24 Nicole J. Buote Laparoscopic ovariectomy (LapOVE) and ovariohysterectomy (LapOVH) have become two of the most popular, if not the most commonly performed, minimally invasive soft tissue procedures in veterinary medicine in the United States.1,2 Although laparoscopic reproductive procedures are performed commonly in women, usually these procedures leave the ovarian tissue behind and are mainly performed for reproductive control.3,4 Not only do surgical specialists perform these types of sterilization procedures, but many general practitioners also enjoy offering the option to their clients. Currently, these procedures can be performed in cats and any size of dog, but originally they were held aside for medium to large breed dogs because of the difficulty with a small working space and rigid instruments in smaller patients.5-8 Laparoscopic procedures are not new to veterinary medicine, with the first sterilization technique being performed in 1985 for laparoscopic occlusion of the uterine horns by electrocoagulation in dogs and cats.10 That study documented that it was possible to provide clinically healthy infertile patients years after the procedure if the separation point was at the uterotubal junction. This procedure may have sterilized the patients but did not stop unwanted sexual behavior or protect against pyometra or mammary carcinoma because the ovaries were left in situ. Work began in earnest in Europe to determine the efficacy and safety of OVE compared with OVH, and the former soon became the standard of care with regards to open surgery.11 In the mid 1990s, LapOVE started to gain popularity in Europe. In the United States, open OVH is still the procedure of choice taught in veterinary schools but among laparoscopists LapOVE has now become the procedure of choice largely because it is simpler to perform.12 Although there were case reports and small case series on artificial insemination in cats, vasectomy for dogs, and OVH for pyometra in two dogs, the majority of interest in these procedures in small animal medicine was not fully realized until the early 21st century.13-15 The first case series in nine dogs that reported successful LapOVH was in 2003.16 This manuscript highlighted some of the challenges to traditional open OVH, including decreased visualization with the risk of incomplete resection of ovarian tissue or ligation of ureters and trauma to tissues as the ovarian pedicle is strummed or torn down.16 In women, laparoscopic hysterectomy is the treatment of choice in most cases and has even been shown to have the same efficacy as open surgery in treatment of cervical cancer with fewer postoperative complications.4 The data on decreased pain perception in patients undergoing LapOVH or LapOVE are clear.17-20 One of the first papers studying this relationship cited complications with the LapOVH procedure and longer operative times than open OVH, but postoperative pain scores were significantly less with the minimally invasive technique.17 This work has been continued by many other authors,18-20 who have continued to determine that laparoscopic procedures consistently cause less discomfort in our patient population. A landmark paper by Devitt et al.19 illustrated that LapOVH had clear biochemical and subjective pain score advantages over open OVH with no notable surgical complications. Other important work showed an increase in postoperative activity levels even in small breed dogs undergoing LapOVE versus open OVE as measured by accelerometry.20 The relevant anatomy for these procedures includes the ovaries, ovarian pedicles, suspensory ligaments, uterine horns, uterine body, and associated connective tissues (Figures 24.1 and 24.2). Although the anatomy is very familiar to most veterinarians, the magnification and view produced by high-quality telescopes provide amazing detail. Canine ovaries are usually completely concealed in the ovarian bursa, which commonly contains fat obscuring the view of the actual ovary. Feline ovaries are only covered by a bursa laterally and usually contain no fat, allowing for much better visualization. The ovary is attached to the dorsolateral abdominal wall by the mesovarium, which contains the ovarian blood vessels. The mesovarium is continuous with the suspensory ligament and caudally with the mesometrium. The uterus consists of the cervix, body, and uterine horns. The uterine horns range from 10 to 14 cm in length in dogs and 9 to 10 cm long in cats and lie completely within the peritoneal cavity. The mesometrium attaches the uterus to the dorsolateral body wall and contains the uterine arteries and veins. Figure 24.1 Intraoperative view from a 0-degree, 5-mm telescope view of the left ovary. Figure 24.2 Intraoperative view from a 0-degree, 5-mm telescope of the left uterine horn. As stated previously, dogs and cats of all ages, sizes, and breeds can be good candidates for laparoscopic sterilization techniques. The size of the patient need not be a contraindication, but every laparoscopist should remember the increased difficulty in performing intraabdominal laparoscopic procedures with a small working space. This difficulty may translate into longer operative times in patients that are already prone to hypothermia because of their small size, so every precaution should be taken to keep patients warm, and surgeons should be prepared to convert if the procedure is not going smoothly. In older or obese patients, these procedures are extremely beneficial because the magnification allows for better confidence during pedicle ligation, and in the case of LapOVE, less bleeding from fatty mesometrial tissue. Older or multiparous dogs or cats may have a greater blood supply to the ovaries and uterus, and along with increased tissue friability, these reasons make LapOVE or LapOVH a preferred option over open procedures in these patient populations. There are very few relative contraindications to a LapOVH or LapOVE other than severe cardiopulmonary compromise or known diaphragmatic hernia, which would make carbon dioxide (CO2) insufflation dangerous. However, even these situations have solutions in laparoscopy today, with techniques such as lift laparoscopy, which uses a specially designed metal ring threaded into the abdomen to lift the body wall away from the underlying organs to create working space, an option in these cases.21 Other relative contraindications could be an active heat cycle, early pregnancy, or pyometra with moderate to large uterine distension. A pyometra or pregnancy can be considered a contraindication to a LapOVE but not to a LapOVH.15,22 It has been shown that laparoscopic treatment of pyometra can be performed very safely if the uterine horns are only mildly distended.15,22 In the author’s experience, performing LapOVH in patients with large, heavy pyometras does not carry an obvious advantage over open OVH. This tissue is extremely friable, and the highly distended uterine horns are usually very close to the abdominal wall, increasing the risk of iatrogenic puncture with trocar–Veress needle placement. Appropriate case selection is key to a successful and safe procedure. Any patient presenting for a LapOVE or LapOVH should have a complete physical examination and routine blood work depending on the age and relevant history of the patient. With young patients, special attention is paid to any visible congenital defects such as umbilical hernias because these may be an indication of other congenital defects that could complicate the procedure (diaphragmatic hernia, peritoneopericardial diaphragmatic hernia [PPDH]). Because of the insufflation used during these procedures, care must be taken to fully evaluate the respiratory system in any patient undergoing laparoscopy. Any predisposition to bleeding (e.g., Doberman Pinschers with von Willebrand’s disease) should also be taken under consideration and appropriate testing and preoperative treatment performed if necessary. Surgical preparation for any surgical patient begins the night before the procedure with appropriate fasting (at least 8–12 hours before the procedure). Water is allowed overnight but withdrawn the morning of surgery, and if there are oral medications that are crucial to the patient’s health, they are given with the tiniest amount of food possible. After the patient presents to the hospital and a physical examination and appropriate blood work have been performed, a premedication is given and an intravenous (IV) catheter placed. Depending on the timing of surgery, walking laparoscopy patients to encourage urination before the procedure is very helpful because a large bladder can limit working space during caudal abdominal procedures.8 In cases in which transabdominal ovarian suspension is not used, the extent of the ventral abdomen that is clipped is similar for LapOVE and LapOVH and similar to that performed for an open OVH, extending to just lateral to the nipple line on each side, just cranial to the pubis and just caudal to the rib cage, in case a conversion needs to be performed (Figure 24.3). For cases in which transabdominal suspension of the ovary is going to be performed using an OVE hook or percutaneously placed suspension needle to hold the ovary for a two-port technique, a wider clip needs to be performed. One author states the lateral margins should be approximately 50% of the distance between the ventral and dorsal midline with this technique8 (Figure 24.4). The OVE hook (Karl Storz Endoscopy, Goleta, CA) is a device with a cutting tip or taper tip surgical needle attached to a weighted handle (Figure 24.5), which keeps the ovary suspended and does not require additional clamps.8 Figure 24.3 Photo of the required hair clip and initial positioning in the operating room for a patient undergoing single-port laparoscopic ovariectomy or three-port ovariohysterectomy. Figure 24.4 Photograph of a hair clip if an ovariectomy hook or needle suspension technique are used. Note that the lateral aspect of the clip must go substantially more dorsal on both sides. Figure 24.5 A resterilizable ovariectomy hook (Karl Storz Endoscopy, Goleta, CA) can be used in place of a suspension suture for two- or single-port ovariectomy or ovariohysterectomy. A dirty scrub should be performed as for any surgical procedure and the patient moved into the operating room, set up on monitoring equipment, and a final aseptic preparation performed before draping. Patient positioning for these procedures is in dorsal recumbency with the legs tied at all four corners of the table. If a tilt table is available, this greatly facilitates the repositioning of the patient during the procedure. Some descriptions cite a lateral tilt of approximately 15 degrees to be adequate to move intraabdominal organs off of the underlying ovary,5,8 but in this author’s experience, the table is sometimes positioned in a much more acute angle, closer to 25 to 30 degrees, or the patient is manually flipped almost into lateral recumbency20,23 (Figure 24.6). This is especially true on the left side, where the spleen has a tendency to cover the left kidney and ovary stubbornly. If a tilt table is used, the patient must be securely attached to the table to prevent any movement during the procedure. If a tilt table is not available, then the limbs are loosely attached because the patient will most likely have to be repositioned several times during the procedure. Placing the patient in a Trendelenburg position (head down) has also been discussed in some texts to aid in cranial displacement of the intraabdominal organs.5 Figure 24.6 Photograph of patient positioned on a tilt table that is used to move organs away from the ovaries during laparoscopic ovariectomy and ovariohysterectomy. The positioning of the surgeon will change depending on the side of ovary being removed. For LapOVE, the tower can be set up at the head or back of the table as long as the monitor is easily adjusted. For OVH, the monitor is best at the end of the table because much of the dissection will proceed in a cranial to caudal direction, so this positioning allows the surgeon to look in the direction his or her hands are moving (Figure 24.7). Figure 24.7 The operating room layout for a laparoscopic ovariectomy (LapOVE) or laparoscopic ovariohysterectomy (LapOVH). The endoscopic tower is usually placed at the foot of the patient, especially for LapOVH, but for LapOVE, some surgeons prefer to place the tower at the head of the patient. Original descriptions of LapOVH describe placement of three or four portals, often with ports placed in paramedian locations. Since that time, there has been a general trend toward fewer ports and placement centered over the linea alba. The four-port technique had one port placed in all four quadrants of the abdomen.15,17 With this configuration, the telescope portal was always the middle portal, and instruments were passed between the cranial and caudal portal for grasping and dissecting. Early three-portal techniques comprised a telescope portal, which was cranial to the umbilicus, and two portals placed paramedian on both sides in the caudal abdomen.5,16,18 More recent three median port techniques for LapOVH22,23 have involved placement of one subumbilical port for the telescope, one port 2 to 3 cm cranial to the umbilicus, and one port 2 to 5 cm cranial to the pubis for eventual removal of the urogenital tract (Figure 24.8). It is very important that this port be placed under visualization because it will be directly overlying the urinary bladder and colon. In 2005, a two-port technique was described using an 11-mm operative laparoscope with an operating channel for insertion of 5-mm instruments.19 This allowed for one port to be placed at the umbilicus for the telescope and one cannula to be placed 4 to 5 cm cranial to pubis at the midline for eventual extraction of the urogenital tract. Figure 24.8 Line drawing of three-port ventral midline placement for ovariectomy. The telescope port is placed at the umbilicus, one instrument port 2 to 3 cm cranial to the umbilicus and one instrument port 2 to 5 cm cranial to the pubis. Many different portal positions have been reported for LapOVE, including one median portal at the umbilicus with two lateral portals24,25 and the three-port technique with all ports on the ventral midline.6,7,26-29 In 2009, a two median port technique was described in which one port was placed 1 cm caudal to the umbilicus and one port was placed 2 to 5 cm cranial to the pubis (Figure 24.9). This technique used the OVE needle suspension method and was very effective at allowing for dissection while minimizing port numbers.20 Also in 2009, a technique paper comparing a one- and two-port technique was published.30
Laparoscopic Ovariectomy and Ovariohysterectomy
Preoperative Considerations
Relevant Anatomy and Pathophysiology
Patient Selection
Diagnostic Workup
Patient Preparation
Portal Placement
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