Laparoscopic nephrosplenic space ablation with barbed suture in eight horses

Marco Gandini Department of Veterinary Sciences, University of Turin, 10095 Grugliasco TO, Italy.

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Sara Nannarone Department of Veterinary Medicine, University of Perugia, 06126 Perugia, Italy.

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Gessica Giusto Department of Veterinary Sciences, University of Turin, 10095 Grugliasco TO, Italy.

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Marco Pepe Department of Veterinary Medicine, University of Perugia, 06126 Perugia, Italy.

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Francesco Comino Department of Veterinary Sciences, University of Turin, 10095 Grugliasco TO, Italy.

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Vittorio Caramello Department of Veterinary Sciences, University of Turin, 10095 Grugliasco TO, Italy.

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Rodolfo Gialletti Department of Veterinary Medicine, University of Perugia, 06126 Perugia, Italy.

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Abstract

CASE DESCRIPTION 8 horses (5 geldings and 3 mares) were evaluated for laparoscopic closure of the nephrosplenic space following a history of recurrent left dorsal displacement of the large colon.

CLINICAL FINDINGS All horses underwent a physical examination and routine clinicopathologic testing. Transrectal palpation and transabdominal ultrasonography were performed to exclude the presence of organs in the left paralumbar region.

TREATMENT AND OUTCOME A left flank laparoscopic approach with the horses standing was used. A continuous suture was placed in a craniocaudal direction between the renal and splenic capsules with unidirectional barbed suture material. This allowed obliteration of the nephrosplenic space without the need for knots to secure the leading and terminal ends of the suture line. In all horses, transrectal palpation was performed 2 months after surgery; at this time, closure of the caudal part of the nephrosplenic space was evident. In 2 horses, follow-up laparoscopy was performed, and complete closure of the nephrosplenic space was confirmed. Telephone follow-up revealed that none of the horses had any signs of recurrent left dorsal displacement of the large colon.

CLINICAL RELEVANCE Results suggested that laparoscopic nephrosplenic space closure with unidirectional barbed suture material could be considered as an option for prevention of left dorsal displacement of the large colon in horses. In the horses of this report, barbed suture material allowed secure ablation of the nephrosplenic space and eliminated the need for intracorporeal knot tying.

Abstract

CASE DESCRIPTION 8 horses (5 geldings and 3 mares) were evaluated for laparoscopic closure of the nephrosplenic space following a history of recurrent left dorsal displacement of the large colon.

CLINICAL FINDINGS All horses underwent a physical examination and routine clinicopathologic testing. Transrectal palpation and transabdominal ultrasonography were performed to exclude the presence of organs in the left paralumbar region.

TREATMENT AND OUTCOME A left flank laparoscopic approach with the horses standing was used. A continuous suture was placed in a craniocaudal direction between the renal and splenic capsules with unidirectional barbed suture material. This allowed obliteration of the nephrosplenic space without the need for knots to secure the leading and terminal ends of the suture line. In all horses, transrectal palpation was performed 2 months after surgery; at this time, closure of the caudal part of the nephrosplenic space was evident. In 2 horses, follow-up laparoscopy was performed, and complete closure of the nephrosplenic space was confirmed. Telephone follow-up revealed that none of the horses had any signs of recurrent left dorsal displacement of the large colon.

CLINICAL RELEVANCE Results suggested that laparoscopic nephrosplenic space closure with unidirectional barbed suture material could be considered as an option for prevention of left dorsal displacement of the large colon in horses. In the horses of this report, barbed suture material allowed secure ablation of the nephrosplenic space and eliminated the need for intracorporeal knot tying.

A 9-year-old 530-kg (1,168-lb) Italian Trotter gelding (horse 1) was referred to the Large Animal Teaching Hospital of the University of Turin. The horse had undergone surgery to resolve left dorsal displacement of the large colon 12 months prior to admission, but because of the recurrent nature of this condition, laparoscopic closure of the nephrosplenic space was recommended.

Written informed consent was provided by the owner. Food was withheld for 24 hours before surgery to reduce the amount of ingesta in the large colon, but water was freely available. Prior to surgery, the horse underwent physical examination, and a CBC, serum biochemical analysis, and coagulation testing were performed. Transrectal palpation and transabdominal ultrasonography were also performed to exclude subclinical left dorsal displacement of the large colon. Ultrasonography was used to identify the positions of the intestines and spleen in the left paralumbar region, to select portal locations, and to measure the abdominal wall thickness at these locations.

Results of hematologic, biochemical, and coagulation testing were within reference limits. Palpation and ultrasonography revealed that the spleen was of expected size and positioned against the left abdominal wall and that the left paralumbar fossa was free from intestines. Procaine benzylpenicillin (8,000 U/kg [3,600 U/lb], IM, q 24 h) and dihydrostreptomycin (8 mg/kg [3.6 mg/lb], IM, q 24 h) were administered prior to surgery and continued for 2 days after surgery. An IV catheter was placed in the left jugular vein, and a single dose of flunixin meglumine (1.1 mg/kg [0.5 mg/lb], IV) was administered to reduce postoperative pain and inflammation. The horse was restrained in stocks, and the left paralumbar fossa was clipped. Detomidine hydrochloride (0.01 mg/kg [0.0045 mg/lb], IV) and butorphanol tartrate (0.02 mg/kg [0.009 mg/lb], IV) were administered. Sedation was maintained with a continuous rate infusion of detomidine hydrochloride (0.6 μg/kg/min [0.27 μg/lb/min], IV) administered with a syringe pump. Portal sites were locally infiltrated with 2% mepivacaine hydrochloride in the skin, fascia, and muscles. The surgical field was aseptically prepared and draped. The first portal was created with a 10-cm-long, 10-mm-diameter blunt trocar-cannula systema in the cranial third of the distance between the caudal border of the last rib and the tuber coxae.1 Subsequently, a 0°, 33-cm-long laparoscopeb was inserted. The abdomen was visually explored but not insufflated. Two additional portals were created ventral to the first under direct vision. The second portal was created just caudal to the last rib at the ventral border of the tuber coxae with a 10-cm-long, 15-mm-diameter trocar-cannula system.c A 10-cm-long, 5-mm-diameter trocar-cannula systemd was introduced in the third portal, which was located 5 cm ventral to the second portal.

To obliterate the nephrosplenic space, a continuous suture was placed in a craniocaudal orientation with a 30-mm-long, one-half-circle taper needle attached to loop-ended, size 0 absorbable polyglyconate knotless suture material.e

The needle was inserted through the looped end before being introduced into the abdomen, creating a large (approx 2-cm-diameter) suture loop. Subsequently, the needle was grasped with a straight 33-cm-long laparoscopic needle holderf that had been inserted through the preformed suture loop (Figure 1)., The needle and needle holder were then introduced into the abdomen through the 15-mm-diameter trocar. A second 33-cm-long needle holderf was then introduced into the third portal, and the needle was positioned in the first needle holder for suturing.

Figure 1—
Figure 1—

Photograph illustrating the method used to lock the beginning of the suture line in place when using size 0 polyglyconate barbed suture material to perform laparoscopic ablation of the nephrosplenic space in horses with a history of recurrent left dorsal displacement of the large colon. The needle was inserted through the looped end of the suture material. A straight 33-cm-long laparoscopic needle holder was then inserted through the loop that was formed and used to grasp the suture material close to the needle.

Citation: Journal of the American Veterinary Medical Association 250, 4; 10.2460/javma.250.4.431

The first suture bite was placed in the cranial-most portion of the perirenal fascia, just ventral to the dorsal edge of the spleen, in a dorsal-to-ventral orientation. The second bite was placed in the splenic capsule in a ventral-to-dorsal orientation, paying particular attention to avoid penetrating to an excessive depth in the parenchyma and exiting near the dorsal edge of the spleen. The needle was then passed through the large suture loop, the needle holder was gently retrieved from the loop, and the suture was tightened (Figure 2)., The suture was continued in this pattern, with tension applied after each bite. After the last bite, an interlocking suture was placed. Tensioning of the suture was completed within the abdomen. Two additional suture bites were placed in the perirenal fascia and splenic capsule in a caudal-to-cranial direction, locking the suture in place. Laparoscopic scissors were introduced via the 5-mm-diameter portal located ventral to the second portal, the suture was cut, and the needle holder was retrieved from the abdomen. After visual inspection of the abdomen for excessive hemorrhage or organ damage, the trocars were removed. For the 15-mm-diameter portal, subcutaneous tissue was closed with 2–0 polyglactin 910 suture materialg and the skin was closed with size 0 nylon suture material.11 For the 5- and 10-mm-diameter portals, the skin was closed with size 0 nylon suture material.h

Figure 2—
Figure 2—

Representative images obtained during laparoscopic ablation of the nephrosplenic space in a gelding with a previous history of left dorsal displacement of the large colon. The first suture bite was placed in the cranial-most portion of the perirenal fascia (A). The second bite was placed in the splenic capsule (B), with the needle and suture material retrieved through a suture loop placed around the needle holder (C). The suture line was then completed (D).

Citation: Journal of the American Veterinary Medical Association 250, 4; 10.2460/javma.250.4.431

Duration of surgery was 60 minutes. The horse recovered from sedation without complications and was allowed access to food 3 hours after the procedure. No postoperative complications were identified, and no signs of pain were detected. All vital signs remained within reference limits. The horse was discharged 3 days after surgery and was prescribed controlled exercise (hand-walk) for a minimum of 40 days before being allowed to resume normal activity.

Sixty days after surgery, transrectal palpation confirmed obliteration of the caudal portion of the nephrosplenic space. Telephone follow-up was performed with the owner 24 months after surgery and revealed that the horse had not had any signs of colic after undergoing nephrosplenic space ablation.

Figure 3—
Figure 3—

Images of the nephrosplenic space in a Holsteiner gelding (horse 4) with a history of left dorsal displacement of the large colon immediately prior to ablation (A) and during repeated laparoscopy 12 months after initial surgery (B).

Citation: Journal of the American Veterinary Medical Association 250, 4; 10.2460/javma.250.4.431

An 11-year-old 550-kg (1,212-lb) Belgian Warmblood gelding (horse 2) was referred to the Large Animal Teaching Hospital of the University of Perugia. The horse had had 2 previous episodes of left dorsal displacement of the large colon. On both occasions, the diagnosis had been made by means of rectal examination and transabdominal ultrasonography and the horse had been treated medically. Because of the recurrent nature of the problem, laparoscopic closure of the nephrosplenic space was recommended.

The procedure was performed as described for horse 1. Duration of surgery was 70 minutes. The horse was discharged 2 days after surgery with no postoperative complications. Rectal palpation was performed 60 days after surgery to confirm obliteration of the caudal portion of the nephrosplenic space. Telephone follow-up was performed with the owners 24 months after surgery and revealed that the horse had not had any signs of colic after undergoing nephrosplenic space ablation.

A 14-year-old 440-kg (970-lb) Selle Francais mare (horse 3) was referred to the Large Animal Teaching Hospital of the University of Perugia. The horse had had 2 previous episodes of left dorsal displacement of the large colon. On both occasions, the diagnosis had been made by means of transrectal palpation and transabdominal ultrasonography and the horse had been treated conservatively. Because of the recurrent nature of the problem, laparoscopic closure of the nephrosplenic space was recommended.

The procedure was performed as described for horse 1. Duration of surgery was 50 minutes. The horse was discharged 2 days after surgery with no postoperative complications. Rectal palpation was performed 60 days after surgery to confirm obliteration of the caudal portion of the nephrosplenic space. Telephone follow-up was performed with the owners 6 months after surgery and revealed that the horse had not had any signs of colic after undergoing nephrosplenic space ablation.

A 9-year-old 560-kg (1,234-lb) Holsteiner gelding (horse 4) was referred to the Large Animal Teaching Hospital of the University of Perugia. The horse had undergone surgery to resolve left dorsal displacement of the large colon 3 months prior to admission.

Ablation of the nephrosplenic space was performed as described for horse 1. Duration of surgery was 45 minutes, and the horse was discharged 3 days after surgery with no postoperative complications. Twelve months after undergoing laparoscopic nephrosplenic space ablation, the horse was readmitted for laparoscopic exploration, and closure of the nephrosplenic space was confirmed. Telephone follow-up was performed with the owners 24 months after nephrosplenic space ablation, who reported that no signs of colic had been seen.

A 5-year-old 500-kg (1,102-lb) Italian Trotter mare (horse 5) was referred to the Large Animal Teaching Hospital of the University of Perugia. The horse had undergone surgery to resolve left dorsal displacement of the large colon 6 months prior to admission.

Ablation of the nephrosplenic space was performed as described for horse 1. Duration of surgery was 30 minutes, and the horse was discharged 3 days after surgery with no postoperative complications. Twelve months after undergoing laparoscopic nephrosplenic space ablation, the horse was readmitted for laparoscopic exploration, and closure of the nephrosplenic space was confirmed. Telephone follow-up was performed with the owners 14 months after nephrosplenic space ablation, who reported that no signs of colic had been seen.

A 11-year-old 500-kg (1,102-lb) Hungarian Warmblood gelding (horse 6) was admitted to the Large Animal Teaching Hospital of the University of Perugia. The horse had undergone surgery to resolve left dorsal displacement of the large colon 2 months prior to admission.

Ablation of the nephrosplenic space was performed as described for horse 1. Duration of surgery was 55 minutes, and the horse was discharged 5 days after surgery with no postoperative complications. Rectal palpation and ultrasonography were performed 60 days after surgery to confirm obliteration of the caudal portion of the nephrosplenic space. Telephone follow-up was performed with the owners 16 months after nephrosplenic space ablation, who reported that no signs of colic had been seen.

An 18-year-old 560-kg (1,234-lb) Belgian Warmblood gelding (horse 7) was admitted to the Large Animal Teaching Hospital of the University of Turin. The horse had undergone surgery to resolve left dorsal displacement of the large colon 1 month prior to admission.

Ablation of the nephrosplenic space was performed as described for horse 1. Duration of surgery was 45 minutes, and the horse was discharged 5 days after surgery with no postoperative complications. Transrectal palpation was performed 60 days after surgery to confirm obliteration of the caudal portion of the nephrosplenic space. Transabdominal ultrasonography was performed 5 months after surgery, and results were similar to those obtained with rectal palpation performed at the same time. Telephone follow-up was performed with the owners 8 months after nephrosplenic space ablation, who reported that no signs of colic had been seen.

A 10-year-old 520-kg (1,146-lb) Arabian mare (horse 8) was admitted to the Large Animal Teaching Hospital of the University of Turin. The horse had undergone surgery to resolve left dorsal displacement of the large colon 3 months prior to admission.

Ablation of the nephrosplenic space was performed as described for horse 1. Duration of surgery was 45 minutes, and the horse was discharged 5 days after surgery with no postoperative complications. Transrectal palpation and ultrasonography were performed 60 days after surgery to confirm obliteration of the caudal portion of the nephrosplenic space. Telephone follow-up was performed with the owners 8 months after the first surgery, who reported that no signs of colic had been seen.

Discussion

Left dorsal displacement of the large colon is a common condition in horses, with reported recurrence rates ranging from 3.2% to 21%.2,3 A number of prophylactic techniques have been proposed, including colopexy, elective large colon resection, and ablation of the nephrosplenic space via left flank laparotomy. Traditional open surgical approaches require general anesthesia, with the attendant potential complications. Unlike other prophylactic treatments for left dorsal displacement of the large colon, laparoscopy is a minimally invasive procedure. Laparoscopy can be performed with the horse sedated but still standing, resulting in a shorter recovery time and other potential benefits, such as improved cosmesis.2

A number of techniques for laparoscopic ablation of the nephrosplenic space have been described,4–8 with the most common being ablation by means of laparoscopic suturing.6–8 Although this technique requires somewhat advanced surgical skills,6 the development of barbed suture material may make the procedure easier. Barbed suture material has a self-anchoring design that does not require knots at the beginning or end of the suture line. This may result in a shorter operative time and a less technically demanding procedure.9–20 The use of barbed suture material for open and laparoscopic procedures,12–24 including nephrosplenic space ablation,25 in horses has been described.

In the present report, polyglyconate barbed suture was used to electively ablate the nephrosplenic space in 8 horses. The suture strength reportedly decreases to 80% by 1 week after surgery and to 65% by 3 weeks after surgery, with absorption complete within 6 months.26 For the procedure described, size 1 suture is recommended6; however, this size is currently not available. Because of the holding characteristics of barbed suture, we chose to use size 0 suture. Although barbed sutures have a lower tensile strength than nonbarbed sutures of the same size, when applied in a continuous pattern, they distribute tension along the entire suture line, decreasing the likelihood of suture pull-out.10

Advantages of barbed sutures when compared with traditional sutures include relative ease of placement, maintenance of tissue apposition during suturing, reduced foreign body response to suture material, and, most importantly, a knotless design, which typically reduces operative time.9–22 The main disadvantage is that an incorrectly placed bite cannot be retrieved and replaced because of the direction of the barbs. A difficult step when using barbed suture material is inserting the needle through the small welded loop. To overcome this, we created a large suture loop prior to introducing the suture into the abdomen, which enabled us to secure the first bite and eliminate this difficult step.

When treating the horses of the present report, we also made some modifications to the laparoscopic technique.3,6,8 When a trocar is placed in the 17th intercostal space, there is a risk of iatrogenic pneumothorax.6 In the present report, all trocars were placed in the paralumbar fossa, thereby avoiding this risk. The placement of the first portal was adjusted to a slightly more dorsal position, compared with the position described in previous reports.3,6,8 This reduced the risk of inadvertent organ laceration while improving observation of the surgical field.3 For the patients of this report, the final decision regarding trocar positioning was made after careful evaluation of the positions of the spleen and kidney. Placement of the laparoscope in the paralumbar fossa provided a view nearly aligned with the instruments. Subjectively, this resulted in improved instrument manipulation, which was important for this procedure, because the suture bites were placed almost vertically. The placement of the first portal was also modified because of the size of the horses. In our clinical experience, restraint of large horses (> 500 kg [1,102 lb]) in stocks can result in an uncomfortable working position for the surgeon, because the stocks are located close to the paralumbar fossa, limiting the surgeon's mobility.

Recently, Albanese et al25 reported an episode of recurrent nephrosplenic entrapment in a horse after the use of barbed sutures for closure of the nephrosplenic space. In that report, the horse developed signs of colic 18 days after surgery. The cause of the recurrence appeared to be suture failure, allowing a portion of the jejunum to become entrapped. Considering that the procedure had been performed under general anesthesia, the authors were inclined to attribute the failure to excessive load on the suture during recovery. The remaining 3 horses in that series had no complications during the 6- to 18-month follow-up period.25 Ragle et al24 described the use of barbed sutures for successful inguinal herniorrhaphy in a horse. In the present report, the procedure was performed with the horses standing and no postsurgical complications were noted. Further investigation is necessary to exclude recovery from general anesthesia as a possible risk factor for suture failure after the use of barbed sutures.

Findings for the 8 horses described in the present report must be interpreted with caution, especially given the limited follow-up. In 3 of 8 horses, we could only perform transrectal palpation to assess procedural outcome.3,5 This examination was performed 60 days after surgery by an experienced surgeon (MG or RG), and closure of the caudal portion of the nephrosplenic space was evident at the time. For patients 6, 7 and 8 of the present report, (the Hungarian Warmblood gelding, the Belgian Warmblood gelding, and the Arabian mare), transabdominal ultrasonography was performed 2 and 5 months after surgery by an experienced internal medicine clinician, but did not provide additional information when compared with results of transrectal palpation performed at the same time. However, it cannot be excluded that repeated transabdominal ultrasonography would have yielded different results if performed by a different individual, as results of transabdominal ultrasonography are operator-dependent. Alternatively, it is possible that ultrasonography may not be suitable because of its lack of sensitivity. Further studies on methods for evaluating outcome of nephrosplenic space ablation after laparoscopic suturing are necessary. Clearly, outcome would ideally have been assessed by means of repeated laparoscopy; however, consent for this invasive procedure was obtained from owners of only 2 of the 8 horses (horses 4 and 5). In these 2 horses, however, follow-up laparoscopy demonstrated complete closure of the nephrosplenic space. It was also evident that there had not been complete apposition between the spleen and perirenal fascia. However, the anatomic modification appeared likely to be effective in preventing large colon entrapment, with both horses having no recurrence of left dorsal displacement of the large colon at the time of telephone follow-up.

Acknowledgments

The authors declare that there were no conflicts of interest.

Footnotes

a.

5- to 12-mm Versaport V2, Covidien, Segrate, Milano, Italy.

b.

0° 33-cm operating laparoscope, Striker, San Jose, Calif.

c.

10- to 15 -mm Versaport V2, Covidien, Segrate, Milano, Italy.

d.

5-mm Versaport V2, Covidien, Segrate, Milano, Italy.

e.

V-Loc 180, Covidien, Segrate, Milano, Italy.

f.

Laparoscopic needle holder, Snowden Pencer, model 908008, Care Fusion, San Diego, Calif.

g.

2–0 Vicryl suture, Ethicon, Johnson & Johnson, Norderstedt, Germany.

h.

Monosof, Covidien, Segrate, Milano, Italy.

References

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  • Figure 1—

    Photograph illustrating the method used to lock the beginning of the suture line in place when using size 0 polyglyconate barbed suture material to perform laparoscopic ablation of the nephrosplenic space in horses with a history of recurrent left dorsal displacement of the large colon. The needle was inserted through the looped end of the suture material. A straight 33-cm-long laparoscopic needle holder was then inserted through the loop that was formed and used to grasp the suture material close to the needle.

  • Figure 2—

    Representative images obtained during laparoscopic ablation of the nephrosplenic space in a gelding with a previous history of left dorsal displacement of the large colon. The first suture bite was placed in the cranial-most portion of the perirenal fascia (A). The second bite was placed in the splenic capsule (B), with the needle and suture material retrieved through a suture loop placed around the needle holder (C). The suture line was then completed (D).

  • Figure 3—

    Images of the nephrosplenic space in a Holsteiner gelding (horse 4) with a history of left dorsal displacement of the large colon immediately prior to ablation (A) and during repeated laparoscopy 12 months after initial surgery (B).

  • 1. Epstein KL, Fehr J. Colic surgery. In: Southwood LL, ed. Practical guide to equine colic. Oxford, England: Wiley-Blackwell, 2013; 173203.

    • Search Google Scholar
    • Export Citation
  • 2. Albanese V, Caldwell FJ. Left dorsal displacement of the large colon in the horse. Equine Vet Educ 2014; 26: 107111.

  • 3. Röcken M, Schubert C, Mosel G, et al. Indications, surgical technique, and long-term experience with laparoscopic closure of the nephrosplenic space in standing horses. Vet Surg 2005; 34: 637641.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4. Mariën T, Adriaenssen A, Hoeck FV, et al. Laparoscopic closure of the renosplenic space in standing horses. Vet Surg 2001; 30: 559563.

  • 5. Muñoz J, Bussy C. Standing hand-assisted laparoscopic treatment of left dorsal displacement of the large colon and closure of the nephrosplenic space. Vet Surg 2013; 42: 595599.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6. Rocken M. Closure of the nephrosplenic space. In: Ragle CA, ed. Advances in equine laparoscopy. Oxford, England: Wiley-Blackwell, 2012; 19128.

    • Search Google Scholar
    • Export Citation
  • 7. Hendrickson DA. A review of equine laparoscopy. ISRN Vet Sci 2012; 2012: 492650.

  • 8. Farstvedt E, Hendrickson D. Laparoscopic closure of the nephrosplenic space for prevention of recurrent nephrosplenic entrapment of the ascending colon. Vet Surg 2005; 34: 642645.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9. Demyttenaere SV, Nau P, Henn M, et al. Barbed suture for gastrointestinal closure: a randomized control trial. Surg Innov 2009; 16: 237242.

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