Vol.18, No.
11 November 1996 V
Continuing Education Article
FOCAL POINT
★By means of enhanced
illumination and magnification,
minimally invasive surgery
provides excellent visualization of
abdominal and thoracic contents.
KEY FACTS
■ Minimally invasive surgery
results in decreased post-
operative pain and morbidity as
well as faster recovery times.
■ Disadvantages of minimally
invasive surgery include the high
cost of instrumentation and the
steep learning curve for the
operator.
■ Carbon dioxide, not air or nitrous
oxide, is recommended for
intraperitoneal and intrathoracic
insufflation.
■ Electrosurgery is essential in
maintaining hemostasis during
minimally invasive surgery.
Minimally
Invasive Surgery:
Laparoscopy and
Thoracoscopy in
Small Animals
University of Saskatchewan
Audrey M. Remedios, DVM, MVetSc
James Ferguson, DVM, MSc, DrMedVet
M
inimally invasive surgery (rigid endoscopy) is an exciting discipline
that is transforming human and veterinary surgery. In the past, the
modality was used primarily by gynecologists to diagnose and treat
pelvic disorders.1 Since the introduction of laparoscopic cholecystectomy by
Mouret in 1987, technologic advances and intense interest by general surgeons
have led to extensive development of minimally invasive procedures.1,2 In
human surgery, virtually every abdominal and thoracic organ has been ap-
proached via rigid endoscopy. Most types of surgery that have been performed
using conventional open techniques have also been done via minimally inva-
sive surgery.
The modality involves placing a rigid endoscope through a cannula into the
abdomen (laparoscopy) or thorax (thoracoscopy). Through small incisions,
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

SURGICAL TECHNIQUES ■ RETRAINING ■ VIDEO-IMAGING SYSTEM

The Compendium November 1996 Small Animal

thoracic cavity. Optimum ing a blood-free operating

light intensity is required for environment.
photography and for scan-
ning panoramic views of ab- OPERATIVE
dominal or thoracic con- INSTRUMENTS
tents. Several basic instruments
Insufflators, which infuse are used in minimally inva-
gas into the abdominal or sive surgery. These tools in-
thoracic cavity, are essential clude an insufflation instru-
for adequate visualization ment, cannulas and trocars,
and surgical manipulation scissors, dissecting forceps,
(Figure 2). High-flow, pres- and graspers.
sure-limited insufflators are Insufflation of the ab-
equipped with feedback dominal or thoracic cavity
mechanisms that regulate with carbon dioxide can be
intraperitoneal or intratho- accomplished via a Hasson
racic pressure to preset lev- cannula or Veress needle14,21
els. Generally, intraabdom- (Figure 3). The Veress nee-
inal pressure is maintained dle is placed through the
at 10 to 15 mm Hg to avoid abdominal or thoracic wall
overinflation and compro- in a blind fashion. It has a
mised venous return. 14,16,17 sharp outer trocar that con-
Pressure in the thorax is tains a spring-loaded blunt
kept below 8 to 10 mm Hg obturator; on initial skin
to avoid cardiovascular com- contact, the obturator is
promise related to tension Figure 1—The video-imaging chain used for minimally in- pushed back to expose the
pneumothorax.18,19 vasive surgery includes the monitor, videocassette recorder, outer cutting edge. On en-
The most common gas camera control unit, remote camera head, and rigid endo- tering each cavity, the inner
source used in minimally scope. portion springs out to pre-
invasive surgery is carbon vent organ injury. Common
dioxide. This gas is readily complications associated
available, is inexpensive, with Veress needle place-
does not support combus- ment include insertion out-
tion, and is readily diffusible side (in the subcutaneous
in blood (thereby minimiz- or retroperitoneal spaces)
ing the risk of embolism). rather than inside the peri-
Other gases, such as air and toneal cavity; laceration of
nitrous oxide, are no longer an omental or intestinal ves-
recommended. sel; and penetration of the
The reduced field of view liver, spleen, bladder, or in-
provided by a rigid endo- testine.20,22,23 Insufflation of
scope necessitates hemo- blood vessels and hollow or
stasis during minimally in- solid organs may produce
vasive surgery. In the past, the disastrous consequence
monopolar electrosurgery of gas embolism.23
was avoided because of the Figure 2—High-flow, pressure-limited insufflators are used The Hasson cannula is
risk of bowel burns or perfo- to regulate the volume of carbon dioxide delivered at a placed using an open tech-
ration resulting from arcing preset intraperitoneal or intrathoracic pressure. nique to allow direct visual-
of high-frequency current.20 ization of the abdominal
Recent histologic evidence, wall. Limited dissection of
however, indicates that such intestinal injuries resulted the skin and subcutaneous tissue is made at the level of
from penetrating instruments. Electrosurgical tech- the umbilicus. The peritoneal cavity is then entered,
niques are now considered safe and essential in provid- and the blunt-tipped Hasson portal is placed and an-

INSUFFLATORS ■ ELECTROSURGERY ■ HASSON CANNULA

Small Animal
chored with sutures. This open
technique avoids perforation of
viscera, especially in the diseased
abdomen.
When the appropriate intra-
peritoneal or intrathoracic in-
sufflation pressure is achieved,
cannulas are inserted to permit
repeated withdrawal and place-
ment of instruments and endo-
scopes (Figure 4). A wide variety
of metal or plastic, reusable or
disposable cannulas is available,
ranging in size from 2.7 to 35
mm (Figure 5). In small animal
procedures, 5- and 10-mm can-
nulas are used most often. Each
cannula has a stopcock to con-
trol insufflation or desufflation
of carbon dioxide and a flapper
valve to prevent loss of gas with
instrument changes.
To prevent pullout, cannulas abdomen or thorax with carbon dioxide.
are designed with a fascia grip
that locks the unit into the skin
and underlying muscle wall. A
trocar within the cannula sleeve
aids insertion. Most trocars have
a sharp, retractable tip that re-
cesses after entry and prevents
trauma to the viscera. After the
cannula is seated, the trocar is
removed to allow placement of
the operating instruments. The
first cannula placed is for the
endoscope. At least two more
placements are necessary, de-
pending on the operative site
and procedure. Cannulas should
be introduced at angles approxi-
mately 45˚ to the endoscope.
Angles smaller than 45˚ cause
instrument interference, and an-
gles larger than 90˚ limit depth
perception.2
LAPAROSCOPY
Although laparoscopic tech-
niques have been used exten-
sively in humans, operative la-
paroscopy is new to veterinary
surgery. In the past, veterinary
laparoscopy was primarily a tool
INTRATHORACIC INSUFFLATION ■ OPERATIVE LAPAROSCOPY ■ ENHANCED ILLUMINATION
Figure 3—A Veress needle is used to insufflate the
Figure 4—After the Veress needle is removed, can-
nulas are used to establish the endoscope and dis-
secting portals. At least two dissecting portals are
necessary for operative laparoscopy or thora-
coscopy.
The Compendium November 1996
for exploring the abdomen,
e s pecially the reproductive
tract.24–27 However, recent stud-
ies have concentrated on the
therapeutic use of laparoscopy.
Urogenital procedures (e.g.,
ovariectomy, ovariohysterecto-
my, and cryptorchid castration)
have been reported in the vet-
erinary literature.28–31 Gastroin-
testinal procedures (including
laparoscopic intestinal anasto-
mosis) and gastropexy have
been described.32–34 These stud-
ies demonstrate that operative
laparoscopy is feasible in small
animals and is associated with
minimal operative complica-
tions.
Laparoscopy has been used
with minimal operative com-
plications to approach vertebral
bodies and intervertebral disks
(L-2 to L-7) in dogs and pigs.35–37
Fenestration of the thoracolum-
bar (T-13 to L-1) and lumbar
intervertebral disks via laparo-
scopic techniques has been re-
ported 36 (Figure 6); the mean
amount of disk material removed
was similar to that in traditional
open surgery. The magnification
and enhanced illumination pro-
vided by the endoscope report-
edly facilitated disk removal and
prevented inadvertent soft tissue
injury.
Laparoscopy affects the car-
diopulmonary function of an
anesthetized patient.16,17,38–41 In-
sufflation of the abdominal cavi-
ty with carbon dioxide decreases
tidal volume and increases intra-
pulmonary shunting and dead-
space ventilation; hypoxemia
results. If dogs are breathing
spontaneously during anesthesia,
hypercarbia may occur, especial-
ly if intraabdominal pressure ex-
ceeds 20 mm Hg.38 To diminish
the effects of insufflation on the
respiratory system, high concen-
trations of inspired oxygen and
Small Animal The Compendium November 1996

appropriate intermittent posi- cilitated by a tightly adherent

tive-pressure ventilation are rec- parietal pleura. Unlike the situa-
ommended.16 Similarly, the car- tion in the abdomen (in which
diovascular system is negatively extraperitoneal insufflation is
affected because high intraab- common), needle or trocar
dominal pressures increase sys- placement into a space other
temic vascular resistance and de- than the thoracic cavity is un-
crease venous return and cardiac common. The thorax is also de-
output.16,17 Cardiopulmonary ef- void of structures that tend to
fects can be minimized by moni- interfere with visualization and
toring via end-tidal capnography instrument manipulation (e.g.,
and blood gas analysis, providing the falciform fat and omentum).
high concentrations of inspired Thoracic organs are anchored
oxygen and keeping intraab- tightly, whereas retraction of the
dominal pressures below 20 mm intestines and spleen is often
Hg.16 necessary to expose other ab-
dominal structures.
THORACOSCOPY The veterinary literature con-
Operative thoracoscopy is tains few reports of the use of
complicated by the necessity of operative thoracoscopy. Like
collapsing the lung lobes in the laparoscopy, thoracoscopy has
associated hemithorax. The lung been used primarily for explo-
must be collapsed to prevent tro- ration of the chest cavity and
car injury to underlying tissue biopsy of intrathoracic organs.42
and (more importantly) to facili- Figure 5—Trocars and cannulas are available in A recent study describes single-
tate examination and surgical several sizes. The trocar must be placed in the lung anesthesia and thoracoscop-
manipulation of intrathoracic cannula before insertion. Plastic trocars have ic subtotal pericardiectomy in
contents. Partial lung collapse sharp, retractable tips that recess after entry dogs. 43 All of the dogs in the
can occur slowly with the passive into the abdominal or thoracic cavity. study demonstrated minimal
entry of ambient air or can be postoperative morbidity and
expedited by insufflation of car- were in less pain than were dogs
bon dioxide into the hemithorax that underwent standard open
or suction on a double-lumen lateral thoracotomy.
endotracheal tube.18
Once the lung is collapsed, gas CONCLUSION
insufflation is discontinued for In small animal patients, op-
the duration of the surgery. erative laparoscopic and thoraco-
Temporary collapse of the lung scopic procedures are technically
lobes in the hemithorax is made feasible and are associated with
possible by ventilating the con- numerous advantages, including
tralateral hemithorax and using diminished postoperative pain
specially designed double-lumen and morbidity. Although these
or bronchus-blocking tubes. The procedures require specialized
risk of hypoxemia can be mini- equipment and are associated
mized by keeping the period of with a steep learning curve, we
lung collapse as brief as possible Figure 6—In dogs, fenestration of the thora- anticipate that the trend toward
and by using a high concentra- columbar and lumbar intervertebral disks can minimally invasive surgery will
tion of inspired oxygen (100%).19 be performed via minimally invasive tech- escalate. Operative laparoscopy
niques.
Patients must be monitored via and thoracoscopy are still in the
pulse oximetry and arterial developmental stages in veteri-
blood gas analysis. nary surgery; during the next 10 years, many tradition-
Operative thoracoscopy is technically easier to per- ally open procedures will be performed by means of
form than laparoscopy.42,43 Entry into the thorax is fa- minimally invasive techniques.

OPERATIVE THORACOSCOPY ■ HEMITHORAX ■ INSTRUMENT MANIPULATION

Small Animal
About the Authors
Dr. Remedios, who is a Diplomate of the American
College of Veterinary Surgeons, and Dr. Ferguson are affili-
ated with the Department of Veterinary Anesthesiology,
Radiology, and Surgery, Western College of Veterinary
Medicine, University of Saskatchewan, Saskatoon,
Saskatchewan, Canada.
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