional ports which was used to grasp the portion of the GIT to be exteriorized. Laparotomy sponges were used to pack off the exteriorized portion of the GIT and

Procedure for Conventional Intestinal
Surgery

The procedure for enterectomy and intestinal anastomosis (case no. B2, D2, E2) and enterotomy (case no. F2) was carried out. The following surgical parameters such as surgical operating time, pain during surgery and the length of the skin incision were noted in all the cases. All the cases were extracorporeal gastro-intestinal surgery was
performed as per routine method.

In case B1, a working port was made, using a 6-mm threaded trocar on the left cranial quadrant of the abdomen almost parallel to the camera port. In case D1, E1 and F1, a working port was made along the ventral
midline caudal to the camera port.In case B1 the intra-luminal intestinal tumour was located and a biopsy was taken using the biopsy cup forceps.The abdomen was lavaged with warm sterile normal saline and the fluid was removed using suction (VET PUMP). The abdominal muscles and subcutaneous tissue were closed using Catgut no. 2-0 with
simple interrupted sutures. The skin was closed using Ethilon No. 0 with cross mattress suture. In case D1, E1 and F1after exploratory laparoscopy, the affected portion of intestine was identified as intussusception. In case no. D1, E1 and F1, the intussusceptions were reduced manually by gently applying traction on the neck of the intussusceptum while milking its apex out of the intussuscipiens. Care was taken to avoid excessive traction, because this could lead to tears on the compromised intestine. In some cases, the intestine was milked to a point
where necrosis and adhesions were minimal. The reduced intestine was then evaluated for viability and perforation. Resection and anastomosis of the non-viable portion of intestine was performed when manual reduction was impossible, and tissue is devitalized, or mesenteric vessels have been avulsed from a portion of the involved
intestine. The intestinal contents were gently milked 4 to 5 cm to either side of the intended incision.The procedure for enterectomy and intestinal anastomosis was carried out.

maintained on injection cefotaxime (50 mg/kg i.v. bid), metronidazole (15 mg/kg i.v. bid), RL (40-90 mg/kg i.v. as per the hydration status of the dogs), DNS (40-90 ml/kg i.v. as per the hydration status), amino acid preparation (4-6 ml/kg i.v. bid) along with B-complex and antacid injections for 5 days. The dogs were kept nil-by-mouth for 21
hours and then they were allowed on oral water intake and if no vomiting was noted semi solid food in the form of lapsi was provided in small quantities 3-4 times in a day. Postoperative pain scores were assessed according to the Colorado State University, canine acute pain scale. They were judged one day post operatively.

Results and Discussion Skin sutures were removed on the 12th day post-surgery. The post-operative care and
follow up done was adequate and led to good healing with no complication.

Laproscopic-assisted procedure: Though the laparoscopic assisted method is more challenging to master and
execute requiring hours of practice and patience, it has its own advantages over the traditional method of GI surgery. The most important factor that was experienced during surgery was the visibility. The same level of
magnification or visibility cannot be achievedby the naked eye. Similar advantages,
associated with magnification have been documented by Rawlings et al. (2003), Rawlings (2009), Pinel et al. (2013) and Case and Ellison (2013). During laparoscopy, a sweeping examination could also be carried
out of all abdominal organs to detect abnormality. Biopsies can also be taken if necessary, as also described by Rawlings et al., (2003). In case B1, in addition to exploratory laparoscopy for confirmatory diagnosis of the intestinal mass, an intestinal biopsy was also obtained, which was much easier compared to conventional method.
Claudio et al. (2011) opined that minimal invasive procedures like biopsies could be taken directly from the desired site with

minimal post-operative discomfort. It helped in confirmatory diagnosis of the gastrointestinal
disorder, especially in cases when diagnosis was doubtful using other modes of diagnostic imaging like radiography (plain or contrast x-rays, ultrasound and CT-scan). This procedure may be preferred, when surgical intervention seemed necessary especially in critical cases.

Conventional intestinal surgery:
Surgical procedures viz. enterectomy and anastomosis and intestinal biopsy were performed by the conventional method via ventral midline abdominal incision. The procedures were performed without difficulty
and with minimal complications.

The mean surgical time was 109.50 ± 21.67min and 97.50 ± 16.03min for group I and group II respectively. There was no significant difference between the groups. Almost similar surgical time for both groups could be due the conversion of LA technique to open method in majority of the procedures performed in group I.The group I took longer time due to multiple additional steps like insufflation, insertion of trocars and telescope, removal of trocars and desufflation.
The mean incision length was 5.43 ± 1.32 in group I and 8.88 ± 1.21 in group II. There was no significant difference between the groups. This could be due to lengthening of the incision to exteriorize the intussusception (case no. D1, E1, F1) depending on its size.
In case F1, peritonitis was noted on exploratory laparotomy as also reported by Ralphas et al. (2003). The intestines also seemed friable. Lesser pain was felt in Group I, possibly due to lesser tissue trauma. Though both groups were provided with the same postoperative analgesia, dogs in group II showed more discomfort. Case and Ellison
(2013) has also stated that laparoscopic assisted technique is associated with decreased pain. Case no F1 showed extreme signs of abdominal pain on palpation due to peritonitis and anastomoses leak 3 days postsurgery.

On comparing the two techniques, visibility, magnification and lower incidence of infection and pain were found to be major advantages in the technique employed in group I. However, bigger sized tumors, foreign bodies (linear), intussusceptions etc. seem to be a limitation to laparoscopic assisted GI surgery (Table3 and 4).

References
Case J.B. and Ellison, G.W. (2013). Single incision laparoscopic‐assisted intestinal surgery (SILAIS) in 7 dogs and 1
cat. Veterinary Surgery, 42(5): 629-634.

Claudio, C., Gianluca, R., Alessandro, V., Claudio, M., Paolo, P.D. and Alberto, M. (2011). Laparoscopy in Diagnosis and Treatment of Small Bowel Diseases. In: Advances in Endoscopic Surgery, Cornel Iancu Eds.; 1st edn., InTech-
Europe, Rijeka, Croatia. Pp.237-258.

Gower, S.B. and Mayhew, P.D. (2011). A wound retraction device for laparoscopic‐assisted intestinal surgery in
dogs and cats. Veterinary Surgery, 40(4): 485-488.

Pinel, C.B., Monnet, E. and Reems, M.R. (2013). Laparoscopic-assisted cystotomy for urolith removal in dogs and cats —23 cases. Can. Vet. J., 54(1): 36–41.

Ralphs, S.C., Jessen, C.R. and Lipowitz, A.J. (2003). Risk factors for leakage following intestinal anastomosis in dogs and cats: 115 cases (1991–2000). J. Am. Vet. Med. Assoc., 223(1): 73-77.

Rawlings, C.A., Mahaffey, M.B., Barsanti, J.A. and Canalis, C. (2003). Use of laparoscopic-assisted cystoscopy for
removal of urinary calculi in dogs. J. Am. Vet. Med. Assoc., 222: 759–761.

Rawlings, C.A. (2009). Endoscopic removal of urinary calculi. Compendium, 31(10): 476-484.

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