Page 120 - Clinical Manual of Small Animal Endosurgery

108 Clinical Manual of Small Animal Endosurgery

Fig. 4.1 Dog positioned in left lateral recumbency for laparoscopy
through the right flank. The tower is positioned across the animal from the
surgeon’s position.

Positioning of the patient and surgical approach depend on the pro-
cedure performed, and on the organs examined. The two most com-
monly used approaches are the right lateral and ventral midline. The
right lateral approach (Fig. 4.1) allows diagnostic evaluation of most of
the liver (approximately 85%), gall bladder and extrahepatic biliary tree,
descending duodenum, right limb of the pancreas, right kidney and right
adrenal gland, and is therefore recommended for biopsy of these organs
(Magne and Tams, 1999). This approach can also be used for laparoscopy-
assisted gastropexy (Freeman, 2009), whereas other surgeons prefer for
this procedure a modified ventral approach (Fig. 4.2).
The ventral midline approach offers a more extensive visualisation of
the abdominal cavity and its content (Fig. 4.3), and is thus chosen for
most surgical procedures (Twedt and Monnet, 2005; Monnet et al.,
2008). For this approach the telescope portal is placed on midline,
caudal to the umbilicus. In this location the falciform fat may interfere
with visualisation of the cranial abdomen, especially in obese animals.
However, withdrawal and manoeuvring of the telescope usually allows
its positioning beyond the caudal border of the falciform ligament.
A left lateral approach is occasionally performed for visualisation and
biopsy of the spleen, left kidney, left adrenal gland and left-sided liver
masses, but since the spleen lies directly underneath the typical entry sites
there is a high risk of puncturing it when positioning the trocar.
Portal entry sites can be more cranial or caudal in any of the above
approaches, depending on the size of the animal and on the procedure
to be performed, in order to ensure adequate organ visualisation and
sufficient working space.