Laparoscopic ovariectomy in a bitch

Re: Laparoscopic ovariectomy in a bitch

bill bowler — Tue, 23 Sep 2014 15:10:04 GMT

I am even later coming in on this thread but have found it very interesting reading all the comments. I am a GP in a 2/3 vet practice. We started doing Laparoscopy around 4 years ago and have now completed over 300 procedures of various types, most of them ovariectomies [300 of these alone]. I, too, was sceptical when I did the training but the dogs definitely recover more quickly with much reduced pain. Most are discharged within around 2 hours of the end of the procedure. There is none of the pain response of tearing the ovarian ligament and virtually no blood loss [usually none from the ovarian sites but a small amount from the port sites]. The only post-operative problem we have had is some swelling at the port sites. It is a brilliant way of removing abdominal cryptorchid testes, and great for ex laps which can be converted to open surgery for splenectomies and so on or quietly closed up for cases with no significant findings or terminal cases that you would rather send home for a few days rather than euthanase under ga- even these cases recover really fast due the minimally invasive nature of the surgery. Clearly the equipment and training costs are significant, but the challenges involved stimulate a lot of job satisfaction for all the staff. Eventually it will become the norm and I am amazed how slowly it is catching on. There does seem to be some resistance/reluctance to introducing it in GP. We are currently advertising a post in our practice and nobody seems interested in the offer of free training in these procedures which I genuinely believe have a big part to play in the future of general practice. I'm not sure if it isn't the fear of the unknown and litigation which is holding people back or whether it revolves around the boss having to drive the change due to cost, and a fear of major investment due to all the challenges facing veterinary practice.

Re: Laparoscopic ovariectomy in a bitch

Evelyn Barbour-Hill — Fri, 22 Aug 2014 11:49:12 GMT

[quote user="Alasdair Hotston Moore"]If I knew about the local risk of transferable infections, I think it would be a pragmatic approach in the mass neutering situation. I am actually quite a practical surgeon

[/quote]

Thanks.

Re: Laparoscopic ovariectomy in a bitch

Alasdair Hotston Moore — Thu, 21 Aug 2014 21:44:31 GMT

If I knew about the local risk of transferable infections, I think it would be a pragmatic approach in the mass neutering situation. I am actually quite a practical surgeon

Re: Laparoscopic ovariectomy in a bitch

Evelyn Barbour-Hill — Thu, 21 Aug 2014 21:33:29 GMT

[quote user="Alasdair Hotston Moore"]A very practical but unanswerable question Evelyn.[/quote]

Would you give it a go, if asked?

Re: Laparoscopic ovariectomy in a bitch

Alasdair Hotston Moore — Thu, 21 Aug 2014 21:00:03 GMT

A very practical but unanswerable question Evelyn. It's not that long ago that cat spays were done just like that though, is it? I recall seeing this as a student in the eighties

Re: Laparoscopic ovariectomy in a bitch

Evelyn Barbour-Hill — Thu, 21 Aug 2014 20:02:23 GMT

[quote user="Evelyn Barbour-Hill"] i'd like to ask this, seriously: if you had, say, six bitches lined up anaesthetised, how great would be the risk of infection if you just moved from one to the next without deep-cleaning or sterilising the equipment? Would the risk be small enough to be outweighed by the benefit to, for instance, mass neutering campaigns?[/quote]

Nobody going to respond?

Re: Laparoscopic ovariectomy in a bitch

Alasdair Hotston Moore — Thu, 21 Aug 2014 19:42:47 GMT

No good answer apart from force of habit. And a weak suggestion that local causes vasodilation that might increase ooze during the surgery, and tend to cause more misting of the scope. Poor excuse tho!

Re: Laparoscopic ovariectomy in a bitch

Ceri Gruffudd Jones — Thu, 21 Aug 2014 18:44:19 GMT

Just watched the video - good to see it in action. Leaving aside all the open vs laparoscopy debate, I have a minor query: why infiltrate the muscle at the port sites with local anaesthetic AFTER the procedure? Surely it would be even better infiltrated before the ports were placed? The time it takes to act could be used for the slightly faffy setting up of camera, ligasure, insufflation etc?

Re: Laparoscopic ovariectomy in a bitch

Tim Charlesworth — Tue, 19 Aug 2014 14:56:44 GMT

[quote user="robloxley"]

[quote user="Tim Charlesworth"]Nobody has said that all spays should or could be done laparoscopically[/quote]

I think what sometimes grates is some suggestion (not from yourself I add) that conventional surgery is somehow outmoded, in the dark ages, brutal, painful, traumatic, riddled with infection and complications.

[/quote]

I can understand this. The vast majority of my caseload is conventional, open surgery and it will never be outmoded. Laparoscopy has got the risk of being over-used (I mentioned the splenectomy case report before - they basically took a 90 min to do a lap splenectomy then removed it via a 7cm incision, or then there is the single port laparoscopic cat spay technique....) but there are a few scenarios where it is genuinely really useful and quicker/safer than the "open" alternatives. I worked in general practice for 10 years and remember often doing 3 (open) bitch spays before lunch. Certainly don't think that we provided a bad service then,it was always mission accomplished. Nowadays as a referral surgeon I tend to see more demanding clients who are more for the newer techniques. It will roll out more and more I'm sure and the techniques really are not complicated (most people get the hang of it after a couple of attempts) but it is only a different approach to a commonly performed surgery

Re: Laparoscopic ovariectomy in a bitch

Rob Loxley — Tue, 19 Aug 2014 13:51:39 GMT

[quote user="Tim Charlesworth"]Nobody has said that all spays should or could be done laparoscopically[/quote]

Re: Laparoscopic ovariectomy in a bitch

Evelyn Barbour-Hill — Tue, 19 Aug 2014 13:33:35 GMT

[quote user="Alasdair Hotston Moore"]when it does, laparoscopy is clearly better than laparotomy.[/quote]

Yep. OK.

But when in a decade or so laparoscopy becomes common practice done by almost anyone (well, maybe it won't, because of cost, but quite likely it will), we'll be seeing the ovarian remnants left, the haemorrhages, the long recovery periods, the wound infections.... betcha.

Anyway, moving on from this moribund debate, i'd like to ask this, seriously: if you had, say, six bitches lined up anaesthetised, how great would be the risk of infection if you just moved from one to the next without deep-cleaning or sterilising the equipment? Would the risk be small enough to be outweighed by the benefit to, for instance, mass neutering campaigns?

Re: Laparoscopic ovariectomy in a bitch

Martin Atkinson — Tue, 19 Aug 2014 13:25:37 GMT

[quote user="Mark Holmes"] I can spay one bitch in the time it takes to clip and prep the next so with adequate nursing staff you can be very efficient.. But the point as Michael pointed out is that kit cleaning sterilisation etc is more complicated.[/quote]I was playing devil's advocate and it was a rhetorical question. Of course I was aware that your 20-30 mins was surgery time not total time, I can spay a bitch from first incision to last suture in 15-20 minutes but being a solo vet with 2 nurses they have to wait their turn and it is rare I'd have more that 2 to do in one session anyway. I do not for one minute say that laparoscopic spaying is a viable alternative in the vast majority of practices but my point was that you were making the assumption the the practice which offers this service isn't as capable as you of getting things prepped and ready and that they only have one set of kit which needs sterilising each time.

Re: Laparoscopic ovariectomy in a bitch

Alasdair Hotston Moore — Tue, 19 Aug 2014 12:02:50 GMT

Very well put Tim. It's not for all owners but it is supported by evidence. And it is a premium procedure in terms of cost. For the interest of this active in this thread, I have just done an ovarian remnant ( after open sx at St Elsewheres) in twenty mins laparoscopically. Of course, this should never be reqd, ho ho, but when it does, laparoscopy is clearly better than laparotomy. Alasdair

Re: Laparoscopic ovariectomy in a bitch

Tim Charlesworth — Tue, 19 Aug 2014 11:41:17 GMT

Nobody is saying that Lap spays will or could replace conventional spays. Yes the costs are high, the equipment maintenance/cleaning more involved and therefore the turnaround time is longer than open surgery (although we can still do 3 in a day). Nobody has said that all spays should or could be done laparoscopically. The only point to all of this (as far as I am concerned) is to make vets aware that if they have a client who asks about whether or not there is any benefit to "key-hole" spays then the answer should be a yes, it is not just a fad and there are proven differences in terms of postoperative pain and return to normal activity which matter to the owners. You can follow that with a "but they can cost more etc etc" if needs be.

Re: Laparoscopic ovariectomy in a bitch

Mark Holmes — Tue, 19 Aug 2014 11:23:58 GMT

[quote user="Martin Atkinson"]

[quote user="Mark Holmes"]To be honest it's not the op time it's the turn around time. On a standard day I can do 2-3 bitch spays in an hour. You simply cannot turn around lap spays at that rate.

[/quote]So you can do a bitch spay from induction, through preparation, surgery and recovery and get the next one on the table in 20 minutes? Wow!

But you are assuming that the practice doing the laparoscopic technique hasn't got 3 sets of kit.

[/quote] With the correct staff yes. I can spay one bitch in the time it takes to clip and prep the next so with adequate nursing staff you can be very efficient.. But the point as Michael pointed out is that kit cleaning sterilisation etc is more complicated. I don't doubt it's very nice to do, but I don't see it being practical enough to replace the routine surgery... Which with domitor, comfortan and good NSAIDS is very comfortable anyway.

Re: Laparoscopic ovariectomy in a bitch

Martin Atkinson — Tue, 19 Aug 2014 11:15:54 GMT

[quote user="Mark Holmes"]To be honest it's not the op time it's the turn around time. On a standard day I can do 2-3 bitch spays in an hour. You simply cannot turn around lap spays at that rate.

[/quote]So you can do a bitch spay from induction, through preparation, surgery and recovery and get the next one on the table in 20 minutes? Wow!

But you are assuming that the practice doing the laparoscopic technique hasn't got 3 sets of kit.

Re: Laparoscopic ovariectomy in a bitch

Mark Holmes — Tue, 19 Aug 2014 11:03:55 GMT

To be honest it's not the op time it's the turn around time. On a standard day I can do 2-3 bitch spays in an hour. You simply cannot turn around lap spays at that rate.

Re: Laparoscopic ovariectomy in a bitch

Malcolm Ness — Tue, 19 Aug 2014 08:54:22 GMT

[quote user="Tim Charlesworth"]everybody agrees that there is a significant difference.[/quote]

I wonder if the difference between Evelyn and Tim/Alistair is about the kind of significant difference. Statistical significance relates to whether the two groups are distinct while clinical significance relates to whether the difference matters.

Re: Laparoscopic ovariectomy in a bitch

Tim Charlesworth — Tue, 19 Aug 2014 08:35:14 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Tim Charlesworth"] We do a lot of them and both we and the clients can see a lot of difference in terms of immediate recovery period when compared to "open" spays.[/quote]

I'm not sure I should be going on and on about this, but..... with what are you comparing the laparoscopic spays? Conventional spays done by yourselves? Conventional spays in the general experience of all your clients? Might it not be that the conventional spays were not done as well as they might have been? Might the lack of a hysterectomy not be the real reason for a difference? Could it be that conventional spays are done by, well, just about everyone, while laparoscopy is at present done only by those highly skilled in the technique?

[/quote]

All the research that has looked at direct comparisons between the 2 techniques (including relatively novice surgeons) show a significant difference. Both ovariectomy and ovariohysterectomy can be performed laparoscopically and the benefits of the minimally invasive approach apply to both and so no, the observed benefits are not due to different techniques being used. The main point is that whether or not you are looking at a peer reviewed evidence base or pure anecdotal observations by vets, students or the pet owners, everybody agrees that there is a significant difference.

Re: Laparoscopic ovariectomy in a bitch

Michael Woodhouse — Mon, 18 Aug 2014 23:52:48 GMT

[quote user="Evelyn Barbour-Hill"]Could it be that conventional spays are done by, well, just about everyone, while laparoscopy is at present done only by those highly skilled in the technique?[/quote]

I'd have thought the surgeons doing lap spays should also be very skilled at a 'normal' spay.

Re: Laparoscopic ovariectomy in a bitch

Evelyn Barbour-Hill — Mon, 18 Aug 2014 22:03:10 GMT

[quote user="Tim Charlesworth"] We do a lot of them and both we and the clients can see a lot of difference in terms of immediate recovery period when compared to "open" spays.[/quote]

Re: Laparoscopic ovariectomy in a bitch

Bob Russell — Mon, 18 Aug 2014 16:09:32 GMT

One way to get one up on the '£80' bitch spay (all sizes, all ages), I suppose.

Re: Laparoscopic ovariectomy in a bitch

Tim Charlesworth — Mon, 18 Aug 2014 13:06:34 GMT

Sorry to come in late on this one (been on hols ) but I'd like to back up everything that Alastair has said about lap-OE's/lap-OHE's. We do a lot of them and both we and the clients can see a lot of difference in terms of immediate recovery period when compared to "open" spays. I agree that there is unlikely to be a significant difference 5 days or more down the line but that initial period matters a lot to many clients. Like all recent(ish) innovations, laparoscopy can be over-used and there are definite limits to its application (there is a dubious report of a lap-splenectomy in a dog). Like all things, it has it's place. The initial set-up costs are currently high but much of the kit can be used for other applications - arthroscopy, rhinoscopy, cystoscopy which helps make the initial investment financially worthwhile. If you are interested in laparoscopy then the easiest thing to do is to contact your local centre and ask to see a case or two, you can then witness first hand the advantages/limitations of the technique and make your own minds up.

Tim

Re: Laparoscopic ovariectomy in a bitch

Hannah Wynne Richards — Fri, 15 Aug 2014 14:31:38 GMT

Id disagree. Admittedly more risky than doing when young, but not half as risky as waiting for a pyometria to develop!

Wynne

Re: Laparoscopic ovariectomy in a bitch

Rob Loxley — Thu, 14 Aug 2014 23:17:55 GMT

[quote user="alex gough"]So no one recommends this as routine? I agree with that approach[/quote]

You agre with routine spaying or not-spaying of middle aged bitches?