In March 2017, Dr Nadejda Tsureva, working at Veterinary Clinic ” Dobro Hrumvane” in city of Sofia, Bulgaria, has done her externship at Centru de Endoscopie si Chirurgie Minim Invasiva Veterinara with Dr Constantin Ifteme in city of Bucharest, Romania.
What is the opinion of Dr Nadejda Tsureva:
“Dear colleagues and friends,
I want to thank you for the opportunity of spending some precious time in Centru de endoscopie si chirurgie digestiva veterinara in Romania. Thanks a lot to Vets on the Balkans and the Vet team of the endoscopic center.
I had the chance of meeting new friends and family. Had the chance of learning from great professionals and great people. Working with love for the animals is really important and when combined with knowledge and great skills that is how “magic” is happening. I am really pleased to know that there are more people of that special “breed”.
Thank you all for the knowledge and the smiles you shared with me.
Hope to see you again.
To my Romanian family with love.
d-r Nadezhda Tsureva
We would like to express our gratitude to Dr Constantin Ifteme and brilliant team for everything. We are proud to have you on The Balkans , such a high level of professionalism and big heart!
When we see something like this on The Balkans, we are so proud. 1st September was the grand opening of the biggest Digestive Endoscopy and Surgery Center on The Balkans. The guest was Dr Fausto Brandao who is emblematic vet in VeterinaryEndoscopy.
The owner and the main vet is Dr Constantin Ifteme who is 36 years old and it is really impressive, so young and so successful. He creates his own team, full of professional and passionate to veterinary medicine. This clinic and Dr Constantin Ifteme are the evidence that veterinary medicine on The Balkans go straight ahead. They also include in their practice laparoscopic surgery, laser surgery and they have Fluoroscopy machine.
Fluoroscopy is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope allows the doctor to see the internal structure and function of a patient, so that the pumping action of the heart or the motion of swallowing, for example, can be watched. This is useful for both diagnosis and therapy and occurs in general radiology, interventional radiology, and image-guided surgery.
The good news is in the center have space for courses and workshops and I am sure most of you will visit this wonderful place and have a nice time with Dr Ifteme and his such a nice team.
The best news is that Dr Constantin Ifteme will support our Endoscopy section and as well the center is included in our project Learn and Travel with Vets on The Balkans.
The team of Vets on The Balkans express their gratitude to Dr Ifteme and his beautiful and kind wife for their support of the journal, for the real friendship and hospitability.
Small Animal Veterinary Clinic More, Šibenik, Croatia
Key words : Gyrus PKS plasma SORD, Laparoscopic ovariectomy
Since the beginning of 2012 two hundred laparoscopic ovariectomyes with two – portal method was done in veterinary clinic More. The average body weight of female dogs was 25 kg. While no surgical problems were encountered in small and medium size dogs, overweight and obese patients demonstrated to be more challenging both for the surgeon and anesthesiologist. Because of problems encountered in large and obese female dogs, especially the difficulties of removing easily ovaries with large ovarian bursa, it was necessary to find new easier and faster way for removing such ovaries through laparoscopic portals without elongation of incision. That was reason for implementation of high frequency bipolar morcellator Gyrus PKS plasma SORD for fast removal of ovaries and its adherent burse in large and obese patients.
Materials and methods
All dogs were sedated using alpha-adrenergic agonists or acepromazine. Induction of anaesthesia was done with propofol. After intubation patients were maintained on isofluran. Analgesia during surgery was provided by constant–rate infusion (CRI) of fentanyl. Most patients were breathing spontaneously and ventilatory assistance was used if needed.
To facilitate ovary visualization laparoscopic positioner was used. Ovarian fixation for resection was done with a percutaneous needle technique. Resection of ovaries was done with bipolar forceps (Grus PKS) or ultrasonic knife (Ethicon). For large and obese female dogs removal of resected ovaries was done by bipolar high frequency Gyrus PKS plasma SORD morcellator.
A total of 200 laparoscopic two portal ovariectomies were done from the beginning of 2012. A body weight span of dogs was from 4.0 kg to 65 kg. The average body weight of female dogs was 25 kg. Of all dogs 29 % (58 dogs) were characterized large (above 30 kg) , overweight or obese (body condition score > 4) .
Time for ovary resection and removal in small and medium size dogs was similar like in large and obese dogs when using PKS plasma SORD morcellator. For both groups surgical time in most of the cases was under 40 minutes. For dogs under 30 kg average time was 23.45 minutes, and for large and obese dogs average surgical time was 34 minutes.
Only one dog had a postoperative wound infection which was managed with antibiotics and in one dog (8 years old Alaskan Malamute) we couldn’t establish pneumoperitoneum because of huge deposits of intra-abdominal fat tissue so we proceeded to open laparotomy.
Veterinary laparoscopic ovaryectomy is traditionally done by three – portal method and we can call it a universal method for every type and size of the patient. But, it’s not as minimally invasive as two and single portal method.
Single portal laparoscopic ovariectomy is only method which is the not universal or ideal for every patient because of technical, intraoperative difficulties (especially in obese and large female dogs) mostly related to difficulty in viewing anatomical structures for precise surgical resection. Single portal ovariectomy in our opinion can be only ideal for small and medium size female dogs from 7 to 20 kg especially before the first heat (5-7 months old female dogs).
Two portal method has some disadvantages, but we can also call it universal method for every type and size of dog. The main deficiency of two portal method was difficult removal of large ovaries with its adherent burse thrue laparoscopic portals in obese and large breeds of dogs. Also, using a percutaneous needle technique in two portal method for fixation of ovaries in the abdomen makes them very often hidden behind its adherent bursa and difficult for viewing in order to do a precise disection to get a smaller tissue piece for easy extraction (Picture 1).
Ovaries with adherent bursa in large and obese female dogs by our own measurements can be over 6 cm in diameter. The traditional method for removal of large ovaries was an elongation of laparoscopic portals by scalpel No. 11. Unfortunately, if you are using threaded trocars (we use endotip trocar type) this can be little challenging. Also making portal larger by incision is abandoning basic principles of minimally invasive surgery and causes more intraoperative trauma. Size of elongated incisions of laparoscopic portals is getting close to standard open laparotomy incision size and then we can’t absolutely say that we did minimally invasive surgery.
Problem of removal of large ovaries in three portal method is not so important because the surgeon can easily use scissors and forceps to divide such ovaries intra-abdominal in two or more segments and take them out separately but that also lengthens operation time.
Removing ovaries with large ovarian bursa is very often time-consuming and elevates stress on the surgeon and its assistants, also lengthens anaesthesia time and increases risk for the patient.
Also, there are mortality risks in obese patients during and after laparoscopic surgery that are proportional to operative time which is often increased in these patients. Because of that operative time becomes very important factor (Table 1).
Taking into consideration things mentioned above, we tried to make two portal method easy and fast even in large and obese patients (> 30 kg) with large ovarian bursa making surgical time for resection and removal of both ovaries under 30 minutes.
To achieve this we started to use human gynaecological bipolar morcellator Gyrus PKS plasma SORD (SORD – solid organ removal device) and HF generator Gyrus G400 (Picture 2, 3 , and 4).
Main advantages when using Gyrus PKS plasma SORD are :
easy to use (Plug and play)
small diameter (12 mm / 15 mm)
light (250 grams)
Main disadvantages are :
single use instrument (can be reprocessed)
smoke production (use of insufflators with the automatic smoke evacuation system resolves this problem)
Two portal laparoscopic ovariectomy using Gyrus PKS plasma SORD morcellator makes this method suitable for technically demanding ovariectmies especially in large and obese dogs. Difficult ovariectmies in these patients are done with minimal intraoperative trauma without elongation of laparoscopic portals and short period of time (up to 30 minutes). After 3 years using Gyrus PKS plasma SORD morcellator we can conclude that to us it’s become a crucial instrument in every two portal laparosopic ovariectomy of obese dogs. Using this instrument makes two portal laparoscopic ovariectomy universal, fast and safe especially in large and obese dogs. Only downside of using Gyrus PKS plasma SORD morcellator is its price.