RU2597991C1 - Method of ovariohysterectomy in cats - Google Patents

Abstract

FIELD: veterinary science.

SUBSTANCE: invention refers to medicine, namely to veterinary science. Skin and subcutaneous fat is incised in ventral abdominal wall in the projection of the white line. Puncture is made in the ventral abdominal wall at the white line with Veress needle, then insufflation of the abdominal cavity, further removal of the Veress needle, incision of the abdominal white line and separation of the wound edges. Peritoneum is introduced with endoscopic instruments for inspection of abdominal organs. Uterus and ovaries are found. Endoscopic instrument is introduced through an instrumental channel for engagement of the uterine horn with the ovary. Endoscopic instruments are extracted from the peritoneum together with the uterus horn and the ovary, desufflation of the abdominal cavity is performed, then fixation of the ovary and the uterine horn, then the ovary and uterine vessels ligation. Ovary together with the uterus horn are amputated and uterus is pulled over the prepared horn and its bifurcation and the counterlateral horn of the uterus and the ovary are removed from the abdominal cavity. Vessels are ligated of the counterlateral ovary and the uterine, then the counterlateral ovary together with the uterus horn are amputated, then processing and separation of the uterus in the neck area and sealing of the incisional wound of the white line and the skin. Additionally massage is performed and the bladder is emptied, incision of skin and subcutaneous fat is performed at the distance from the navel caudal in the projection of the abdominal white line of not less than 2.0 cm and not more than 3.5 cm. Wound edges of the skin and the subcutaneous fat are drawn apart with the help of Demarr lid retractors. Then the abdominal white line is punctured with a tracheostomy hook and the aponeurosis of the external oblique muscles and a white line are elevated. Insufflation of the abdominal cavity is performed with passed through a filter cleaned atmospheric air. After cutting off the ovary with the uterus horn vessels of the suspensory muscle ligament of the ovaries and the uterus within the neck area are additionally ligated with a nonabsorbable suturing material. Wound of the white line and skin and subcutaneous fat of the ventral abdominal wall is sealed by suturing.

EFFECT: method allows to reduce anesthesiologic and operational traumatism of the intervention, prevents separation of the uterus from the vagina during its removal accompanied by uncontrolled haemorrhages.

3 cl

Description

The invention relates to the field of veterinary medicine.

A known method of two-port video endoscopic access, in which the areas of operational access are four points of injection: two points for introducing trocars along the midline of the abdomen, departing 2 cm cranial and 2 cm caudal from the navel. At the same time, a video endoscope is inserted into the cannula of one of the trocars to find the uterus and ovaries, and manipulation clamps to capture the uterus and ovaries are inserted into the other trocar. The method uses two injections and two punctures with fixation needles in the area of the projection of the left and right ovary onto the lateral abdominal walls to suspend the uterus and ovary to the dome of the abdominal wall. After sequentially crossing the suspensory ligaments and ovarian vessels on both sides with an electrocoagulator, both uterine horns with the uterine body and ovaries are removed outside through the caudal trocar injection hole, the cervix is ligated and the uterus with horns is cut off, and the stump is set into the abdominal cavity (“Small Animal Endoscopy” "3rd edition, Todd R. Tams, Clarence A. Rawlings, Copyright © 2011, 1999, 1990 by Mosby, Inc., an affiliate of Elsevier Inc, p. 466).

The disadvantage of this method is the significant area of the surgical field, requiring his haircut, shaving, treatment with antiseptics. In addition, this method is traumatic due to significant damage to the musculoskeletal cover: two punctures with trocars and four punctures with fixation needles, and due to increased intra-abdominal pressure during insufflation of 12-15 mm Hg and the penetration of carbon dioxide through these holes into the subcutaneous tissue of the abdomen.

The closest in technical essence and the achieved result is a method of ovariogysterectomy in cats, ferrets with video endoscopic control, providing for an incision of the skin and subcutaneous tissue of the ventral abdominal wall in the projection of the white line of the abdomen; puncture of the ventral abdominal wall along the white line of the abdomen with a Veress needle, insufflation of carbon dioxide in the peritoneal cavity; subsequent removal of the Veress needle; puncture of the white line of the abdomen and the extension of the edges of the wound; the introduction of endoscopic equipment into the peritoneal cavity, revision of the abdominal organs, finding the uterus and ovaries and the subsequent introduction through the cannula of a trocar of a video endoscope, a hook for engaging the uterine horn with the ovary; extraction of a video endoscope and hook from the peritoneal cavity along with the uterine horn and ovary; peritoneal cavity desufflation; fixation of the horn of the uterus and ovary, hemostasis of the vessels of the ovary and uterus; clipping of the ovary with the uterine horn; pulling up the uterus by the prepared horn and removing its bifurcation and contralateral horns of the uterus and ovary from the peritoneal cavity, hemostasis of the vessels of the contralateral ovary and uterus; cutting off the contralateral ovary together with the contralateral horn of the uterus; processing and cutting off the uterus in the cervical region, as well as subsequent sealing of the surgical wound of the white line of the abdomen and skin (Patent for the invention No. 2503419, publ. 10.01.2014).

The disadvantage of this method is its high anesthetic and operational risk caused by the non-use of preoperative diagnosis of the animal’s health and high trauma due to a skin incision in the umbilical region caudal to the umbilicus by 1.5 cm, which is practically on par with the projection onto the ventral abdominal wall of the ovaries and creating a strong tension when stretching the body and cervix, projected onto the pubic region of the ventral abdominal wall. Moreover, the use of this method, even with a healthy uterus, and not compromised by the inflammatory process, can lead to its separation from the vagina with the occurrence of uncontrolled bleeding. In addition, electrocoagulation of strained uterine vessels may be ineffective, inferior, which can also lead to bleeding.

At the same time, the use of carbon dioxide for insufflation of the peritoneal cavity of an animal fed under high pressure from a balloon through a reducer can cause various complications and mechanical damage to the internal organs of the animal in the event of a reducer breakdown, therefore this technique requires constant monitoring by the surgeon of the speed and pressure of the supplied gas through insufflator.

Also, the use of wounds in this method of electrocoagulation increases the risk of bleeding due to possible rupture of the vessel walls (Medical Encyclopedia. Internet address: http://www.medical-enc.ru/5/diathermocoagulation.shtml).

The risk of injury to the abdominal organs, as well as damage to endoscopic equipment and instruments, creates the use of a trocar with a magnetic valve in this method, which, when introduced, and especially when excreted, increases the risk of damage to the endoscope by a steel ball striking at the very center of the distal end of the optics, which damages his lens. When using a trocar with a magnetic valve, the effect of wedging endoscopic instruments between the wall of the trocar and the valve ball also occurs. Moreover, the very use of a magnetic valve in a trocar leads to the magnetization of the instruments used in the operation.

Sources

1. Illustrated Guide to Endoscopic Surgery: A Training Manual for Surgeons / Ed. S.I. Emelyanova - M.: Medical News Agency. 2004.S. 28.

2. Wikipedia. Internet page address:

https: // ru. wikipedia.org/wiki

3. Agency for the Implementation of Innovative Technologies. Internet address: http://www.avitcom.ru/content/troakary).

This closest known method of ovariogisterectomy in cats increases the risk of injury to the faces of the trocar stylet of the internal organs of the abdominal cavity. And the use of a trocar stylet with a blunt end creates critical tension of the abdominal wall, tears the tissue or spreads them, creating squeezing and ischemia at the site of penetration (Wikipedia. Internet page address: https://ru.wikipedia.org/wiki).

The technical result of the proposed solution is to reduce anesthetic and surgical injuries due to the preoperative detection of possible pathology of the abdominal organs of the animal and emptying of the bladder, as well as the use of non-invasive instruments and techniques of the operation, reducing the time of the operation, which takes from 9 to 12 minutes.

The technical result is achieved by the fact that in the method of ovariogysterectomy in cats, comprising an incision of the skin and subcutaneous tissue of the ventral abdominal wall in the projection of the white line of the abdomen; puncture of the ventral abdominal wall along the white line of the abdomen with a Veress needle, insufflation of the peritoneal cavity; subsequent removal of the Veress needle; section of the white line of the abdomen and the extension of the edges of the wound; introduction of endoscopic instruments into the peritoneal cavity; revision of the abdominal organs, finding the uterus and ovaries and subsequent introduction through the instrument channel of an endoscopic instrument to engage the uterine horn with the ovary; extraction of endoscopic instruments from the peritoneal cavity along with the uterine horn and ovary; peritoneal cavity desufflation; fixation of the horn of the uterus and ovary, hemostasis of the vessels of the ovary and uterus; clipping of the ovary with the uterine horn; pulling up the uterus by the prepared horn and removing its bifurcation and contralateral horns of the uterus and ovary from the peritoneal cavity, hemostasis of the vessels of the contralateral ovary and uterus; cutting off the contralateral ovary together with the contralateral horn of the uterus; processing and cutting off the uterus in the cervical region, subsequent sealing of the surgical wound of the white line of the abdomen and skin, as well as the fact that, before starting the operation, possible pathologies of the abdominal and thoracic cavities of the animal are revealed using ECG, echocardiography, radiography and ultrasound; tracheal intubation with a tube with a swelling cuff, as well as massage and emptying of the bladder, connecting a cardiomonitor for intraoperative monitoring of the functions of the cardiovascular and respiratory systems, and after cutting the skin and subcutaneous tissue, the ventral abdominal wall is additionally elevated, and after cutting the ovary with the uterine horn, they additionally ligate non-absorbable suture material vessels of the suspensory ligament of the ovaries and the uterus in the neck, while the skin and subcutaneous tissue are cut, departing from heel caudally in the projection of the white line of the abdomen at a distance of not less than 2.0 cm and not more than 3.5 cm, and the edges of the wound of the skin and subcutaneous tissue are separated by eyelids and the peritoneal cavity is insufflated by purified atmospheric air passed through the filter, and the white line wound is sealed the abdomen and skin, as well as the subcutaneous tissue of the ventral abdominal wall, are sutured.

The use of a trocar as an endoscopic instrument with a flap or universal valve without a stylet is a more perfect atraumatic technique, since the valve does not have any effect on the instrument inserted into the abdominal cavity, ensures its complete tightness and minimizes the possibility of damage to the internal organs of the abdominal cavity and retroperitoneal vessels by the distal end of the cannula of the trocar.

The use of a rat-tooth flexible endoscopic forceps as an endoscopic instrument of the hysteroscope with an instrumental channel, and as a tool for engaging the uterus and ovary horns, is a more high-tech and modern method in endosurgery, which allows surgical operation to be less traumatic due to the convenient design of the forceps providing reliable capture of the horns of the uterus and ovaries and excluding the possibility of injury to the abdominal organs.

The choice of an endosurgical instrument (trocar or hysteroscope) for carrying out the proposed method of ovariogisterectomy is based on the analysis of the totality of data obtained during preoperative examination and preparation of the animal.

The proposed method of ovarian hysterectomy in cats is implemented using the following equipment and tools.

1. General purpose equipment

1.1. An operating table (mechanical, or mechanical-hydraulic, or electro-hydraulic) with the possibility of changing the geometry of the countertop in three planes (tilting left and right, back and forth, raising and lowering).

1.2. Mechanical ventilation apparatus.

1.3. Laryngoscope.

1.4. Inflatable tube with inflated cuff.

1.5. Monitor for monitoring vital functions (ECG, heart rate, NPV, pulse oximetry, thermometry).

1.6. Electrosurgical generator with mono-and bicoagulation modes (10 or more modes).

1.7. Oxygen Concentrator.

2. Endosurgical equipment

2.1. Endovideo system with a video head.

2.2. An electronic unit for recording video and photos.

2.3. Video monitor (tube or LCD, or plasma).

2.4. Electronic insufflator.

2.5. Electronic compressor for supplying air to the insufflator.

3. General purpose tools

3.1. Aerial lifts Demarra - 2 pcs.

3.2. Shassenyak sharp single-tooth hook (Tracheostomy hook) - 1 pc.

4. Endosurgical instruments

4.1. Veress Needle - 1 pcs.

4.2. Endoscopic trocars with casement or universal valves with diameters from 5.0 mm to 12.0 mm smooth or with external thread (including Endopath 5-12 mm and Endo Tip) without stylet - 1 pc.

4.3. Video endoscopes with a diameter of 2.7 mm to 10.0 mm with end (0 °) or oblique (30 °) optics - 1 pc.

4.4. A hook made of a blunt needle made of titanium alloy with a diameter of 1.0 mm and a length of 250 mm, the distal end of which is bent so that it can be inserted into a trocar with a diameter of 5.0 mm - 1 pc.

4.5. Operating hysteroscope Fr18 with instrumental channel.

4.6. Flexible endoscopic rat-tooth forceps.

The proposed method of ovariogisterectomy of cats is as follows.

When making a preliminary decision to conduct or refuse an operation, as well as to determine the size of the skin incision, subcutaneous tissue, white line of the abdomen and its location relative to the navel, the animal is examined by conducting ECG, echocardiography, ultrasound of the abdominal cavity organs, panoramic radiography of the chest and abdominal organs cavities.

After deciding on the operation and on the endoscopic instrument used during the operation (trocar or hysteroscope), the animal is anesthetized.

Then the animal is fixed on the operating table in a supine position. Using an operating table with a variable geometry of the tabletop in three planes allows it to be tilted left and right, to raise or lower the head or caudal edges, to raise or lower the tabletop to change the dislocation of the abdominal organs. The animal’s bladder is emptied by massage through the ventral abdominal wall to reduce the risk of damage to the abdominal organs.

After that, the hair is cut and shaved from the skin of the ventral abdominal wall of the animal to highlight the surgical field relative to the navel: cranially - 3.0-4.0 cm cranial to the navel; caudally - 1.0-1.5 cm cranial to the pubic symphysis; laterally (from the sides) - 1.0-1.5 cm laterally departing from the nipples of the mammary glands, treated with antiseptic solutions and isolated with sterile dressing, the edges of which are fixed to the skin of the ventral abdominal wall.

The skin of the ventral abdominal wall is linearly dissected to a length of more than 5.0 mm in the projection of the white line of the abdomen, departing caudally from the navel 2.0-3.5 cm, thereby eliminating the strong tension of the horns and body of the uterus when they are stretched to prevent uterine separation from the vagina with the occurrence of uncontrolled bleeding.

Subcutaneous adipose tissue is dissected in a projection of the skin incision to expose the aponeurosis of the external oblique muscles of the abdomen and the white line of the abdomen, the edges of the surgical wound of the skin and subcutaneous tissue are pulled by Demarra eyelids, the white line of the abdomen is punctured with a tracheostomy hook, or the temporary piercing ligature of the abdomen and elevate the aporone and the white line of the abdomen.

The use of a tracheostomy hook for elevating the ventral abdominal wall helps to minimize the risk of damage to the abdominal organs during operative access due to the reliable fixation of the ventral abdominal wall and creating the maximum possible distance between the ventral abdominal wall and abdominal organs.

A white abdomen line is pierced with a Veress needle, a hose from an electronic insufflator is connected to the needle pavilion, and air passed through the filter is introduced into the peritoneal cavity to elevate the ventral abdominal wall and subsequent visualization of the internal organs of the animal. Since the air is neutral, it does not cause any complications and mechanical damage to the internal organs and peritoneum of the animal. The air pressure in the peritoneal cavity is automatically adjusted to a level of about 9.0 mm Hg. Then the needle is removed from the peritoneal cavity and disconnected from the insufflator.

After that, the opposite edges of the skin wound and subcutaneous tissue are again pushed back by the eyelids of Demarr in different directions.

Using as a tool to push the edges of the wound of the eyelids Demarra is more gentle and less traumatic due to their ergonomics and adaptability to mini-incisions.

Then, with a scalpel, a white line of the abdomen is linearly cut with a length of more than 5.0 mm distal to the superimposed tracheostomy hook or temporary piercing ligature. Billroth's clamp is inserted into the obtained incision, the edges of the wound of the white line of the abdomen are pushed open, and the trocar is inserted into the peritoneal cavity, to which the hose from the insufflator is connected to the tap, air is fed into the peritoneal cavity, the tracheostomy hook is removed and the demarra eyelids are removed.

An endoscope is inserted through the cannula of the trocar, the abdominal organs are examined according to the Wittmann scheme, and the uterine horn with the ovary is visualized, after which the endoscope is removed from the trocar cannula. Then, a hook is led through the cannula of the trocar and after it the endoscope, under visual control, grabs the junction of the caudal pole of the ovary with the apex of the uterine horn, traces and synchronously removes the ovary and cranial part of the uterine horn together with the hook, endoscope and cannula of the trocar through the surgical wound in the white line of the abdomen from the peritoneal cavity. At the same time, air from the peritoneal cavity is desufflated, the ovary and uterine horn are left fixed with a hook.

Two hemostatic clamps, respectively cranial and caudal from each other, are placed on the hanging ligament of the ovary and the location of the fallopian tube with adjacent blood vessels and the hook is removed. The ovary together with the uterine horn is cut off, and the suspensory ligament of the ovary with vessels is ligated under the cranial clamp with a ligature of non-absorbable suture material. After that, remove the cranial clamp.

Ligation technique is a more reliable way to connect tissues, in comparison with other known methods of their connection.

Uterus bifurcation and the contralateral ovary and the cranial part of the uterine horn are extracted from the peritoneal cavity. After that, two hemostatic clamps are placed cranially and caudally from each other on the suspensory ligament of the contralateral ovary and the location of the fallopian tube with adjacent blood vessels and the round ligament of the uterus. The ovary is cut off along with the uterine horn, and the suspensory ligament of the ovary with vessels is ligated under the cranial clamp with a ligature of non-absorbable suture material. After that, remove the cranial clamp.

The demarr eyelid lifts the edge of the wound of the white line of the abdomen caudally, as a more gentle and less traumatic instrument, removes the uterine body from the peritoneal cavity and puts two ligatures on it from non-absorbable suture material. Then the uterine body is crossed, the stump is treated with an electrocoagulator, the ends of the ligatures are cut off and returned to the peritoneal cavity.

Suture on the wound of the white line of the abdomen from non-absorbable suture material, which allows the most reliable sealing of the wound.

On the skin wound of the ventral abdominal wall and subcutaneous tissue, a Donati suture is made from a non-absorbable suture material that is treated with antiseptics.

In the near postoperative period, the animal undergo oxygen therapy.

Thus, the set of essential features in the proposed method allows to ensure the maximum reduction in the anesthetic and operational risk of injury to the animal due to the preoperative identification of possible pathologies of internal organs; massage and emptying the animal’s bladder, which improves the visualization of the abdominal organs and reduces the possibility of damage to the bladder; skin incision, departing from the navel caudally in the projection of the white line of the abdomen at a distance of not less than 2.0 cm and not more than 3.5 cm, excluding the separation of the horns and body of the uterus from the vagina and uncontrolled bleeding; use as a endoscopic instrument a trocar with a flap or universal valve without a stylet, and as tools for spreading the edges of the wound - the Demarr eyelids and tracheostomy hook for elevating the ventral abdominal wall, as more sparing, atraumatic and ergonomic instruments; ligation of animal vessels and insufflation of the peritoneal cavity with atmospheric air passed through the filter, as well as reducing the time of the operation to 9-12 minutes.

The proposed method of ovariogysterectomy is currently tested by the author on 70 cats and accepted for use in the veterinary clinic "Friend" (Samara).

Claims (3)

1. The method of ovariogysterectomy in cats, including an incision of the skin and subcutaneous tissue of the ventral abdominal wall in the projection of the white line of the abdomen, a puncture of the ventral abdominal wall along the white line of the abdomen with a Veress needle, insufflation of the peritoneal cavity, subsequent removal of the Veress needle, an incision of the white line of the abdomen and the extension of the edges of the wound , the introduction into the peritoneal cavity of endoscopic instruments for revision of the abdominal organs, the location of the uterus and ovaries and the subsequent introduction through the instrument channel of an endoscopic instrument for hooking uterine horn with ovary, extraction of endoscopic instruments from the peritoneal cavity along with the uterus and ovary, desufflation of the peritoneal cavity, fixation of the uterus and ovary horn, doping of the vessels of the ovary and uterus, cutting off the ovary with the uterine horn, pulling the uterus by the prepared horn and removing the peritoneal cavity of its bifurcation and the contralateral horn of the uterus and ovary, doping of the vessels of the contralateral ovary and uterus, cutting off the contralateral ovary with the uterine horn, processing and cutting off the uterus in the neck and, sealing the surgical wound of the white line of the abdomen and skin, characterized in that they additionally massage and empty the bladder, cut the skin and subcutaneous tissue, departing from the navel caudally in the projection of the white line of the abdomen at a distance of at least 2.0 cm and not more than 3.5 cm, and push the edges of the wound of the skin and subcutaneous tissue with the help of the eyelids Demarra, then pierce the white line of the abdomen with a tracheostomy hook and elevate the aponeurosis of the external oblique muscles and the white line of the abdomen, insufflation of the peritoneal cavity produces DYT passed through a filter with purified atmospheric air, after clipping of ovary a horn of the uterus is further ligated nonabsorbable suture vessels suspensory ligament ovaries and the uterus in the cervical region, the white line seal wounds and skin of the abdomen, and the subcutaneous tissue of the ventral abdominal wall is effected by suturing. 2. The method of ovariogysterectomy in cats according to claim 1, characterized in that a trocar with a flap or universal valve without a stylet is used as an endoscopic instrument. 3. The method of ovariogysterectomy in cats according to claim 1, characterized in that a hysteroscope with an instrumental channel is used as an endoscopic instrument, and flexible rat tooth endoscopic forceps are used as an instrument for engaging the uterine and ovarian horns.