Advances in standing laparoscopy

Over the last 25 years laparoscopic surgical techniques in horses have been improved and some abdominal surgeries are now entirely replaced by laparoscopic approach. Ovariectomy, closure of the nephro-splenic space and closure of the vaginal/internal inguinal ring are good examples.
Some procedures like abdominal cryptorchidectomy are still performed the “old way” under general anaesthesia or by a standing laparoscopic approach depending on the surgeon’s experience and/or the owner’s request.

There is a list of standing laparoscopic surgeries that are not so common and are only performed in some specialist centres:

• Diagnostic laparoscopy (chronic colic, weight loss, intestinal biopsy)
• Closure of inguinal/vaginal ring using a peritoneal flap or mesh covering the vaginal ring
• Rupture bladder in adult male horses  
• Nephrectomy: left or right kidney
• Imbrication of the mesometrium to restore normal horizontal orientation of the uterus
• Closure of the epiploicum foramen
• Equine thoracoscopy

Standing laparoscopy has some advantages like avoiding general anaesthesia (cheaper, no Trendelenburg positioning, no recovery risk), better visualisation of the left and right dorsal abdomen, better visualisation of blood vessels/safer ligation/coagulation, controlled access to organs/area’s that can not be reached or visualized in any other way (vaginal ring, kidneys, bladder, duodenum, base of cecum, epiploic foramen). There are however still limitations in equine laparoscopy and one of the most frustrating one is the lack of custom made laparoscopic instruments that are adapted to specific surgical needs for example sufficiently long to operate easily in the abdomen of an equine adult.

During this talk I will focus on a few topics where changes in the technique have improved the functional or cosmetic outcome for the patient.

Diagnostic laparoscopy and full thickness intestinal biopsies for IBD (inflammatory bowel disease) causing chronic weight loss and muscle wastage

Inflammatory bowel disease is a cause of chronic weight loss/muscle wastage, which presents itself often as a diagnostic challenge. Different types of IBD exist and they are categorized depending on the type of cell infiltration within the intestinal wall. The ethiology can be linked to the microbiome present within the intestine or to the food composition. Exact prognosis and treatment of IBD is difficult at the moment and full thickness biopsies can help to achieve a more accurate diagnosis. Rectal and duodenal biopsies are not representative enough for small intestinal pathology, they are small in size and never full thickness. Full thickness biopsies taken on several locations (duodenum, jejunum and ileum) will give a better representation/ mapping off the small intestinal pathology, an will increase the chance of diagnosing and typing IBD (eosinophilic, lymphoplasmacytic, granulomatous, alimentary lymphoma).

Laparoscopic full thickness biopsy taking have been described in 2006 by Morgan Schambourg et all, using an intracorporeal suturing technique and in 2008 by Bracamonte et all, using an endoscopic linear stapler.

We adapted the technique and perform a diagnostic laparoscopy of the abdomen where all small intestines are checked from duodenum to ileum and subsequently full thickness biopsies are taken extra-corporeal by enlarging one of the portals. This can be done without loosing a pneumoperitoneum.

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