Page 159 - Clinical Manual of Small Animal Endosurgery

Operative Laparoscopy 147

and proper ovarian ligament or the proximal portion of the uterine horn
follows. The ovary is thus isolated, suspended to the body wall. At this
point, the laparoscope is transferred to the caudal port and endoscopic
grasping forceps are inserted through the larger, sub-umbilical port to
grasp and retrieve the ovary. The intra-abdominal pressure is reduced,
the trocar is removed and the stay sutures are used to elevate the body
wall as the ovary is removed. A slight twisting or rotating motion
enhances removal of the ovary. Following inspection, the trocar is then
replaced and the procedure is repeated for coagulation and transection
of the right ovary.
An ovariohysterectomy can be performed using a similar approach;
however, with only one working port it can be difficult to mobilise the
ovary and keep it retracted to gain access to the broad ligament. If so,
an additional port can be placed to provide caudo-medial retraction
while the energy modality is used to coagulate and divide the broad liga-
ment to the level of the uterine arteries and uterine bifurcation. Once
both broad ligaments are transected, the uterine body is coagulated and
cut or ligated. If the uterine body is small, the LigaSure, ENSEAL or
Harmonic Scalpel can be used to coagulate and cut it. If very large, the
uterine body may need to be ligated. The caudal midline trocar is removed
and the incision enlarged so that the uterine body can be exteriorised.
An extracorporeal ligature can then be used to ligate it in the same
fashion as in open surgery (technically performing a laparoscopy-assisted
ovariohysterectomy). Another alternative is to use pre-tied loop sutures.
The pre-tied loop is introduced and the ovaries and uterine horns are
passed through it such that the loop can be positioned on the uterine
body. The nylon cannula is broken and advanced to tighten the loop,
taking care to avoid incorporating other structures into it. When the loop
is tight, the suture tail is cut with laparoscopic scissors. The uterus is
then transected and removed from the sub-umbilical port.
If the tissue is suspected to be friable, malignant or infected, a specimen-
retrieval bag can be utilised to safely remove the tissue while protecting
the body wall from contamination. The bag is introduced through
one of the ports, tissue is placed in it and the mouth of the bag is closed
for withdrawal from the body. Final inspection is performed to ensure
haemostasis and the port sites are closed routinely. Complications
are rare, and the most common are iatrogenic trauma to the spleen
or other abdominal organs during insertion and removal of laparoscopic
equipment, electrocautery injury to surrounding tissue, subcutaneous
emphysema and inflammation of the port sites. Usually these complica-
tions are self-limiting and are treated conservatively with no serious
consequence.
Recent studies have evaluated the operative time and potential
complications of using one or two ports in laparoscopic ovariectomy
procedures. Both methods result in acceptable outcomes; however, the
one-port technique may require greater laparoscopic skills or result in
longer surgical time (Dupré et al., 2009).