Contents of Today's Veterinary Practice - JAN-FEB 2012

Today's Veterinary Practice provides comprehensive information to keep every small animal practitioner up to date on companion animal medicine and surgery as well as practice building and management.

Page 18 of 83

THE CUTTING EDGE: INTRODUCING REDUCED PORT LAPAROSCOPIC SURGERY |
Step by Step: SPA Technique 1. The SPA technique in canine patients is accom- plished by creating a 1- to 2-cm incision midway between the umbilicus and the xyphoid.
Ó°Ê1Ãin}Ê ÌhiÊ >ÃÃ>nÊ >L`omin>lÊ >VViÃÃÊ ÌiVhniµÕiÊ (direct trocar insertion without prior pneumo- peritoneum), a 5-mm blunt laparoscopic trocar iÃÊ inÃiÀÌi`Ê inÌoÊ ÌhiÊ >L`omin°Ê 1Ãin}Ê minim>lÊ blunt dissection, 2 subcutaneous tunnels are undermined approximately 1- to 2-cm laterally on either side of the initial camera trocar.
3. Through these tunneled incisions, 2 additional, very low profile (head size < 2 cm) 5-mm trocars ÕnÌÊ ÌÀoV>À]Ê Voo«iÀÃÕÀ}iV>l°Vom®Ê >ÀiÊ inÃiÀÌi`Ê caudolaterally; then carefully inserted into the abdominal wall using the sharp trocars.
4. The 3 trocars are arranged in a triangulated position, each through separate fascial open- ings, but exiting through the same skin incision (Figure 1).
SINGLE PORT DEVICE PLATFORMS (Multitrocar Ports)
SILS Port (Single Incision Laparoscopic Surgery) /hiÊ - -Ê mÕlÌiÌÀoV>ÀÊ `iÛiViÊ iÃÊ >nÊ
->««ÀoÛi`Ê
access system used for reduced port laparoscopic surgery in humans. This port allows the clinician to simultaneously pass multiple instruments through a single access point (Figure 2). The efficacy and learning curve of this access system
in veterinary surgery is currently being evaluated clini- cally for select procedures in canine and feline patients >ÌÊ1niÛiÀÃiÌÞÊ ovÊ *innÃÞlÛ>ni>Ê -VhoolÊ ovÊ 6iÌiÀin>ÀÞÊ Medicine (Figure 5).
Port Placement /hiÊ- -ÊmÕlÌiÌÀoV>ÀÊ«oÀÌÊ iÃÊ«>Vk>}i`Ê>n`ÊÃÕ««lii`Ê >ÃÊ>ÊÃÌiÀiliÊÃin}li-ÕÃiÊ`iÛiVi°Ê ÌÊiÃÊ>ÊLlÕiÊvliÝiLliÊ«oÀÌÊ
Figure 6. Articulating instruments that allow trian- gulation: SILS dissector & clinch articulating instru- ments (covidien.com)
made from hourglass-shaped elastic polymer that conforms and fits snugly within the abdominal inci- sion. UÊ/hiÊ«oÀÌÊVonÌ>inÃÊ{Êo«inin}Ã\Ê£ÊvoÀÊinÃÕvvl>ÌionÊ and 3 to accommodate separate rigid trocars from 5 to 12 mm in size.
UÊ/hiÊ«oÀÌÊ iÃÊinÃiÀÌi`ÊÌhÀoÕ}hÊ>ÊÓ-VmÊv>ÃVi>lÊ inVi- sion by placing 2 staggered, curved Rochester carmalt clamps at the base of the port and direct- ing the tips of the carmalt into the abdomen.
UÊ/hiÊ Vom«ÀiÃÃiLiliÌÞÊ ovÊ ÌhiÊ «oÀÌÊ >lloÜÃÊ iÌÊ ÌoÊ expand and fit snugly in the fascial incision, extending down to the level of the peritoneum.
UÊ/hiÊhii}hÌÊovÊÌhiÊÀi}i`ÊÌÀoV>ÀÃÊÌh>ÌÊ«>ÃÃÊÌhÀoÕ}hÊ the port is staggered, allowing the heads to have freedom of movement without touching.
UÊ-«iViminÊ >n`Ê liLiÀ>Ìi`Ê ÌiÃÃÕiÊ V>nÊLiÊiÝÌÀ>VÌi`Ê either during or after the procedure is completed LÞÊ}inÌlÞÊ«Õllin}ÊÌhiÊ- -Ê«oÀÌÊoÕÌÊovÊÌhiÊinViÃion°Ê
UÊ/hiÊ«oÀÌÊV>nÊLiÊ Ài«i>Ìi`lÞÊ inÃiÀÌi`ÊoÀÊ ÀimoÛi`Ê through the fascial incision during the procedure.
Instrument Placement As with all laparoscopic surgery, adequate visualiza- tion of the operative field is essential. A basic tenet of laparoscopic surgery requires a degree of triangula- tion of instruments in order to produce adequate intracorporeal working space for dissection and manipulation of tissue. 7hinÊÕÃin}Ê ÌhiÊ - -Ê«oÀÌÊÜiÌhÊ ÃÌ>n`>À`Ê l>«>Ào-
scopic instruments, the parallel and close proximity of the left and right hands may result in crowding, ultimately preventing adequate triangulation. This problem is offset by using novel instruments that have the capability to articulate (Figure 6). UÊ/hiÊ ÌiVhniµÕiÊ ovÊ VÀiÃÃ-VÀoÃÃin}Ê ÓÊ ÀiÌiVÕl>Ìin}Ê instruments ("cross handed") has been described ÌoÊ«iÀvoÀmÊÛ>ÀioÕÃÊ-
-Ê«ÀoVi`ÕÀið12
Figure 5. SILS port placement for a canine ovari- ectomy
UÊ"ÌhiÀÃÊh>ÛiÊ>`ÛoV>Ìi`ÊÕÃin}Ê£ÊÀiÌiVÕl>Ìin}ÊinÃÌÀÕ- ment and 1 straight instrument.13
January/February 2012 Today's Veterinary Practice 17