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Laparoscopic Ovariectomy on the Standing Horse (Granulosa Cell Tumour)
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Several reports can be found in recent literature on laparoscopic ovariectomy. The procedure can be performed on the standing horse or in dorsal recumbency. We perform all the ovariectomies including all sizes of granulosa cell tumours on the standing horse and until now we never had to convert to a general anaesthesia. The scope portal is located between the 17th and 18th rib. The instrument portals are located in the paralumbar fossae halfway between last rib and tuber coxae.
Good local anaesthesia of the mesosalpinx and mesovarium is necessary.
A 10 mm diameter and > 40 cm long claw forceps is needed to have a strong grasp of the ovary. Mesosalpinx and oviduct are generally cut with scissors, which sometimes results in a minor bleeding. The mesovarium contains a number of large vascular structures, they can be very important especially in large size granulosa cell tumours.
There are several ways to ligate the ovarian pedicle. Intracorporeal or extracorporeal ligation, endoloop ligatures, stapling devices (endo-GIA), bipolar vessel-sealing device, polyamide tie-rap and laser techniques have been successfully used to seal the blood vessels in the ovarian pedicle.
We use a bipolar electrosurgical vessel sealing devices (LigaSure-Valleylab/Tyco) for both normal ovaries and granulosa cell tumours. This makes ligation of the pedicle unnecessary and it reduces surgical time considerably.
If a bilateral ovariectomy is performed the left ovary will be passed, after dissection and cutting the pedicle, from the left to the right side of the abdomen. This allows removal of both ovaries from the abdomen from one side (right side) and thus creating only 1 enlarged endoscopy portal. It reduces surgical time and cosmetic outcome.
If a large size tumoral ovary needs to be exteriorized from the abdomen both instrument portals are connected to create one large single skin incision and the abdominal muscle are bluntly separated along the axis of their fibbers (grid technique). Abdominal muscles should never be sharply dissected to avoid complications in healing.
Removing large size granulosa cell tumours (15-20 cm diameter) can be a challenge. Some of these ovaries are filled with fluid. This should be aspirated to reduce the size and to facilitate removal. The presence of fluid should be checked pre-operatively using ultrasound examination. We also use what we call the “plastic bag technique” to remove large size ovaries. The commercial endopouch retriever (a specimen retrieval bag designed by Ethicon Endo-Surgery) can only contain 224 ml, which is often too small for granulosa cell tumours. After dissection of the granulosa cell tumour we introduce a sterile laparoscopic instrument bag in the abdomen after connecting both instrument portals. The large ovary is introduced into the bag. Using a large and strong plastic bag containing the large tumoral ovary has several advantages.
- It facilitates removing of a large diameter ovary through a relative small incision. By pulling the edges of the plastic bag more force can be exercised on the ovary without the risk of slipping of the claw forceps and loosing it in the abdomen.
- The large ovary is completely isolated from the abdominal cavity and can be pushed against the abdominal wall where it can be visualized through the skin incision. Large size ovaries can be cut in pieces within the bag or stab-incision can be made in the ovary to empty isolated pockets of fluid reducing the size of the ovary without risk of metastatic spread of the tumour within the abdominal cavity.
Using the above-mentioned techniques, 15-20 cm diameter granulosa cell tumours can be removed through a ± 10 cm skin incision.
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