How to perform a two-portal laparoscopic ovariectomy - Veterinary Medicine
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How to perform a two-portal laparoscopic ovariectomy
Learn more about this laparoscopic procedure, which produces less pain and tissue trauma than a routine open ovariohysterectomy does. Then consider whether you should take the necessary steps to offer it in your practice.


VETERINARY MEDICINE


Step 10: Remove the right ovary

Before you remove the ovary, keep in mind that to ensure hemostasis, you will use the LigaSure to create coagulation or a seal and will press the blade cutting button only after the LigaSure unit's energy cycle signal tone has ended. Always try to grasp the same amount (depth) of tissue each time you go through the sequence. To prevent sticking, periodically use saline-moistened gauze to wipe off any eschar from the instrument's jaws and to clean off the end of the laparoscope.

The LigaSure has a six-bar, or power level, graph display; I use three bars for large dogs, two bars for medium dogs, and one bar for cats and small dogs. Pass the LigaSure through the cranial portal, and direct it toward the tacked ovary. The LigaSure shaft can be rotated in either direction, and the bezel helps facilitate instrument placement on the tissue to be coagulated and cut. Remove only a small amount of tissue on either side of the ovary to speed up the procedure and facilitate tissue removal through the portal. Use the LigaSure as close to the abdominal wall as safely possible.


Figure 12
Place the laparoscope in your caudal hand and the LigaSure in your cranial hand, and gently grasp the ovarian suspensory ligament one instrument jaw width away from the ovary. Close the LigaSure on the ligament by squeezing the front hand grip toward the handle until it clicks and locks, and push the power button until the tone stops (Figure 12). Then advance the cutting blade by pulling the lever on the front of the hand piece. The tissue on both sides of the instrument jaws turns white and steam is generated. Release the LigaSure grip by squeezing the handle again and opening the jaws. Carefully move the instrument toward the ovary so that its next position overlaps that of the first. Activate the power again, and when the tone stops, advance the cutting blade by pressing the button on the front of the instrument handle. Again, gently open the LigaSure jaws and release.

Continue this sequential technique until the entire ovarian suspensory ligament and the blood supply to the ovary have been carefully coagulated and cut. Then direct the LigaSure to the ovariouterine juncture and, using the same technique, sever the ovary from the uterus. Again, by applying gentle traction on the LigaSure, you ensure that you will not damage the body wall.

Once the ovary has been cut free, immediately check the remaining tissue bed (ovarian pedicles) for bleeding. Bleeding is rare, but if any is found, grasp the bleeder with the tip of the LigaSure, and then with only one bar on the power setting, seal the vessel. Alternatively, an endoscopic blunt probe (or the tip of the LigaSure) can be used to apply gentle pressure to the bleeding area. If this fails, you can use an absorbable gelatin compressed sponge (Gelfoam—Pfizer) or 10-mm Autosuture clips. If you think you have major uncontrolled bleeding, immediately convert to an open procedure.


Figure 13
Next, replace the LigaSure with the endoscopic forceps in the cranial portal, and grasp and click on the tag of suspensory ligament or the tag of ovariouterine juncture tissue that attaches to either side of the ovary (Figure 13). Once you have it, release the needle holding the tacking suture (remove it), and bring the ovary to the operative/cranial portal. It may be necessary to slightly enlarge the portal opening to allow the ovary to be removed. Removing the ovary and the cannula at the same time may be easier (Figure 14). A hemostat may be used to grasp the ovarian tissue as it exits the body wall to prevent losing it. Often, the ovarian tissue, if small enough, can be carefully pulled into the cannula by its tissue tag.


Figure 14
If using a Versaport with the Versaseal feature, carefully unscrew the Versaseal portion by rotating it counterclockwise as you hold the cannula in your opposite hand. Then you may remove the endoscopic forceps, ovary, and Versaseal in one move and replace the Versaseal without losing the pneumoperitoneum. If you removed the cranial cannula, replace it, and reestablish pneumoperitoneum. You may need to place an Allis tissue forceps next to the portal to assist in resealing the portal if you had to enlarge the opening to remove the ovary.

Step 11: Find, tack, and remove the left ovary


Figure 15
Step around the table, and have an assistant change the patient positioner so you may use the same technique to remove the left ovary. The landmarks are the stomach, spleen, kidney, and ovarian suspensory ligament. Often, the left ovary lies just beneath the spleen's lateral edge. If this is the case, gently pass your closed endoscopic forceps between the spleen and abdominal wall to move the spleen medially to allow you to visualize the ovary. Remember to check for any bleeding before removing the LigaSure. And always check the tissue you have removed to ensure complete ovarian tissue removal (Figure 15).

Step 12: Close the incisions

Finally, deflate the abdomen, remove both cannulas, and close the two portal entry points. Use absorbable Monocryl (Ethicon) or similar suture (e.g. polydioxanone, Maxon [Covidien], Dexon [Covidien])—2-0 for medium to large dogs and 3-0 for cats and smaller dogs—to close the linea alba deeply in either a simple interrupted or cruciate pattern. Additionally, place one or two skin sutures or staples per portal. I also seal the skin with tissue glue.


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Source: VETERINARY MEDICINE,
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