A 4-month-old 53-kg (117-lb) Hampshire ram was evaluated at the Colorado State University Veterinary Teaching Hospital because of right-sided scrotal swelling that developed following a kick injury 1 week prior. Palpation and ultrasonography of the scrotum were performed both with the ram standing and under anesthesia. Results indicated the presence of a scrotal hematoma, and the ram was treated medically with cold hydrotherapy and administration of NSAIDs and antimicrobials. One month after initial evaluation, the ram was returned to the hospital because of persistent right-sided scrotal swelling. Palpation and ultrasonography of the scrotum were repeated and revealed right-sided omental herniation, which was treated with unilateral open herniorrhaphy with orchiectomy under anesthesia as has been described previously.1 The omentum was partially resected at the time of orchiectomy because of adhesions to the testicle, and the remaining omentum was then reduced prior to herniorrhaphy. Careful palpation of the left inguinal ring and scrotal compartment was performed, and no abnormalities were detected. Ultrasonographic examination of the left inguinal ring was not performed. No postsurgical complications were observed, and the ram successfully bred after surgery.
At 11 months of age (weight, 98 kg [216 lb]), the ram was reevaluated because of intermittent left-sided scrotal swelling of approximately 1 month's duration. The site of the previous surgery had healed, and the right inguinal ring was closed. Palpation of the enlarged left scrotal compartment revealed an apparently normal testicle. Ultrasonography revealed heterogenous tissue present on the medial and cranial aspects of the scrotum that obscured the underlying testicle and some hypoechoic fluid that had accumulated at the scrotal apex. The primary differential diagnosis was left-sided indirect inguinal herniation of omentum. After discussion with the owner, which included ethics of repair in light of the heritable potential of the condition, a laparoscopic hernioplasty without orchiectomy was authorized.
Results of presurgical hematologic and serum biochemical analyses indicated mild anemia (Hct, 31% [reference interval, 40% to 45%]; RBC count, 10.1 × 106 RBCs/L [reference interval, 11.5 × 106 RBCs/L to 17.5 × 106 RBCs/L]; and hemoglobin concentration, 11.9 g/dL [reference interval, 13.0 to 15.8 g/dL]) and mildly high creatine kinase activity (404 U/L; reference interval, 100 to 300 U/L). The clinicopathologic abnormalities identified were mild and did not imply serious underlying disease, although mild anemia could have been consistent with chronic inflammation and decreased erythrocyte production from bone marrow.
Prior to surgery, food was withheld from the ram for 48 hours and water was withheld for 12 hours. On the morning of surgery, a jugular venous catheter was placed and the ram was administered flunixin meglumine (1.1 mg/kg [0.5 mg/lb], IV) and tulathromycin (2.5 mg/kg [1.1 mg/lb], SC). Anesthesia was induced with diazepam (0.1 mg/kg [0.045 mg/lb], IV) and ketamine hydrochloride (4.0 mg/kg [1.8 mg/lb], IV) and maintained with sevoflurane (2% to 4%) in oxygen via an orotracheal tube. During anesthesia, a constant rate infusion of ketamine (20 μg/kg/min [9.1 μg/lb/min]) and lidocaine (20 μg/kg/min [9.1 μg/lb/min]) was administered. Anesthetic monitoring included ECG, pulse oximetry, capnography, arterial blood gas analyses, and both direct and indirect blood pressure measurements. Intermittent positive pressure ventilation was started prior to surgical incision and continued until the end of surgery. The ram was placed in dorsal recumbency and secured to a surgical table with ability to tilt the animal into Trendelenburg position. Hair was clipped from the xiphoid process to the pubis and lateral to the flank. The left testicle was carefully retracted caudad and secured to prevent contamination of the surgical field. Aseptic surgical site preparation (alternating scrubs of 7.5% povidone-iodine solution and alcohol) was performed prior to draping.
The prepuce was retracted to the left side, and a No. 15 blade was used to make a stab incision through the skin and external sheath of the rectus abdominis muscle, 15 cm caudal to the umbilicus. A teat cannula was inserted through the peritoneum, and insufflation with CO2 performed to a pressure of 10 to 12 mm Hg. The incision was enlarged to allow insertion of an 11-mm threaded cannulaa into the abdomen (laparoscope portal). A 10-mm, 30°, 33-cm rigid laparoscopeb was inserted through this cannula, and the ram was tilted into Trendelenburg position with the table at approximately 15°. Based on triangulation, 2 instrument portals were created in identical fashion (Figure 1) for additional 11-mm threaded cannulas. A third instrument portal was created for passage of a 12-mm laparoscopic cannula.c The left inguinal ring was identified, and omentum was evident passing through the ring (Figure 2). By use of 2 laparoscopic Babcock forceps placed in the instrument portals, the omentum was carefully removed from the inguinal ring until the underlying vas deferens and pampiniform plexus could be visualized. A laparoscopic fan retractord was used to retract the omentum away from the inguinal ring during the remainder of the surgical procedure. It was inserted alternately through the first and second instrument portals to facilitate retraction. A 3 × 2-inch section of polypropylene meshe was then rolled up and passed through the second instrument portal with the Babcock forceps. It was secured over the internal inguinal ring with a 12-mm laparoscopic staplerf passed through the third instrument portal (Figure 3). A section of peritoneum extending 2 cm cranial and 2 cm caudal to the inguinal ring with its base oriented dorsally was created with laparoscopic scissors. After careful dissection, the peritoneal flap was then secured over the polypropylene mesh to the cranial, craniodorsal, caudodorsal, and caudal margins of the internal inguinal ring with the laparoscopic stapler.f The ram was returned to normal dorsal recumbency, and gas was expressed from the abdomen before cannula removal. The abdominal incisions were closed with size 0 glycolide-lactide copolymer braided absorbable multifilament sutureg in the external sheath of the rectus abdominis muscle with cruciate sutures and intradermal sutures were placed with 2–0 glycolide-dioxanone-trimethylene carbonate monofilament absorbable suture.h
The ram recovered uneventfully from anesthesia. The day after surgery, the left testicle seemed normal on palpation and the scrotum was markedly reduced in size. Ultrasonography of the scrotum revealed a small amount of hypoechoic fluid and no evidence of herniated tissue. The left testicle appeared normal, and the medial or cranial aspects (which had been previously obscured by the herniated tissue) were visible and without abnormalities. A breeding soundness examination was performed 5 months after surgery; spermatozoa count and motility were adequate, and the ram returned to breeding. The incision sites had healed well, and there was no recurrence of the scrotal hernia.
Storz Endo Tip Cannula, Karl Storz, Tuttlingen, Germany.
Forward-Oblique Telescope 30°, Karl Storz, Tuttlingen, Germany.
Endopath XCEL TROCAR 12 mm, Ethicon, Somerville, NJ.
Laparoscopic Fan Retractor, Surgical Direct, DeLand, Fla.
Surgipro Flat Sheet mesh SPMM-149, Covidien, Mansfield, Mass.
Endo universal, 4.0 mm, 65°, 12 mm diameter, Covidien, Mansfield, Mass.
Polysorb, Covidien Animal Health, Mansfield, Mass.
Biosyn, Covidien Animal Health, Mansfield, Mass.
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