The rhomboid flap

22264908_689114241295076_1764003733_nFlorin Cristian Delureanu

DVM, MRCVS

 

 

ABSTRACT

 

In plastic and reconstructive surgery flaps have an important place not only for the aesthetic results obtained but also because they can be used to cover an area without producing tension. The flap mechanism mainly consists of moving a piece of skin from the donor site and moving it to the recipient site (primary defect). The rhomboid flap have a big versatility because can be done anywhere on the surface of the body. Filling small and large wounds with tissue similar in texture, colour and thickness is the ideal objective of the flap. This article describes the surgical approach of two cases, one with an abscess and the other with a benign tumor located at the cutaneous level, both of which are approached by the use of the rhombic flap.

 

 

Introduction

A skin flap represent a partial detachment of a piece of skin and the adjacent subcutaneous tissue with its vascular supply intact. All skin flaps have a pivot point or base. Survival of the skin flap is made by blood circulation through its base during the procedure. From this point of view, it is important that the base of the flap be large enough to prevent necrosis.

Local flaps are based on two types of vascularization: the subdermal plexus or a vein and an artery (figure A; right side- island flap).

Classification of skin flaps is based on blood supply, transfer mode (primary motion), location, composition and configuration (most described in human medicine). Depending on the transfer method, local flaps are classified as follows: -advancement flaps: those who advance forward; -rotational flaps: describe a rotation motion (curvilinear configuration) to the primary defect.

Classification of skin flaps is based on blood supply, transfer mode (primary motion), location, composition and configuration (most described in human medicine).
Depending on the transfer method, local flaps are classified as follows:
-advancement flaps: those who advance forward;
-rotational flaps: describe a rotation motion (curvilinear configuration) to the primary defect.

 

 

The rhombic flap was invented by a human maxilofacila surgeon called Limberg Alexander Aleksandrovich in 1946. By name, the flap has rhomboid shape with two angles of 120 degrees and two angles of 60 degrees. Depending on the primary defect / lesion pattern which require coverage, the flap angles may change. It is often used in reconstructive surgery of the face in humans: eyelid, floor of nose, alar rim and chin defects with good cosmetic results. This skin flap also called Limberg flap is a transposition flap – the elevated skin will have both advancement and rotation movement when is applied over the primary defect.

 

How to design the rhombic flap

 

Whether it is a wound or a tumor, around a defect is drawn a diamond with angles of 120 degrees and 60 degrees as mentioned above. First, the short diagonal that joins the 120 degree angles (BD) must be measured and then extended in the desired direction. The extension (DE) to the outside must have the same length with the short diagonal (BD) and with the sides of the diamond. The next step is to extend another line wich is equal and parallel with the closest side of the diamond (EF). Finally the skin flap is obtained (ADEF).

Figure 1. The sketch of the rhomboid flap.The primary motion of the flap is the motion placed on it to close the primary defect; the secondary motion is the motion placed on the tissue surrounding the primary defect by the flap.

Figure 1. The sketch of the rhomboid flap.The primary motion of the flap is the motion placed on it to close the primary defect; the secondary motion is the motion placed on the tissue surrounding the primary defect by the flap.

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Figure 2. Transferring the flap to the primary defect. The direction of rotation of the flap is indicated by the purple arrow. After rotation in point A dog ear will occur (yellow elipse). During the rotation the flap describes a 120 degree movement. The higher the angle, the dog ears will be more prominent. The secondary defect will be closed following the transfer of point F to the initial position of the D point

 

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Figure 3. The final shape of the rhomboid flap. Point D reached point B, point E reached point C and point F reached point D. A is the only point which maintain the initial position.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The surgical defect created can be covered with the rhomboid flap from 4 sides (Picture 4).

Figure 4. The variants of flap usage. The best choice is to select the side with the most laxity because in this way the adjacent anatomical structures will not be disturbed. The flap has a mathematical formula in which all sides are made to be equal.

Figure 4. The variants of flap usage. The best choice is to select the side with the most laxity because in this way the adjacent anatomical structures will not be disturbed. The flap has a mathematical formula in which all sides are made to be equal.

 

 

 

 

 

 

 

 

 

Case 1

                  

History

 

Daisy, a six years old female cat of the Maine Coon breed presented with a sebaceous cyst, 2 cm diameter, round shape, locatad on the dorsal lombo-sacral area. The owner says that the cat have a decreased appetite. The pacient was rescued and adopted and was vaccinated just when was young. The cat lives with another 3 cats in the same house, all with the same vaccination status.

General Examination

At clinical examination, apart from the wound, dehydration 6%  and a small buccal ulcer behind the last molar on the right mandible were detected. The patient was initially treated with clindamycin and meloxicam for 7 days but no improvement observed. The cyst was infected, with bad smell, partially covered with agglutinated hair and inside soft tissue necrosis was present.

Figure 5. The initial appearance of the wound, 24 hours prior to surgery.

Figure 5. The initial appearance of the wound, 24 hours prior
to surgery.

After inspection, dead space was noticed under the skin around the wound. One day before the surgery we noticed fever (40,1°C) and dehydration 8%. CBC, serum biochemistry and FeLV/FIV test were performed. Neutropenia (0.15 x 109/L, normal range: 1.48 – 10.29) and hyperglobulinemia (57g/L, normal range: 28-51) and decreased ALKP (<10 U/L, normal range: 14-111). IDEXX Snap FeLV/FIV was negative. The cat was hospitalized 24 hours for fluid therapy and i.v. antibiotic (Cefuroxime-Zinacef). After stabilizing the patient the intervention was performed.

 

 

 

Descripting the surgical steps

 

The area was clipped and clorhexidine was used for local antisepsis. Sterile marker was used to draw the rhombic shape around the primary defect.

Figure 6. Appearance of the wound after cleaning. Necrotic tissue and pus was present in the middle of the wound;

Figure 6. Appearance of the wound after cleaning. Necrotic tissue and pus was present in the middle of the wound;

 

 

 

 

 

 

 

 

 

 

Due to the presence of dead spaces   under the skin, the round shape of the primary defect was converted to a rhomboid and the rhombic lines were positioned about 1 cm from the wound margin. In this way the tissue that was not healthy was removed. Identifying the area with the highest laxity is the next step. This was done by pinching the skin around the primary defect. After choosing the appropriate area, the flap that must be transferred was drawn.

The first side of the flap (the extended line outward of the defect) and the second side of the flap (line that is the same length as the first, to the adjacent side of the defect and makes an angle of 60 degrees at the flap apex) were cut and the flap was elevated after undermining

Figure 8. The rhomboid flap is designed. The blue arrow describe the direction in which the flap will be rotated.

Figure 8. The rhomboid flap is designed. The blue arrow describe the direction in which the flap will be rotated.

Figure 9. The primary lesion was excised and the underlying tissues are undermined.

Figure 9. The primary lesion was excised and the underlying tissues are undermined.

Figure 7. The picture illustrates the extension to outside of the short diagonal of the diamond

Figure 7. The picture illustrates the extension to outside of the
short diagonal of the diamond

 

 

 

 

 

 

 

 

 

Skin cuts were made perpendicular with No.10 scalpel blade and and the flap was mobilized with help of Metzenbaum scissors. The surrounding tissues are widely undermined to avoid any tension and the flap is rotated into the recipient site. After rotation, the flap is locked in place by fixing its corners by subcutaneous sutures. The donor site is closed as the flap moves over into the new location. Finally the skin was closed with 4/0 PDX in simple interrupted suture pattern.

Figure 10. Elevation of the flap. Stay suture are used to decrease the risk of flap tip necrosis. This inconvenience usually occurs due to faulty handling during the transfer procedure (usually crushing between fingers).

Figure 10. Elevation of the flap. Stay suture are used to decrease the risk of flap tip necrosis. This inconvenience usually occurs due to faulty handling during the transfer procedure (usually crushing between fingers).

Figure 11. The flap is rotated in the desired place and the first stich is applied on the maximum point of tension. The second and the third stich are placed on the other two corners of the flap (yellow dots).

Figure 11. The flap is rotated in the desired place and the first stich is applied on the maximum point of tension. The second and the third stich are placed on the other two corners of the flap (yellow dots).

Figure 12. Immediate postoperative appearance of the flap. Simple interrupted sutures are used for skin closure

Figure 12. Immediate postoperative appearance of the flap. Simple interrupted sutures are used for skin closure

 

 

 

 

 

 

 

 

 

 

 

 

A common unaesthetic appearance after transposed flap was the “dog ears” at the pivot point. In this situation, dog ear was corrected by excising one triangle along one side of its base.

Figure 13. The aspect of the flap at 48 hours after surgery

Figure 13. The aspect of the flap at 48 hours after surgery

Figure14. The aspect of the flap in the eighth day after surgery. The direction of the hair grow is change because of the rotation.

Figure14. The aspect of the flap in the eighth day after
surgery. The direction of the hair grow is change because of the rotation.

 Figure 15. Seventeen days post surgery. The stiches were removed after ten days. No complicatios were encountered. Is very difficult to distinguish the change of the hair growth direction


Figure 15. Seventeen days post surgery. The stiches were removed after ten days. No complicatios were encountered. Is very difficult to distinguish the change of the hair growth direction

 

 

 

 

 

 

 

 

 

 

 

 

Case 2

 

History

 

Coco, a mix breed male dog, three years old was brought to the clinic because a lump was identified on the skin. Owner reports that the mass was seen some days ago and does not believe it has increased significantly. Also says it makes itching and that the dog often scratch there and bleeds. This was the owner’s only concern.

 

General examination

 

No abnormalities were detected after clinical examination except the lump. With a cauliflower aspect, the lump had a small base of implantation and 1,2/1,4 cm in diameter. After palpation of the skin around, no pain or local temperature were identified. FNA and blood tests were recommended before surgery and histopathological examination after. The owner declined for financial reasons the FNA and blood test but accepted the histopathological examination. In this situation, a two centimeter safety margin clearance was decided.

 

Surgical approach

 

            Surgical steps along with flap drawing were described above except for asepsis. In this case  iodine povidone was used.

Figure 16. The mass is identified on the left scapular area after clipping; local asepsis was made.

Figure 16. The mass is identified on the left scapular area after clipping; local asepsis was made.

Figure 17. The diamond is designed around the mass; The mid-third skin of the cranial chest was chosen for transfer

Figure 17. The diamond is designed around the mass; The mid-third skin of the cranial chest was chosen for transfer

Figure 18. Sectioning on contour lines.Control of bleeding is done by hemostat forceps

Figure 18. Sectioning on contour lines.Control of bleeding is done by hemostat forceps

 

 

 

 

 

 

 

 

 

Figure 19. The final aspect of the flap; the skin is closed with 3/0 PGA in simple interrupted pattern.

Figure 19. The final aspect of the flap; the skin is closed with 3/0 PGA in simple interrupted pattern.

 

 

 

 

 

 

 

 

Histopathological result

               Description: Cutaneous/ subcutaneous mass composed of  chistic masses well delimited by a cheratinized multilayered epithelium with epithelial cells with squamous differentiation oxifiles, mixed with abundant, granular and amorphous keratin; multifocal with the tendency of confluence, inflammatory infiltration with neutrophils, macrophages and epithelial cells is observed. Malignant neoplastic cells are not present in the examined sections.

 

               Interpretation: Benign follicular tumor – pilomatrixoma with associated granulomatous inflammatory process.

 

Figure 20. Wiev of the flap 4 days after surgery; small necrosis was noticed on the tip of the flap (green arrow).

Figure 20. Wiev of the flap 4 days after surgery; small necrosis was noticed on the tip of the flap (green arrow).

Figure 21. The aspect of the flap 23 days after surgery; the hair was cut to facilitate flap view. Small crusts are present on the tip of the flap and on the pivot point (blue arrows).Notice the cosmetic scar lines (yellow arrows).

Figure 21. The aspect of the flap 23 days after surgery; the hair was cut to facilitate flap view. Small crusts are present on the tip of the flap and on the pivot point (blue arrows).Notice the cosmetic scar lines (yellow arrows).

 

 

 

 

 

 

 

 

 

 

Common complication of the flap

 

  • Hematoma;
  • Bleeding;
  • Flap necrosis;
  • Secondary infection.

 

Short indications for proper surgical procedure

 

  • The sides of the rhomboid must have the same length;
  • The sides of the flap must must have the same length;
  • Depending on the shape of the primary lesion, the diamond angles may vary in degrees;
  • Any defect in rhombic shape shows 4 variants in which it can be covered.
  • The lowest laxity region should be chosen and as far as possible so as not to alter anatomical plans.

 

 

Full thickness mesh graft in a cat with degloving wound – case presentation

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Delureanu FlorinCristian

Dr Delureanu FlorinCristian

Veterinary Center Otopeni

Bucharest, Romania

 

 

Introduction

An ample loss of skin with underlying tissue and exposure of deep components (eg. tendons, ligaments, bones) define a degloving injury. This kind of wounds are most frequent seen on the distal limbs, medial tarsus/ metatarsus. The main cause of deglowing wounds is car accident, special when the animal is dragged or pushed by a moving car. In all of the cases bacteria and debris are present in the wound.

Free grafts are described as a piece of skin detached from an area of the body and placed over the wound. There are two tipes of free grafts when we talk about graft thickness: full thickness (epidermis and entire dermis); partial/split thickness (epidermis and a variable portion of dermis). Skin grafts are using when exist a defect that cannot be closed by skin flaps or direct apposition. Two factors influence skin graft survival: revascularization and absorbtion of the tissue fluid.

Case report

A 4 years old female shorthair cat, weighting 3,25kg was presented to our clinic. Before that, the owner was at another clinic for consult and he was disappointed because they recommended euthanasia or amputation of the limb. Besides, the first vet treated the cat with Amoxi+Clavulanic Acid and Nekro Veyxym. The owner said that she went missing for about 10 days.

Clinical examination

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Picture 1. Dorsal aspect of the metatarsal wound Deep tissue is affected; low to moderate discharge is present.

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Picture 2. Ventral aspect of the wound; Note the big swelling and the holes at the base of the fingers (red arrows)

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Picture 3. Deep wound with circular aspect, approximate 1,5cm diameter located near saphenous vein

After a thorough clinical exam we found that all was normal excepting the degloving injury. The back right leg was affected. There was a massive inflammation with infection and a lot of debris on the dorsal surface of metatarsal area and ventral, above metatarsal pad. On the dorsal surface of metatarsal area (Picture 1). Besides, also in the ventral area, another wond proximal to the metatarsal pad and 3 deep holes was identified at the base of second, third and fourth finger (Picture 2). It could be distinguished the chronic aspect. A third lesion was registrated on the same leg, in the medial aspect of the thigh. This wound was deep with a circular shape (Picture 3). We estimated that the lesion occurred about two weeks ago. We register pain and high local temperature after palpation. The cat was stable, normothermic, with normal color on mucous membrane, CRT 3seconds and normal superficial lymph nodes.

 

 

 

 

 

 

 

Radiograph of the affected back limb

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Picture 4a

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Picture 4b

Two x-ray views was made to eliminate bone changes or foreign bodies (Picture 4a, Picture 4b).

Picture 4a, 4b- Specialist describe: Suspected slight thickening of phalanges cortical 1 fingers 3-4 and gently bending them. Soft tissue swelling of the tibio-tarso-metatarsian region.

 

 

 

 

 

 

 

Approach 

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Picture 5a

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Picture 5b

After evaluation, the initial recommendation include a good wound management under anesthesia. Before surgical debridment (Picture 5a, 5b), culture was done.

Picture 5a and Picture 5b – Dorsal and ventral aspect of the lesions after surgical debridment

 

Next, wound lavage was initiated with one bag of 500 ml of worm saline (the most easy way to deliver fluids on the wound is to connect the saline bag with a administration set to the syringe and needle with a 3-way stop cock a large amount of liquid is needed to be effective).

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Picture 6. Wound closure by simple interrupted suture.

Finally, this first stage ends with a wet to dry bandage. A primary wound closure was performed for the lesion placed on the medial aspect of the thigh (Picture 6), after intensive cleaning, removal of foreign bodies and dead skin .

Empirically the cat receive Cefquinome until the result arrive and for pain management we administered Tramadol 3mg/kg and Meloxicam 0,1-0,2mg/kg. The cat recover well after anesthesia.

 

 

 

Culture result

One day before performing surgery, we recived the culture result. Streptococcus canis (++++) was identified and was sensible to many antibiotics. Amoxicilin+Clavulanic Acid (Synulox) was initiate for general therapy and chloramphenicol ointment (Opticlor-Pasteur) for local therapy.

Next, a full thickness mesh graft was used on the dorsal aspect of the limb due to the length and depth of the wound and the other wound was left for healing by second intention, both being protected by bandages. In the next 10 day the limb wounds was treated in the same manner. Removal of bacteria, granulation tissue formation and the beginning of epithelization were supported by next bandages as follows: ·

Day 1 – wet-to-dry bandage was used after surgical debridment. (this kind of bandages adhere to the wound and remove the little layer of dead tissue when we take off). Soaked in warm saline 1-2 minutes before removing, they were changed after 24hours one to the other. Cotton gauze was the primary contact-layer of the bandage.

  • Day 2 and day 3
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    Picture 7a Fresh Sorbalgon is applied on both wounds. This dressing can absorb 20-30 times its weight in fluid, stimulate fibroblast and macrophage activity.

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    Picture 7b Calcium alginate dressing must be changed when the fibres transforms in gel.

– moisture retentive dressing (MDR) – calcium alginate (Sorbalgon-Hartmann) was the primary contact-layer. It is good to use when it exist high exudate like in our patient (Picture 7a, 7b).

 

 

 

  • Day 4,6 and day 9
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Picture 8. Hydrocolloid is indicated because he stimulate granulation and epitelisation and have a good autolytic debridment

– moisture retentive dressing (MDR) – hydrocolloid (Hydrocoll-Hartmann) was the primary contact-layer because the discharge decreased (Picture 8).

 

 

 

 

 

Describing surgical procedure:

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Picture 9. The wound is refreshed by removing the new epithelium formed around the whole wound

Preoperative surgical site preparation: The cat was placed in left lateral recumbency, with the wound exposed. The limb was clipped entirely and povidone iodine and alcohol was used for aseptic surgery. Sterile warm saline 0.9% was use for wound lavage. Meanwhile a colleague prepare the donor site in the same manner- lower cranio-lateral thorax (right side). Almost 1mm of epithelium that has started to grow from the wound edges over the granulation tissue was removed using a thumb forceps and a no. 10 scalpel blade (Picture 9). A perpendicular incision was made right at the edge of haired skin with epithelium. The wound was incised all around and after that the epithelium was removed by advancing the scalpel blade under the epithelium around

the wound. Then, undermining was performed around the wound edges. A fragment of sterile surgical drape was used over the wound to get the exact shape. The drape “pattern” was placed to the donor area.

 

 

To maintain the wound moist, i placed over it a cotton gauze moistened in warm sterile saline 0.9% while the graft is transferred.

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Picture 10. The donor site-removing the skin; black arrow show the direction of the hair groth.

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Picture 11a. Skin from dorsal thorax is advanced

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Picture 11b. Simple interrupted suture is used for skin closure.

The direction of hair groth was marked with a black arrow above the donor site so that the direction of the hair groth on the graft will be the same as the hair groth direction on the skin surrounding the wound. After that, the margins of the drape “pattern” was traced on the skin. The skin of the donor bed was incised with No.10 scalpel balde and removed using thumb forceps and Metzenbaum scissors (Picture 10). The defect left after removing the graft was primary closed by undermining and advancing the skin edges with walking sutures using 3-0 monofilament absorbable suture material and finally the skin was sutured in a simple interrupted suture manner using 2-0 monofilament absorbable suture (Picture 11a, 11b).

 

 

 

 

 

 

 

 

 

 

Preparing the graft

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Picture 12. Final aspect of the skin graft after removal

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Picture 13. The skin is stretched on the receiving bed so the incisions made in it expand.

The dermal side of the graft was placed on a polystyrene board with a thickness of 10cm covered with a sterile drape and after that we fixed and stretched with 21G needles. The subcutaneous tissue was removed from the graft. Next, made parallel incisions was made in the graft, 0.5-0.7cm long and apart (Picture 12). At the end, the graft was placed on the granulation bed and sutured with 4-0 monofilament nonabsorbable suture in a simple interrupted suture manner. Additional tacking suture was placed to ensure the expansion of the mesh incision and allow the fluid drainage (Picture 13).

 

 

Choosing the right bandage after grafting and aftercare

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Picture 14. Grassolind is ointment free of medication, broad mesh, air permeable and exudate; impregnated with neutral ointment. Ointment contain petroleum jelly, fatty acid esters, carbonate and bicarbonate diglycerol, synthetic wax.

It is important to use a nonadherent primary dressing. My initial choise was Grassolind (Hartmann), is sufficiently porous to allow easy passage of exudate from the wound surface, preventing maceration of surrounding tissue (Picture 14). The ventral metatarsal wound maintain hydrocolloid dressing (Hydrocoll-Hartmann) as primary layer. After that, a thin layer of chloramphenicol oinment (Opticlor-Pasteur) was used all around both wounds and over the graft.

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Picture 15. Note that the “half clamshell” is extended with approximately 1cm toward fingers (red arrow) so the leg does not touch the ground

Over the first dressings was applied 5cmx5cm compress (Medicomp-Hartmann) and a roll gauze was the second layer. After a few laps of gauze stirrups was placed to secure the bandage in place. Extemporaneous half “clamshell” splint (Picture 15) was made from plastic material wich was curved in such a way that the limb was fixed in semi flexion. The splint is a little bit longer than the extremity of the pelvic limb (“toe-dancing” position), thus provide a maximum relief pressure. In the proximal area, under the splint, I put cotton to prevent pressure injuries on the caudal aspect of the thigh. Applied from proximal to distal and with moderate tension, elastic warp was the final protective layer of the bandage and it was secured at the proximal end with tape.

 

 

 

 

Changing bandages

The bandage was changed in day 1, 3, 5, 7 and 10 post op. In day 10 the suture material was removed from the graft and from the donor site. From day 17 to day 29 hydrogel (Hydrosorb-Hartmann) was used as primary bandage layer and the bandage was changed from 4 to 4 days. In day 29 no discharge was present in the bandage; the wound was completely healed and 0,2-0,4 mm of hair was present in the center of the graft.

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Picture 16. Delayed healing on day 45 – epitelization stopped at this level.

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Picture 17b. Honey improve wound nutrition, promotes the granulation tissue and epithelization, reduce inflammation and edema. Also it has a wide antibacterial effect.

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Picture 17a. DTL laser type is alaser light emitting diode in the red field (wavelength 650 nm) and infrared (wavelength 808 nm) of the light spectrum with next clinical effect: anesthetic effect; decreases edema and inflammation; activates microcirculation; stimulates wound healing; improves tissue trophicity; reflexogenic effect.

A delayed healing occurred at the wound in the ventral region (Picture 16). From day 29 to day 59 epithelization has advanced very hard and granulation tissue has captured an appearance of ulcer (in this time the wound was asepseptic prepared and hydrocolloid and hydrogel was used as primary layer bandage and without the splint). In day 59 the wound was refreshed on the surface with a scalpel blade and laser therapy (Picture 17a) and medical Manuka honey (Picture 17b) was used daily for 14 days. After that, a complete healing was reached.

 

 

 

 

 

 

 

Illustrating wounds evolution after surgery

 

Day 1

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Day 11

 

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Day 28

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Day 35

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Day 49

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Day 11 after honey and laser therapy

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 Day 16 after honey and laser therapy

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Comparing day 1 and after 3 Months

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Laparoscopic surgery in IVAVET clinic

Picture 1.Expert team at IVAVET clinic, Belgrade, Serbia.

Picture 1.Expert team at IVAVET clinic, Belgrade, Serbia. In front from right to left are Ivan Jevtić, DVM, and doctor specialist for laparoscopic surgery, owner and the main surgeon at IVAVET clinic. Next to him is Marija Pavlović, DVM, intern at IVAVET clinic. Behind from left to right are Biljana Jevtić, VT and owner at IVAVET clinic. Next to her is Radenko Savić, DVM, doctor specialist for intern medicine in small animals at IVAVET clinic.

Laparoscopic surgery is a minimally invasive surgery, a technique that allows the intervention to be performed by using multiple small abdominal incisions. Specialized camera with fiber-optical fibers (laparoscope) is introduced through one of these portals in order to allow visualization of the internal contents of the abdomen. Similarly, through other portals surgical instruments necessary for the intervention are inserted into the abdominal cavity. Table 1.

Laparoscopic surgery at ‘IVA VET’ clinic is performed by the team of experts. ‘IVA VET’ surgical team (picture 1.) utilizes advanced technology for the prophylactic, diagnostic, and therapeutic surgical procedures.

Picture 2. A Tissue appearance after laparoscopically performed surgery.

Picture 2. is presented tissue appearance after laparoscopically performed surgery.

Picture 2. B Tissue appearance after traditional open surgery.

Picture 2 is presented tissue appearance after traditional open surgery

The most common type of surgery performed using minimally invasive technique is ovariectomy. This procedure is performed to prevent unwanted offspring, and to reduce the risk of infections and cancers of the female reproductive tract. Compared with traditional open ovariohysterectomy, laparoscopic ovariectomy is technically less complicated and time-consuming. Further, in a study published in the 2005 Journal of the Veterinary Medical Association has been documented that laparoscopic surgery diminishes pain, reduces the risk of hemorrhage and speeds recovery times up to 65%. In table 1. are presented laparoscopic surgery advantages over traditional open surgery.

 

The most common reasons for laparoscopic intervention are:

• Diseases causing acute or chronical pain in abdominal or pelvic cavity.
• Visualization of miscellaneous growths and patches in abdominal cavity, and collection of various samples (biopsy) for pathohistological examination.
• Ovariectomy and ovariohysterectomy
• Determining possible causes for free fluid accumulation in abdomen.
• Cancer staging for specific tumors.
• Surgical removal of tumors or organ invaded by tumor.

Laparoscopic procedures in abdomen cavity:
• Ovariohysterectomy (in this procedure both, ovaries and uterus are removed)
• Ovariectomy (spay), only the ovaries are removed
• Sterilization of male dog
• Cancer and cystic kidney surgery
• Hernia Repair
• Ultrasound guided percutaneous sampling (biopsy) of abdominal organs
• Surgery of polycystic ovaries
• Gastropexy (Bloat/GDV Prevention)
• Removal of various tumor masses

Pre-operative assessment
Animal owners should expect the following procedures to be preformed during the preparation for the laparoscopic intervention:
1. General physical examination to determine animal health status.
2. Laboratory blood analysis (1.Blood chemistry panel—Used to evaluate organ function, electrolyte status, hormone levels, and more; 2.Complete blood count—Gives us information on hydration status, anemia, infection, clotting ability, and the ability of the immune system to respond to disease)
3. Laboratory urine analysis (Checks the condition of the urinary and genital tracts and screens for conditions such as diabetes, liver disease, and Cushing’s disease)
4. Abdominal ultrasound (enabling a partial examination of the abdominal cavity- A non-invasive, real-time, moving picture of your pet’s abdomen, chest and heart)
Contraindication for Laparoscopic surgery
Absolute contraindications

 Diaphragmatic hernia
 Septic peritonitis
 Conditions in which conventional surgical intervention is obviously indicated

Relative contraindications

 Obesity (obscure the view of many organs)
 Poor patient condition
 Ascites

 Poor clotting time
 Patient body weight <2 kg (instrument size)
 Patient that is a poor anesthetic risk or an extreme surgical risk

Patient preparation before surgery
Owners should withhold food for 6-12 hours (over night) before surgery.
Anesthesia for laparoscopic surgery
Laparoscopic surgery is routinely performed in general anesthesia.
Laparoscopic Surgery Procedures in general
Preoperative preparation of patient
Empty urinary bladder for a better visualization of the abdominal cavity and to minimize the danger of tapping. Position the patient. Aseptically prepare the surgical field in the standard fashion.

Surgery

Picture 3. First incision in naval area

Picture 3. First incision in naval area

A surgeon makes one initial incision (picture 3.) commonly in the navel area. Then, a small needle is inserted through this incision, through which carbon dioxide gas can be pumped into the abdomen to inflate it allowing for better visualization of the abdomen’s contents. Pressure in abdomen (picture 4.) must not be higher than 15 mm Hg (maintain the abdominal insufflation pressure at 12 to 15 mm Hg). If pressure in abdomen is higher, patient respiration will be impeded.

 

Next, a laparoscope is inserted through one of the incisions. The camera illuminates the interior of the abdomen and transmits high-quality, magnified images to a video screen in the operating room, allowing for precise maneuvering. After that, surgeon can begin with organ examination. If required, more incisions are made on abdomen to insert instruments (basic equipment and instruments required to perform laparoscopic surgery in dogs and cats are listed in table 2.), and perform the surgery or/and sample collections (biopsy). Once the procedure is completed, the carbon dioxide is let out of the abdomen and the incisions are closed using stitches or clips.Table 2.

 

Picture 4. Laparoscopic equipment

Picture 4. Laparoscopic equipment

Postoperative procedures
Any collected tissue or liquid sample during laparoscopic surgery will be sent for further pathohistological examination. Results of those analyses can be expected few days after the procedure.
Postoperative recovery after the laparoscopic surgery is much faster, safer and less stressful for your animal companion.
Duration of laparoscopic surgery
Depending on the complexity of procedure, laparoscopic surgery can last anywhere from half an hour to several hours.

Three portal laparoscopic cat sterilization performed by cutting both ductus deferens without testicle extraction:

 

Case report

Picture 5. Patient, seven months old cat named Lion

Picture 5. Patient, seven months old cat named Lion

Case description:
A seven month old half-breed cat named Lion (picture 1.) was presented to our clinic “IVAVET” for the sterilization. The patient’s caring owner wanted to know which surgical procedure would provide safer, less stressful and easier recovery to her loving animal companion. In addition, she wanted to know if there is any possibility to perform sterilization without removing testicales, thus Lion’s aesthetic appearance could stay undisrupted. Therefore, we thoroughly presented to her all possible solutions and recommended laparoscopicaly performed sterilization achieved by cutting both vas deferens without need to remove gonads.

Aim of this minimally invasive surgery is cutting the tubes (ductus deferens) that transport sperm from the testicles to the penis, without removing gonadal glands. By cutting these tubes permanently sterile animal retain hormonal balance due to kept ability to produce testosterone. Moreover, after this procedure there will be no need for any kind of special diet.

The patient’s owner accepted our advice so we obtained a signed permission form to perform laparoscopic sterilization, including permission to convert to an open procedure, should it be necessary.
Clinical finding
General physical examination and laboratory analysis indicated Lion’s good health condition confirming him as ideal candidate for laparoscopic intervention. Examination revealed a slightly elevated body weight (3.9 kg).

Patient and instrument preparation for laparoscopic surgery
Discarding our professional advice the owner fed her cat night before surgery. Consequently, cat vomited food, luckily for us before surgery took place. We prepared and sterilized all instruments (picture 2.), and put them on instrument table near operating.

Surgery

Picture 6. Basic sterilized instruments

Picture 1. Basic sterilized instruments

Picture 7. Cat position during procedure

Picture 2 Cat position during procedure

Anesthesia was achieved with appropriate dose of the domitor/ketamidor combination. We use this combination during surgery because it provides a suitable anesthesia for cats characterized by rapid induction, good muscle relaxation, good analgesia and bradycardia. During anesthesia our nonsterile assistant monitor all patient vital functions, instruments and keep connecting cables outside of patient sterile zone.
Patient was restrained in dorsal recumbency on positioner that has been securely attached to the surgery table, and the surgical field was aseptically prepared in the standard manner for all abdominal operations (picture 3.).

Next to the umbilicus we made a small skin incision (1 cm), trough which we placed the Veress needle. While placing the Veress needle we were very vigilant in order to avoid damage to internal abdominal content (especially spleen or liver). After penetrating the abdomen we attached the insufflation line to the Veress needle (picture 4.), turned the carbon dioxide gas on and started insufflation to establish pneumoperitoneum.

Picture 8. The Veress needle

Picture 4. The Veress needle

After that, we removed the Veress needle and in the same port we placed primary trocar through which we inserted laparoscope with a video camera and light source. After initial exploration with laparoscopic camera we placed two more lateral secondary ports (picture 5). Through this ports secondary trocars were placed, lateral to the primary trocar and halfway between the umbilicus and pubis. We used these two secondary ports to insert required instruments and to make easier access to the vas deferens.

Picture 9. A. Three trocars are visible (one primary, two lateral secondary

Picture 5. A.

Picture 9. B. Primary trocar with inserted Laparoscope with video camera and light source.

Picture5 B

Picture 11. A. Removing of instruments, after successful intervention

Picture 6 Removing of instruments, after successful intervention

Picture 11. B. Small portals left after removal of laparoscopic equipment.)

Picure 6 Small portals left after removal of laparoscopic equipment.)

Laparoscopic procedure was observed on video monitor placed in the operating room so that all team members could supervise whole procedure.First, in inguinal area we located left ductus deferens, using laparoscope. Second, with grasping forceps we elevated previously located left ductus deferens (as much as it was possible, look at picture 8.), inserted through one of the secondary ports. Third, through other secondary port we inserted bipolar forceps with an electro generator and coagulated one small place on the left ductus deferens. Finally, after removing bipolar forceps we used same port to insert scissor forceps and transect left ductus deferens. We have done the same process on the right ductus deferens.

We thoroughly checked for any bleeding or tissue damage before removing all instruments (picture 6.). After intrabdominal administration of antibiotics, deflating abdomen and removing trocars we sutured all ports using 3-0 thread for cats, in standard manner.

 

Postsurgical treatment
Lion was released home within a few hours after surgery. He didn’t show any signs of pain or altered general condition. We prescribed a postoperative analgesic for three days and instructed owner to return in a week for recheck.
Conclusion

Picture 12. Secondary ports sutured. Primary still not, but will be also sutured).

Picture 7 Secondary ports sutured. Primary still not, but will be also sutured).

Picture 10. Ductus deferens elevated with grasping forceps (instrument on the left) and coagulated with bipolar forceps (instrument on the right) on the same place where it will

Picure 8 Ductus deferens elevated with grasping forceps (instrument on the left) and coagulated with bipolar forceps (instrument on the right) on the same place where it will

Laparoscopic vasectomy performed by cutting tubes is more challenging for a surgeon but for the patient is undeniable better due to faster recovery time, decreased stress and pain, improved visualization, undisrupted hormonal balance and last but not the least important unchanged aesthetic appearance of your animal companion.