14 Kayla M. Corriveau, Jeffrey J. Runge, and Clarence A. Rawlings A gastropexy is the creation of a permanent adhesion of the stomach to the body wall and is most commonly performed for prevention of gastric dilatation and volvulus (GDV) either in animals currently having an episode of GDV or prophylactically in those that have not had the syndrome yet. GDV is a life-threatening condition of uncertain etiology that affects approximately 60,000 dogs annually.1 It is characterized by gastric dilatation, varying degrees of malpositioning of the stomach, compression of the portal, splanchnic, and caudal vena caval blood flow, hypotensive and cardiogenic shock, gastric necrosis, tissue acidosis, cardiac arrhythmias, disseminated intravascular coagulation, and possibly death.2 Without surgical intervention, most GDV-affected dogs die, but only 1% or fewer die when the stomach is dilated (GD) but no torsion has occurred.3 Even with aggressive management and surgical correction, the mortality rate for GDV-affected dogs remains high at 10% to 33%.3-7 Mortality rates increase with need for splenectomy (32%), partial gastrectomy (35%), or both (55%).8 Dogs treated surgically for GDV without a gastropexy have recurrence rates of more than 50%, but recurrence of GDV after gastropexy is less than 5%.5 As a result, gastropexy is now considered a standard of care adjunctive procedure that should be performed at the time of surgical GDV correction.5 Because of the high morbidity and mortality rates associated with the development of GDV, prophylactic gastropexy should be considered in at-risk dogs. Unfortunately, few risk factors for GDV have been clearly identified, and the condition is assumed to be multifactorial.9 Dog breed has consistently been found to be a predisposing factor with a 24% lifetime likelihood of GDV in large breed show dogs and 21.6% in giant breed show dogs.10 Reported predisposed breeds include Great Danes, German shepherds, Gordon setters, Irish setters, Bassett hounds, Airedale terriers, Irish wolfhounds, Borzois, bloodhounds, Akitas, bull mastiffs, chow chows, and Weimaraners.3,4,11 When evaluating Great Danes, Irish setters, Rottweilers, standard poodles, and Weimeraners, studies have shown that prophylactic gastropexy reduced lifetime mortality over a range of 2.2-fold for Rottweilers to 29.6-fold for Great Danes.12 Other significant dog-related risk factors include increased age,4,13,14 first-degree relative with GDV,14 and increased thoracic depth-to-width ratio.15,16 Less consistent dog-specific risk factors include an aggressive or fearful temperament,9,14 being underweight,9 and male gender.9 Concurrent medical conditions have been noted in association with GDV, including histologic evidence of inflammatory bowel disease,17 gastric foreign body,18 and history of splenectomy,19 but causal relationships have not been established. Environmental factors may also influence risk of GDV such as experiencing a stressful event within 8 hours prior.4 Lastly, dietary management is considered a contributing factor with increased risk associated with small particle size (<30 mm diameter),13 the presence of oil or fat among the first four ingredients in a dry food,20 once-daily feeding,9,21 feeding from an elevated bowl,14 eating quickly,9,14 and aerophagia.21 Recent studies have brought into question the long-standing theory that pre- and postprandial exercise increases the risk of GDV. A large study of 1637 show dogs concluded no advantage to exercise restriction14 around feeding time, but in a large cross-sectional study, moderate physical activity after a meal significantly decreased risk of GDV.22 The only other factors found to be associated with a decreased incidence of GDV were owner-perceived personality trait of happiness14 and supplements with fish or eggs.22 A variety of gastropexy techniques have been described, including incisional, belt loop,23 circumcostal,14 incorporating,24 and fundic gastropexy.25 Gastric fixation via gastrojejunostomy26 and gastrocolopexy27 have also been reported but are rarely used. Right-sided grid (mini-laparotomy),28 endoscopically assisted,29,30 totally laparoscopic,31-34 and laparoscopic assisted35-38 approaches have been described as minimally invasive options to perform prophylactic gastropexy. Right-sided percutaneous endoscopic gastrostomy (PEG) is another minimally invasive technique reported for permanent gastropexy but is not recommended because of inconsistent weak adhesion formation and greater procedure-related complications.39 Other than the PEG technique, biomechanical testing on a variety of the gastropexy techniques has been very comparable (Table 14.1). Unfortunately, the maximal tensile strength needed to prevent GDV is not known and may differ among individual dogs. Therefore, prevention of GDV recurrence and reliability of adhesion formation are arguably better clinical evaluation parameters for gastropexy techniques. Current published GDV recurrence rates after gastropexy are as follows: incisional, 0%40; belt loop, 0%23; circumcostal technique, 3.3% to 9%41,42; and gastrocolopexy, 15%.42 Barium gastrography, ultrasonography, follow-up laparoscopy, and necropsy studies have been used to confirm formation of permanent gastropexy adhesions. Consistent formation of permanent adhesions has been confirmed by one or more of these methods with incisional gastropexy,24,43 incorporating,24 right-sided grid approach,28 laparoscopic-assisted techniques,35,37,44 totally laparoscopic stapled gastropexy,32 and intracorporeally sutured gastropexy.31,33 Table 14.1 Biomechanical Testing of Gastropexy Techniques With many of the commonly performed gastropexy techniques having comparable biomechanical values and clinical outcomes (i.e., GDV recurrence rate and consistency of adhesion formation), the type of gastropexy performed is largely up to surgeon preference and the stability of the patient (see Table 14.1). Typically, an open laparotomy technique is used for GDV-affected dogs; however, there has been one report of laparoscopic correction of GDV in clinically affected dogs.44 In this report, two dogs with confirmed GDV in which a stomach tube could be passed were successfully treated laparoscopically. The gastric contents from the tube in these cases did not indicate gross gastric hemorrhage, and the dogs were hemodynamically stable after fluid resuscitation. Although select patients may fall into this category, our current recommendation is to reserve minimally invasive gastropexy techniques for prophylaxis of GDV syndrome in noncritical patients with no signs of current GDV. Emergency open laparotomy, in the authors’ opinion, remains the treatment of choice for GDV patients to allow rapid gastric decompression, derotation of the stomach, evaluation of gastric and splenic viability, and gastropexy. This chapter focuses on laparoscopic and laparoscopic-assisted prophylactic gastropexy techniques. As stated earlier, indications for prophylactic gastropexy include clinically stable dogs at risk for GDV. Laparoscopic and laparoscopic-assisted gastropexy can also be easily performed concurrently with other elective laparoscopic procedures such as ovariectomy,37,38 cryptorchidectomy,45 and abdominal organ biopsy. Before prophylactic gastropexy, a routine preoperative biochemical panel and complete blood count are recommended. Screening thoracic radiographs are recommended in older patients (older than 8 years) or if clinical suspicion warrants thoracic investigation. As with other elective abdominal surgeries, the dog should be fasted for at least 12 hours before anesthesia. The dog’s abdomen should be clipped and aseptically prepared from the xiphoid to the pubic brim. For laparoscopic-assisted techniques that place the gastric antrum to the adjacent body wall; the right lateral abdominal wall may benefit from a wider clipping to a midlateral level to accommodate the creation of a right paramedian port (Figure 14.1). For an intracorporeally sutured laparoscopic gastropexy, the dog is draped for a conventional open celiotomy in case conversion or additional port placement is required. Figure 14.1 For laparoscopic-assisted gastropexy, a wide margin should be clipped around the planned site of the incision. Prophylactic perioperative antibiotics are recommended (cefazolin, 22 mg/kg intravenously every 90 minutes) because during the early portions of the learning curve, surgical time may be significant with this procedure, especially when the intracorporeally sutured technique is used.31 For the single-port and multiport laparoscopic gastropexy techniques, the dog is placed in dorsal recumbency with the front and rear limbs secured for the procedure. The primary surgeon should be positioned on the dog’s right side with the laparoscopic monitor on the opposite side of the patient (Figure 14.2). Abdominal access is obtained via either Veress needle or with the Hasson technique; the location of the initial port placement depends on the particular gastropexy technique used. Pneumoperitoneum is established with carbon dioxide (CO2) using a mechanical insufflator to a pressure not exceeding 10 to 15 mm Hg. After the initial trocar–cannula assembly is placed (or single-port device is inserted), the insufflator pressure should be reduced to 6 to 10 mm Hg. Depending on which gastropexy technique is selected (or if additional laparoscopic procedures are performed), the number and location of laparoscopic ports can vary because the gastropexy can be performed using one, two, or three ports. Figure 14.2 The operating room layout for a multiport or single-port laparoscopic-assisted gastropexy. The laparoscopic-assisted gastropexy was originally described by Rawlings et al. in 2001.36 To perform a laparoscopic-assisted gastropexy, the dog is placed in dorsal recumbency. The abdomen is clipped and aseptically prepared from the xiphoid cartilage to the brim of the pubis. The telescope is initially placed through a subumbilical port, and the second port is inserted adjacent to the lateral margin of the rectus abdominis on the patients right side, approximately 3 to 5 cm caudal to the last rib depending on the patient’s size (Figure 14.3). The second trocar–cannula assembly should be large enough to accommodate 10-mm instrumentation (Figure 14.4). After the telescope has been placed into the abdomen, transillumination of the body wall at the proposed location of the instrument portal can help identify a safe region for insertion of the second port by avoiding unwanted body wall and neurovascular trauma during insertion. A laparoscopic 10-mm Babcock or 10-mm DuVall forceps can be used for grasping the stomach from the second instrument port (Figure 14.5). These instruments can be safely used to manipulate the cranial abdominal organs and obtain an unobstructed view of the antrum of the stomach. If exposure of the stomach is still not ideal for the surgeon, the patient can be tilted in reverse Trendelenburg positioning to shift the abdominal viscera caudally. After it is clearly visualized, the antrum of the stomach is grasped with the forceps midway between the greater and lesser curvature of the stomach, approximately 5 to 7 cm oral to the pylorus. This site also becomes the location for the incisional gastropexy. After the surgeon has grasped the antrum securely, the pneumoperitoneum is evacuated. The forceps and antrum are exteriorized by removing the cannula and extending the port incision to 4 to 5 cm in an orientation parallel to the last rib (Figure 14.6). This dissection of the body wall can be accomplished with a number of techniques that use either sharp dissection or electrosurgical dissection. Alternatively, a muscle-splitting approach to the external and internal abdominal oblique muscles by incising parallel to the orientation of their fibers has also been described.36
Laparoscopic and Laparoscopic-Assisted Gastropexy Techniques
Preoperative Considerations
Gastropexy Technique
Strength (Newtons)
Time of Testing (days postoperative)
References
Circumcostal
109
21
Fox et al.46
Incisional
60
21
Fox et al.46
Incisional
62
44
Waschak et al.39
Incisional
85 71
730
Hardie et al.32
Belt loop
53
Immediate,cadaver
Coolman et al.47
Belt loop
109
50
Wilson et al.46
Right-sided percutaneous endoscopic gastrostomy
22
44
Waschak et al.39
Laparoscopic assisted
77
50
Wilson et al.48
Laparoscopic assisted
107
30
Rawlings et al.36
Laparoscopic assisted
51
70
Mathon et al.35
Total laparoscopic stapled
45 72
730
Hardie et al.32
Patient Preparation
Surgical Techniques
Laparoscopic-Assisted Gastropexy (Multiport Technique)
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
