Page 130 - Clinical Manual of Small Animal Endosurgery

118 Clinical Manual of Small Animal Endosurgery

In case of diffuse liver disease, if only liver evaluation and biopsy are
required a right lateral approach is preferred by some laparoscopists.
With this approach approximately 85% of the liver surface can be visu-
alised, together with the extrahepatic biliary system and the right limb
of the pancreas. The telescope portal is placed in the caudo-dorsal
abdominal wall, just ventral to the lumbar muscles, approximately
halfway between the caudal border of the ribs and the iliac wing. In
patients with a small liver, or in large dogs, the entry site is positioned
more cranially. Conversely, in small patients or in patients with hepatome-
galy a more caudal entry site allows for increased working space for the
scope and instruments. A second port is positioned again in the region
of the paralumbar fossa, but midway between the spine and ventral
midline. A single instrument port is often adequate.
Once the accessory port has been created, a blunt probe is inserted to
manipulate the liver. The tip of the probe has always to be in the field
of view, and is initially used to shift the omentum in a caudal direction.
The liver is evaluated for size, texture, colour, margins, and presence of
adhesions, mass lesions or nodules. Liver lobes are then individually
lifted with the probe and inspected. The normal liver should be uniform,
smooth, dark red in colour, with sharp margins, and should not tear or
bleed when manipulated (Fig. 4.9).
The gall bladder and biliary system are now examined by retracting
the scope slightly and elevating the right lateral and right middle liver
lobes with it. While the liver lobes are elevated the gall bladder is pal-
pated with the probe, and its size and turgidity are noted. Fig. 4.10 shows
the appearance of a normal gall bladder. By elevating the gall bladder is
then possible to examine the cystic, hepatic and common bile ducts and
follow them to the duodenal insertion. This can be difficult in an obese

Fig. 4.9 The liver and gallbladder of a normal dog, in dorsal recumbency.
Photograph courtesy of Mr P.J. Lhermette.