Page 162 - Clinical Manual of Small Animal Endosurgery

150 Clinical Manual of Small Animal Endosurgery

subcutaneous tissue and the skin are closed routinely. A final inspection
with the laparoscope is performed (Fig. 5.10B), the carbon dioxide is
allowed to escape and the camera port is removed. The fascia, subcuta-
neous tissue and skin are closed routinely. A 5% lidocaine patch can
then be applied to the skin around the incision.

Totally laparoscopic technique
This technique requires three midline ports, two needle holders and
endoscopic suture. The stomach can be sutured to the abdominal wall
from inside the abdomen without the need for full-thickness incision in
the body wall. Although technically more difficult, this technique appears
to result in more rapid return to activity than the laparoscopy-assisted
approach (Mayhew and Brown, 2009). The stomach is temporarily
anchored to the body wall at the proposed gastropexy site with a single,
percutaneously placed stay suture. Adjacent incisions are then made in
the abdominal wall and seromuscular layer of the stomach with laparo-
scopic Metzenbaum scissors. One technique uses a pair of laparoscopic
needle holders to suture the stomach to an incision in the transversus
abdominis muscle using a simple continuous pattern with 2-0 absorbable
suture on a ski-shaped needle. During suturing, and especially during
tying of the initial knot, the abdominal pressure is reduced so that the
stomach is apposed to the body wall with less tension. The lateral margin
is sutured first with one continuous pattern. The suture is then tied and
cut and another strand is used to suture the medial margin. The stay
suture is then removed. As an alternative to needle holders, the Endo
Stitch™ 10 mm Suturing Device (Covidien) is available with absorbable,
silk, nylon and polyester materials in sizes 0 to 4-0 suture. If this device
is used, at least one of the ports must be 10 mm in diameter. The Endo
Stitch is a suturing device with two jaws and a design that allows a needle
(with suture swaged in the centre) to be passed between the jaws by
activating a toggle switch on the handle. By closing the jaws on tissue
and flipping the toggle switch, the needle is passed from one jaw through
the tissue to engage the other jaw of the instrument. Thus, the needle is
held securely at all times and orientation is maintained. Once the needle
is passed through the stomach and through the body wall it is possible
to tie a surgical knot by passing the needle around the free end of suture,
creating a loop, and passing the needle through the loop (Fig. 5.11). For
complete instructions readers should refer to the manufacturer’s website
and DVDs. No matter which technique is selected, the surgeon must
develop laparoscopic suturing skills in a box trainer and, preferably, on
a cadaver prior to attempting these procedures on client-owned animals.

Endoscopically assisted gastropexy
This technique requires a flexible endoscope and a 76 mm-long needle
with size 2 polypropylene suture (Dujowich and Reimer, 2008). The