Rates of intraoperative complications and conversion to laparotomy during laparoscopic ovariectomy performed by veterinary students: 161 cases (2010–2014)

Adam M. Nylund Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, WA 99164.

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Adam Drury Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO 80521.

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Heather Weir Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO 80521.

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Eric Monnet Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO 80521.

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Abstract

OBJECTIVE To assess rates of intraoperative complications and conversion to laparotomy associated with supervised veterinary students performing laparoscopic ovariectomy in dogs.

DESIGN Retrospective case series.

ANIMALS 161 female shelter dogs for which elective laparoscopic ovariectomy had been performed by supervised senior (fourth-year) veterinary students from 2010 through 2014.

PROCEDURES Medical records of all dogs were reviewed and data collected regarding duration of surgery, surgical complications and other characteristics, and whether conversion to laparotomy was required.

RESULTS Laparoscopic ovariectomy was performed with a 2-cannula technique and a 10-mm vessel-sealing device for hemostasis in all dogs. A Veress needle was used for initial insufflation in 144 (89.4%) dogs; method of insufflation was not reported for the remaining 17 (10.6%) dogs. Mean ± SD duration of surgery was 114.90 ± 33.40 minutes. Surgical complications, all classified as minor blood loss, occurred in 24 (14.9%) dogs. These included splenic puncture during insertion of the Veress needle (n = 20 [12.4%]) and minor bleeding from the ovarian pedicle (4 [2.5%]). Splenic puncture required no intervention, and ovarian pedicle bleeding required application of the vessel-sealing device an additional time to control the bleeding. Two ovaries were dropped in the abdominal cavity at the time of removal. Both were retrieved without complication. Conversion to laparotomy was not required for any dog. All dogs were discharged from the hospital within 24 hours after surgery.

CONCLUSIONS AND CLINICAL RELEVANCE Laparoscopic ovariectomy in dogs was performed safely by closely supervised novice surgeons, with only minor intraoperative complications encountered and no need for conversion to laparotomy.

Abstract

OBJECTIVE To assess rates of intraoperative complications and conversion to laparotomy associated with supervised veterinary students performing laparoscopic ovariectomy in dogs.

DESIGN Retrospective case series.

ANIMALS 161 female shelter dogs for which elective laparoscopic ovariectomy had been performed by supervised senior (fourth-year) veterinary students from 2010 through 2014.

PROCEDURES Medical records of all dogs were reviewed and data collected regarding duration of surgery, surgical complications and other characteristics, and whether conversion to laparotomy was required.

RESULTS Laparoscopic ovariectomy was performed with a 2-cannula technique and a 10-mm vessel-sealing device for hemostasis in all dogs. A Veress needle was used for initial insufflation in 144 (89.4%) dogs; method of insufflation was not reported for the remaining 17 (10.6%) dogs. Mean ± SD duration of surgery was 114.90 ± 33.40 minutes. Surgical complications, all classified as minor blood loss, occurred in 24 (14.9%) dogs. These included splenic puncture during insertion of the Veress needle (n = 20 [12.4%]) and minor bleeding from the ovarian pedicle (4 [2.5%]). Splenic puncture required no intervention, and ovarian pedicle bleeding required application of the vessel-sealing device an additional time to control the bleeding. Two ovaries were dropped in the abdominal cavity at the time of removal. Both were retrieved without complication. Conversion to laparotomy was not required for any dog. All dogs were discharged from the hospital within 24 hours after surgery.

CONCLUSIONS AND CLINICAL RELEVANCE Laparoscopic ovariectomy in dogs was performed safely by closely supervised novice surgeons, with only minor intraoperative complications encountered and no need for conversion to laparotomy.

Ovariectomy and OHE are the most common surgical procedures performed in general veterinary practice. These procedures can be performed via laparotomy or laparoscopy As minimally invasive surgery becomes more common in veterinary practice, it is important to expose veterinary students to laparoscopy and laparoscopic OVE in a safe environment. Laparoscopic OVE has been performed in female dogs with various techniques with minimal complications.1–6

Laparoscopic surgery requires development of a different set of skills than that used for open abdominal surgery7–9 Certain laparoscopic skills can be acquired through the use of simulators; however, refinement of such skills for application in a live animal remains an important step in the learning process. The ability to develop laparoscopic skills in nonterminal conditions would be ideal and has been a goal of laparoscopic training courses.10 Learning laparoscopic techniques through a routine and common surgery such as OVE in dogs could be an ideal teaching model because patient anatomic characteristics would be familiar and complications could be anticipated and treated with an open surgical approach if needed.

Before laparoscopic OVE can be recommended as a teaching model for laparoscopy, it would be important to determine the rate of complications of laparoscopic OVE performed by individuals with little to no experience in minimally invasive surgery under close supervision. The purpose of the study reported here was to determine intraoperative complications associated with closely supervised senior (fourth-year) veterinary students performing laparoscopic OVE in dogs. We hypothesized that laparoscopic OVE performed by novice surgeons would result in minimal intraoperative complications.

Materials and Methods

Case selection criteria

Medical records of female dogs for which laparoscopic OVE had been performed at the Colorado State University Veterinary Teaching Hospital from 2010 through 2014 were reviewed. To be included in the study dogs were required to have had laparoscopic OVE performed by a senior veterinary student. Dogs were excluded from the study if another procedure was performed at the time of OVE.

Medical records review

Data were collected from the medical records of included dogs regarding signalment, pressure of insufflation, number of cannulas used, duration of surgery, and surgical complications. Anesthetic complications were not recorded for the purpose of this study. Anesthesia records were reviewed to identify whether administration of fluid boluses or blood transfusions was required because of hemorrhage during the procedure.

Duration of surgery was defined as the interval from beginning the skin incision to completing the last skin suture. A complication was defined as an intraoperative event that required additional management to correct or increased the risk of a poor outcome.11 Intraoperative complications were classified as minor (no need for conversion to laparotomy) or major (conversion to laparotomy required). Minor blood loss was defined as any incident of bleeding that did not require medical or surgical intervention, and this was considered a minor surgical complication. Moderate blood loss was defined as any incident of bleeding that did not require medical attention but required placement of an extra seal or suture to control the bleeding but not conversion to laparotomy. Major blood loss was defined as any incident of bleeding that required placement of several seals or sutures to control the bleeding or conversion to laparotomy12

Conversion to laparotomy was classified as elective or emergent. Elective conversion was defined as a surgery for which the decision to convert was made by the supervising veterinarian and not because a major complication was happening. Emergent conversion was defined as a surgery with a major complication that could not be adequately managed via laparoscopy.11

Preparation and intraoperative guidance

Before performing the laparoscopic OVE, each student was required to have performed OVE or OHE in a live dog by an open surgical approach at least once. The supervising veterinarian (HW) was not a board-certified surgeon but had extensive training in laparoscopic OVE and closely supervised the students throughout the procedure. This faculty member ran the spay-neuter program at the Colorado State University Veterinary Teaching Hospital for both shelter and client-owned animals. During all laparoscopic procedures, the same faculty member always supervised the students. The procedure and instrumentation were described to students in detail before surgeries began, and intraoperative guidance was provided orally with each step. If necessary, the faculty member was available to physically intervene with surgery, and a board-certified surgeon was available in the hospital for assistance if needed. Registered veterinary technicians familiar with laparoscopy were also present to help prepare, position, and rotate the dogs from one side to the other to expose the ovaries. Laparoscopic ovariectomies were performed with a 2-cannula technique as described elsewhere.1 Two students scrubbed in for each laparoscopic OVE procedure. For the first ovary, one student was designated the primary surgeon, and the other assisted with camera and instrument handling to facilitate the procedure. Roles were switched for the second ovary. A Veress needlea was used to establish pneumoperitoneum. Incisions were made into the midline with a No. 11 blade. The first cannula with a blunt-tip trocarb (5 mm in diameter) was placed 1 cm caudal to the umbilicus. The second cannula with a blunt-tip trocarb (10 mm in diameter) was introduced 1 cm cranial to the umbilicus. Five-millimeter fine-tooth grasping forcepsb were used to elevate the ovary in the abdominal cavity. The ovary was suspended against the body wall by means of a percutaneously placed OVE hook.c Dogs were tilted approximately 30° to 45° from one side to the other to improve exposure of the ovarian pedicle during the procedure. A vessel-sealing deviced was used to seal both ovarian pedicles and the uterine horn close to the proper ligament of the ovary. Routine closure was performed for the portal incisions.

Statistical analysis

Data were summarized by computation of descriptive statistics. Continuous data are reported as mean ± SD.

Results

A total of 161 shelter dogs undergoing laparoscopic OVE were included in the study. Mean ± SD body weight was 26.50 ± 9.80 kg (56.32 ± 21.56 lb), and mean age was 25.30 ± 23.70 months. A Veress needle was used in 144 (89.4%) dogs to establish pneumoperitoneum; no initial insufflation technique was recorded for 17 (10.6%) dogs. Mean pressure for abdominal insufflation was 12.60 ± 1.80 mm Hg. An OVE hook was placed percutaneously to suspend the ovary against the abdominal wall in 147 (91.3%) dogs; no ovarian suspension technique was recorded for 14 (8.7%) dogs. A 10-mm vessel-sealing device was used for hemostasis in each dog. Mean duration of surgery was 114.90 ± 33.40 minutes.

Surgical complications occurred in 24 (14.9%) dogs. All complications were classified as minor blood loss. Splenic puncture occurred in 20 (12.4%) dogs and was visually identified after insertion of the first cannula. Puncture of the spleen was recorded as minor blood loss because no medical or surgical treatment was required. Bleeding from the ovarian pedicle was observed in 4 (2.5%) dogs. These incidents were classified as moderate blood loss because the vessel-sealing device needed to be applied a second time to the ovarian pedicle to stop the bleeding, but no medical treatment was required.

Two ovaries (each in a different dog) were dropped in the abdominal cavity while removal from the cannula port was attempted. Each was visually located with the endoscope, grasped, and removed from the abdominal cavity. Cannula incisions required enlargement to allow removal of ovaries in 16 (9.9%) dogs because the ovaries were larger than the 10-mm cannula port. All retrieved specimens were inspected to ensure the entire ovary had been removed. The supervising veterinarian did not assist physically in surgery during any of the procedures. The only additional assistance given other than oral guidance was to rotate the dogs from one side to the other to facilitate visual identification of each ovary.

No major surgical complications were recorded. No conversion to laparotomy was required for any of the 161 dogs, and all dogs were returned to their shelter of origin within 24 hours after surgery.

Discussion

Laparoscopic OVE performed by supervised senior veterinary students was associated with a low intraoperative morbidity rate in the dogs of the present study. Only minor complications occurred, requiring no conversion to laparotomy. All students had performed at least 1 OVE or OHE by laparotomy before the laparoscopic OVE procedure and were closely supervised by a faculty member.

Splenic puncture was the most common surgical complication, occurring in 12.4% of dogs by injury from the Veress needle used to access the peritoneal cavity. For experienced veterinary surgeons, the reported rate of splenic puncture is between 0% and 18.7% when the Veress needle is used.1–5 Splenic puncture required no surgical intervention to stop bleeding in the present study, which is consistent with findings in other studies1–5 for which splenic puncture was reported. To decrease the risk of puncture of abdominal organs, recommendations are to place the Veress needle in the ninth intercostal space on the right side.13 The Hasson technique has also been recommended to prevent puncture of the spleen.14 However, these techniques require more soft tissue dissection and could cause leakage of carbon dioxide during surgery, which might not be ideal for novice surgeons.15

Bleeding from the ovarian pedicle was recorded for 2.5% of dogs in the present study. No medical intervention was required to support these patients. The vessel-sealing device was applied a second time to control the bleeding. The rate of moderate bleeding from the ovarian pedicle in dogs undergoing OVE via laparotomy is reportedly between 5.5% and 42.8%, which is higher than the rate in the present study1–5,12,16–19 With OHE performed via laparotomy hemorrhage from the ovarian pedicle or uterine artery is the most common complication.20–22 In a study21 involving 142 OHEs performed by veterinary students, bleeding from the ovarian pedicle was the most common complication, occurring in 6.3% of dogs. A hemorrhage rate as high as 79% has been reported for dogs undergoing OHE that weighed > 25 kg (55 lb).20

A 10-mm vessel-sealing device was used to ligate and transect the ovarian pedicles in dogs of the present study. This device is reportedly safe and reliable for sealing blood vessels up to 7 mm in diameter and can safely seal uterine horns < 9 mm in diameter.23–25 Vessel-sealing devices can be used to seal blood vessels without dissecting them from perivascular tissue or fat, making the devices highly suitable for laparoscopic OVE. Monopolar and bipolar electrocautery suture, ultrasound and laser devices, and clips have also been used to ligate the ovarian pedicle during laparoscopy.2–6,12,16–19,26 Bleeding from the ovarian pedicle has been reported with all these techniques but not major blood loss requiring conversion to an open abdominal approach. These techniques have also been used by surgeons experienced in minimally invasive surgery. Given that the techniques require more experience to achieve a safe degree of hemostasis, they may not be recommended for surgeons new to minimally invasive surgery because these techniques may place patients at increased risk of hemorrhage.16

Complication rates during laparoscopy are related to the surgeon's level of experience.27 This relationship has been demonstrated for advanced procedures such as laparoscopic cholecystectomy.27 Laparoscopic OVE is a simple procedure requiring none of the same surgical and laparoscopic skills as laparoscopic cholecystectomy. The rate of minor intraoperative complications (14.9%) identified in the present study was no different from rates reported for boarded-certified veterinary surgeons with experience in laparoscopic OVE (0% to 55%).2–6,12,16–19,26 Minor blood loss from puncture of the spleen, bleeding from the ovarian pedicle, or bleeding from placement of suture material to suspend the ovary in the abdominal cavity is commonly reported. In addition, the rate of major complications requiring conversion to laparotomy in the present study (0%) was similar to previously reported rates of major complications associated with laparoscopic OVE.2–6,12,16–19,26 Emergent conversion to laparotomy has not been reported for laparoscopic OVE.

Veterinary students in the study reported here had no previous experience with laparoscopy prior to performing the laparoscopic OVE procedure. One might argue that minimal training with a terminal surgery laboratory or simulator would be more appropriate prior to performance of a live-recovery surgery7,28 However, in most veterinary teaching institutions, veterinary students also have no previous experience in terminal surgery laboratories before performing their first supervised recovery OVE or OHE via laparotomy. At Colorado State University veterinary students have been afforded several surgical experiences with dry and wet laboratories during their education. Therefore, they had some surgical experience when they performed their first recovery surgery, but the procedures involved in these laboratories did not include OVE or OHE in dogs. Before students could perform a laparoscopic OVE in the present study, they were required to have had experience with at least 1 supervised routine (via laparotomy) OVE or OHE at the teaching hospital.

The complication rate identified in the present study was similar to the complication rate reported for veterinary students performing OHE via laparotomy in a teaching hospital setting.21 Because laparoscopic OVE was performed with a vessel-sealing device, requiring no advanced laparoscopic skills, practicing of the technique on a simulator should reduce the duration of surgery but not necessarily affect the complication rate.7,8,28 Complications in the present study were mostly related to Veress needle insertion and not to identification of the ovary or handling of tissue.

Close faculty supervision was provided during the entire procedure in the study reported here. Only 1 laparoscopic OVE procedure could be performed each day owing to equipment limitations. In addition to overseeing the laparoscopic OVE procedures, the faculty member was supervising at the same time 2 open OHEs or castrations that were being performed by other veterinary students. The supervisor did not have to surgically assist the students, even if the ovary was dropped in the abdomen. None of the dogs had any life-threatening intraoperative complications that required supervisor intervention. Surgery technicians familiar with laparoscopic surgery assisted the students with setting up the laparoscopic towers and instrumentation. Similar close supervision was provided to students at Colorado State University when they performed their first recovery OVE or OHE via laparotomy.

Laparoscopy is associated with a steep learning curve. The students in the present study were not considered proficient in laparoscopic skills following a single laparoscopic OVE procedure. Other researchers have reported that 8 procedures are sufficient to become proficient with laparoscopy6 and that 80 procedures are required to become proficient with laparoscopic OVE5; however, the minimal number of procedures required to become proficient with laparoscopic OVE has not been established.

Laparoscopic OVE and OHE can be performed with 1, 2, or 3 cannulas.1,3,4,19 The triangulation technique involving 2 or 3 portals is recommended to simplify the procedure, particularly when performed by novice laparoscopic surgeons.29 A 2-cannula technique was used in the present study because it has been shown to induce less pain in dogs after surgery and is associated with a shorter duration of surgery than the other techniques.1 This approach still allows for triangulation, but it requires placement of a percutaneous hook, which may represent a challenge for novice surgeons. The placement of the hook did not appear to represent a problem in the present study. The 1-cannula procedure requires use of an operating telescope and requires more experience to master given that the surgeon has only a linear vision of the tip of the instrument with the target organ.1,3,4 This situation makes it more difficult to appreciate the depth of field, which may increase the risk of organ puncture. It also eliminates the possibility of triangulation, and a percutaneous hook is required as well. The 3-cannula technique could have been used by students in the present study and would have eliminated the need for percutaneous placement of a hook to suspend the ovaries during surgery.

The duration of surgery in the study reported here was longer than that reported for other studies. This difference was attributable to differences in level of surgeon experience among studies.1–5,12,16–19 Experienced surgeons can perform a laparoscopic OVE in < 30 minutes.1–5,12,16–19 Even with the prolonged duration of surgery in the present study, all dogs recovered from anesthesia without any complications. Practice with simulators prior to performing the laparoscopic procedure would be a valuable addition to the training process, allowing students to gain experience with the hand-eye coordination required for successful laparoscopy and thereby likely reducing the amount of time required to perform the procedure.9,30–33 It would be interesting to repeat the same study with students trained on a simulator prior to performing a laparoscopic OVE.7,28

The present study had several major limitations, including its retrospective nature. The amount of postoperative follow-up was limited to 1 day for most dogs because they originated from an animal shelter, and no follow-up was performed after dogs were returned to the shelter after surgery. However, the primary objective of the study was to determine intraoperative complications related to the surgical technique. Only OVE is performed via laparoscopy at the Colorado State University Veterinary Teaching Hospital because OVE is easier to perform via laparoscopy than OHE. Ovariohysterectomy would require a laparoscopic-assisted approach instead of a total laparoscopic approach for OVE.

Findings of the present study suggested that laparoscopic OVE can be performed by novice veterinary surgeons with no prior training in minimally invasive surgery. The procedure was associated with few intraoperative complications when performed by closely supervised veterinary students. We believe that laparoscopic OVE can be used as an entry-level technique to enhance training in basic laparoscopic skills, provided the appropriate equipment and supervision are available to minimize the risk of complications.

ABBREVIATIONS

OHE

Ovariohysterectomy

OVE

Ovariectomy

Footnotes

a.

VersaStep, Medtronic, Minneapolis, Minn.

b.

Reposable, Medtronic, Minneapolis, Minn.

c.

Karl Storz Veterinary Endoscopy, Goleta, Calif.

d.

Ligasure Atlas with ForceTriad energy platform, Medtronic, Boulder, Colo.

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