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Veterinary Forum November 2009 (Vol 26, No 11)

Minimally invasive, minimal drawbacks

by Paul Basilio

    No longer confined to the specialist's operating room, laparoscopic surgery is growing in popularity among general practitioners because of its versatility, safety and ability to reduce recovery time in postoperative patients.

    With more clients choosing laparoscopic surgery for their own medical procedures, it is only natural that they are drawn to minimally invasive surgery for their pets. Compared with traditional surgeries, which require large incisions and can cause collateral tissue damage, minimally invasive surgery offers smaller incisions, which can greatly reduce the surgical insult to patients.

    "The great thing about minimally invasive surgery is that there are many simple surgical applications as well as some advanced applications," says Philipp D. Mayhew, BVM&S, MRCVS, DACVS, a surgeon at Columbia River Veterinary Specialists in Vancouver, Wash. "I have helped teach a few laboratories at some of the larger veterinary conferences, and the rooms are full of general practitioners, not specialists."

    Although the number of small animal practices that have purchased laparoscopic surgical equipment and offer minimally invasive surgical options is still relatively small, the field, and interest in it, is growing as laparoscopy becomes more popular in human medicine.

    "One of my colleagues in Ohio exclusively performs laparoscopic spays," Mayhew says. "He says that his clients opt for it, even though it is slightly more expensive. He gets a lot of word-of-mouth business from clients because of his laparoscopic spays."

    Mayhew points out that the number of simple soft tissue surgeries that general practitioners can perform laparoscopically is growing, which helps expand the field of minimally invasive surgery beyond the realm of the specialist and into smaller general practices.

    Learning curve

    While it can be intimidating to replace a tried-and-true surgical technique with a new, unfamiliar one, Mayhew says that the learning curve for minimally invasive surgery is not very steep. "I don't think performing minimally invasive soft tissue procedures is as complex as performing arthroscopies. Arthroscopy is quite challenging to learn, and it takes a while to get good at it, which is why few general practitioners do it," he explains. "When I was at the University of Pennsylvania [Penn], I taught residents how to perform laparoscopy. They would do two or three laparoscopic ovariectomies, and they would be off and running, performing them on their own."

    The hardest part, Mayhew says, is getting the equipment to function properly the first time and then remembering how it works during the second procedure. "The physical execution of the surgery is not that difficult if you have the right equipment," he adds.

    When he started performing minimally invasive surgeries at Penn, Mayhew says he had to make do with hand-me-downs from human medicine. "We would struggle to do simple things with the equipment," he says, "but as soon as the school made an investment in modern minimally invasive equipment, it wasn't difficult to operate at all."

    Converting to closed

    A few veterinary companies make laparoscopic surgical equipment. The initial purchase can be expensive, but the equipment can be used in a general practice in a variety of ways.

    "It's common for a practice to purchase endoscopy equipment in which the central components — the monitor, camera and light source — are common not just to laparoscopy or thoracoscopy, but can also be used for GI endoscopy and colonoscopy," explains Mayhew. "All of the '-oscopies' run off of the same technology."

    Thus, when practices are faced with a hefty price tag for laparoscopic equipment, the cost/benefit calculation can be based not only on how many laparoscopic spays must be performed to pay off the equipment but also on the many other areas in which the equipment can be beneficial. For example, some minimally invasive equipment can also be used for the ears and GI tract.

    Mayhew acknowledges that the cost and specialized training required to perform procedures may make some practices hesitant to test the new technology. "We also tell the owners about the possible need for conversion to an open procedure if things go wrong," he says. "If things go wrong and you don't have your hands in your patient, it tends to be more difficult to fix a problem. However, it is rare to have to convert something like a spay into an open procedure. I have done more than 100 laparoscopic spays, and I can't remember the last time I had to convert one."

    Pros and cons

    The time in surgery tends to be longer for laparoscopic procedures than for traditional procedures. "For an average general practitioner who has performed more than 10,000 spays, it is probably going to take some time to get used to laparoscopy," Mayhew says. "As the learning curve gets better and the general practitioner performs more laparoscopic spays, the magnitude of time difference will decrease."

    Mayhew has met practitioners who believe minimally invasive surgery is a great leap forward in veterinary medicine as well as those who are not yet convinced. Practitioners who favor the surgical technique tend to have had a positive experience with human laparoscopic procedures.

    Videos of minimally invasive surgeries may make the procedure appear as if it is being performed through a narrow keyhole, but the technology does offer several advantages, Mayhew says. "The magnification and the quality of the image are incredible," he explains. "The cameras now are of such high quality that you can get a crystal-clear image and get a magnified view of the tissue you are working with."

    Measuring pain

    "Traditionally, we have had very inaccurate, largely subjective indices of pain and stress surrounding surgery in animals," Mayhew says.

    To help convince practitioners that minimally invasive surgeries carry a proven benefit, Mayhew conducted studies at Penn that quantified the postoperative activity of animals that had undergone traditional surgery and compared it with the activity of animals that had undergone a minimally invasive procedure.

    In one study published in Veterinary Surgery, Mayhew and his colleagues compared laparoscopic and open ovariectomy. Dogs were randomized into two surgical groups, and their levels of preoperative and postoperative activity were measured by placing an accelerometer on each dog's collar.

    "We found significant differences between postoperative activity in the minimally invasive group compared with the open group," Mayhew says. "The minimally invasive group showed activity levels that were close to preoperative levels almost immediately after the surgery. The dogs that had the open procedure tended not to return to their normal activity level for about 4 or 5 days."

    Mayhew acknowledges that the results should be interpreted with caution because the measured activity level does not necessarily transfer perfectly to a measurement of pain.

    "There are still some people who will say that they want their patients to experience some pain to keep them from running around and damaging the incision, but that is an old way of thinking, and I think most people have moved away from that attitude."

    Mayhew is convinced that a difference in pain levels exists between traditional open procedures and minimally invasive procedures. "I think the area where it makes an even bigger difference is in the chest," he explains. "If you can avoid a thoracotomy incision, then I think the magnitude of the benefit is much larger. At the end of the day, animals recover well from open spays, but they may not recover as well from major chest surgery. For soft tissue minimally invasive procedures, I think that's an area where there can be a huge benefit."

    For more information:

    Culp WT, Mayhew PD, Brown DC. The effect of laparoscopic versus open ovariectomy on postsurgical activity in small dogs. Vet Surg 2009;38(7):811-817.

    Runge JJ, Mayhew PD, Rawlings CA. Laparoscopic-assisted and laparoscopic prophylactic gastropexy: indications and techniques. Compend Cont Pract Vet 2009;31(2):58-65.

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