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Indications and Techniques Overview of the Veress Needle and Hasson ❯❯ Jeffrey J

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Indications and Techniques Overview of the Veress Needle and Hasson ❯❯ Jeffrey J Section Name Laparoscopic-Assisted and At a Glance Risk Factors for Gastric Laparoscopic Prophylactic Gastropexy: Dilatation–Volvulus Page 60 Indications and Techniques Overview of the Veress Needle and Hasson ❯❯ Jeffrey J. Runge, DVM Technique for Obtaining University of Pennsylvania Abdominal Access Page 60 ❯❯ Philipp Mayhew, BVM&S, MRCVS, DACVS Columbia River Veterinary Specialists Laparoscopic-Assisted Vancouver, Washington Gastropexy Page 61 ❯❯ Clarence A. Rawlings, DVM, PhD, DACVSa Laparoscopic The University of Georgia Gastropexy Page 63 astric dilatation–volvulus (GDV) is open surgical gastropexy techniques have a syndrome characterized by rapid been described: tube, circumcostal, belt G accumulation of gas or food in the loop, muscular flap, gastrocolopexy, and stomach, increased intragastric pressure incisional. Because of the high mortality and wall tension, and rotation of the rate associated with the development of stomach about its long axis. Gastric dis- GDV, these procedures may be used pro- tention unleashes a series of potentially phylactically in dogs that have not had GDV lethal pathophysiologic events, the most but are considered to be at high risk.8,9 important of which are compression of Studies have indicated that a prophylac- the portal and caudal vena caval venous tic gastropexy can result in a twofold to blood flow, gastric necrosis, tissue aci- 30-fold reduction in lifetime mortality asso- dosis, cardiac arrhythmia, disseminated ciated with GDV for rottweilers and Great intravascular coagulation, and hypoten- Danes, respectively.10 sive and cardiogenic shock.1 For dogs Recent advances in veterinary medicine that develop GDV, surgical correction have included a move toward more mini- is strongly recommended. Among those dogs, mortality remains high (15% to TO LEARN MORE 33%), even with aggressive resuscitative management.2–5 A gastropexy is the creation of a perma- nent adhesion between the gastric antrum For a detailed description of abdominal access using a Veress needle or the Hasson and the adjacent right body wall. Failure to technique, see the August 2008 Surgical perform a gastropexy at the time of surgery aDr. Rawlings discloses Views article, “Canine Laparo- that he has received fi- for GDV correction results in a >50% recur- scopic and Laparoscopic- nancial support from Bio- rence rate,4 whereas performing a prophy- Assisted Ovariohysterectomy vision, Covidien, Ellman lactic gastropexy during corrective surgery and Ovariectomy.” This article International, Endoscopic for GDV decreases the recurrence rate by is avail able at Support Services, and 4,6,7 CompendiumVet.com. Karl Storz Veterinary En- 4% to 10%. As a result, gastropexy is now doscopy. considered the standard of care.4 Several 58 Compendium: Continuing Education for Veterinarians® | February 2009 | CompendiumVet.com mally invasive procedures, and the use of lap- aroscopic surgery for creating a less invasive prophylactic gastropexy has been investigated. These techniques can be performed in isola- tion or in conjunction with surgical steriliza- tion. Laparoscopic-assisted,11 laparoscopic,12–14 and endoscopic15 gastropexy techniques have proven successful. The clinical outcome of a reported laparoscopic-assisted gastropexy16 indicated a persistent attachment between the stomach and the body wall with few compli- cations and effective prophylaxis against GDV development. Studies reveal that an intracor- poreally sutured laparoscopic gastropexy can be performed safely and effectively and has QuickNotes less impact on the dog’s postoperative activ- ity level than a laparoscopic-assisted gas- Predisposition tropexy.13 However, the adhesion strength and to GDV has been long-term outcome of the intracorporeally demonstrated for sutured laparoscopic technique have not yet several breeds. been evaluated.13 In this article, we describe the techniques for laparoscopic-assisted and laparoscopic gastropexy. Risk Factors for Gastric Dilatation–Volvulus A breed predisposition has been demonstrated for Great Danes, German shepherds, standard poodles, Weimaraners, Saint Bernards, Gordon setters, Irish setters, bassett hounds, Airedale terriers, Irish wolfhounds, borzois, blood- hounds, Akitas, and bull mastiffs.2,3 Large, Overview of the Veress Needle and Hasson Technique for Obtaining Abdominal Access BOX 1 The Veress needle has a blunt-tipped, spring-loaded stylet within a sharp-tipped needle. As it is advanced through the body wall, the sharp tip penetrates the abdominal musculature; once within the peritoneal cavity, the spring-loaded protective stylet is deployed, thus minimizing risk of iatrogenic organ damage when the abdominal cavity is penetrated. Peritoneal insufflation can then be performed through the needle, followed by trocar placement. The Hasson technique uses a blunt cannula in a trocar–cannula assembly that is passed through a very small incision, usually created in a subumbilical location. Once the peritoneum has been sharply penetrated, the trocar–cannula assembly is advanced into the abdomen, pointing to the right side to minimize the risk of splenic laceration. If a 5-mm telescope and instrumentation are used, a 6-mm trocar–cannula assembly should be placed first. 60 Compendium: Continuing Education for Veterinarians® | February 2009 | CompendiumVet.com mixed-breed dogs are also predisposed. FIGURE 1 Various non–breed-associated risk factors have been shown to be associated with GDV. Nondietary risk factors include lean body con- dition, older age, male sex, increased thoracic depth-to-width ratio, first-degree relative with GDV, aggressive or fearful temperament, histo- logic evidence of inflammatory bowel disease, and increased hepatogastric ligament length.15 Dietary risk factors that can lead to the devel- opment of GDV include food characteristics— small food particle size and the presence of oil or fat among the first four ingredients of a dry food—and feeding practices or behav- iors, including feeding a large amount of food, once-daily feeding, feeding from an elevated QuickNotes bowl, eating quickly, and aerophagia.15 Based on these risk factors, it may be reasonable to Dietary risk factors conclude that certain canine subpopulations that can lead to the are at such a high risk of developing GDV that Patient positioned in dorsal recumbency. development of they could be considered good candidates to The camera port is placed on the midline just GDV include food receive prophylactic treatment. caudal to the umbilicus. The instrument port is characteristics and placed just lateral to the right margin of the rectus feeding practices or abdominus and 3 to 5 cm caudal to the last rib. Laparoscopic-Assisted Gastropexy behaviors. To perform a laparoscopic-assisted gastropex y, Courtesy of Clarence Rawlings, DVM, PhD, DACVS. place the dog in dorsal recumbency and clip and aseptically prepare the abdomen from cannula assembly should be large enough to the xiphoid cartilage to the brim of the pubis. accommodate 10-mm instrumentation. Abdominal access can be obtained by use Transilluminate the incision site to iden- of a Veress needle or the Hasson technique tify and avoid abdominal wall vessels. Nerves (BOX 1). If the Hasson technique is used, a parallel vessels; thus, avoiding the vessels blunt cannula must be employed for initial reduces the risk of hemorrhage and nerve port placement. If a pneumoperitoneum has injury. Pass a 10-mm laparoscopic Babcock or already been established through the use of a DuVall (FIGURE 2) forceps through the instru- Veress needle, a sharp cannula can be used ment port to manipulate the cranial abdomi- for this purpose. nal organs and obtain an unobstructed view A pneumoperitoneum is usually established of the antrum of the stomach. Then grasp the with carbon dioxide, using a mechanical insuf- FIGURE 2 flator that allows controlled insufflation and 10-mm DuVall laparoscopic forceps are useful for grasping intraabdominal pressure monitoring. The intra- the antrum of the stomach. abdominal pressure measured with the insuf- flator should not be allowed to exceed 10 to 15 mm Hg while the trocars are placed; it should then be reduced to 6 to 8 mm Hg, or just suf- ficient to maintain an optical space, during the laparoscopic portion of the gastropexy. Place a 0° or 30° 5-mm laparoscope through the sub- umbilical port, just lateral to the right margin of the rectus abdominus and 3 to 5 cm caudal to the last rib (FIGURE 1). The second trocar– Rawlings. of Clarence Courtesy CompendiumVet.com | February 2009 | Compendium: Continuing Education for Veterinarians® 61 Section Name FIGURE 3 FIGURE 4 Courtesy of Clarence Rawlings. of Clarence Courtesy The antrum of the stomach is grasped using 10-mm Babcock or DuVall forceps. antrum of the stomach with the forceps mid- way between the mesenteric and antimesen- Rawlings. of Clarence Courtesy teric sides, approximately 5 to 7 cm oral to During antral exteriorization, take care to the pylorus (FIGURE 3). This is also the site for avoid twisting. Place stay sutures at either end of the proposed seromuscular incision in the stom- incisional gastropexy. ach to aid in exposure. These stay sutures are later Once you have a firm hold on the antrum, removed before closure. evacuate the pneumoperitoneum. Exteriorize the forceps and antrum by removing the right- the mucosa to ensure that the sutures are not side cannula and extending the port incision to placed through the mucosa into the lumen 4 to 5 cm in an orientation parallel to the last and that adequate muscle
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