Thanks a lot to you guys. And it's a pleasure to be able to help, guide you through some of the advances in equine laparoscopy, which is a, an ever-increasing field. So, moving on, the, I think before we talk about advances in equine laparoscopy, we really have to look at where it's come from, and, and it's nothing new.
We back right into the first. Centuries and, the, the original, first reported use of, light to examine a cervix. It was a reflected light was by the Arabian physician Abi Qasim, way back in 1013 AD.
But moving on into more present times and in 1901, George Kelling, he reported using a flexible endoscope to have a look at the peritoneal cavity of the dogs and, and reported using, filtered oxygen for insulation. And then in the 1930s, the first actually truly laparoscopic interventions were used when, the, looking into the abdomen of of humans to achieve a resection of adhesions and obtain biopsies. And this is, done with the use of these cannulas you can see on the side of your picture there, helped massively by the, the invention by Bertram Bernheim, a German, physician who, starts to develop specific instrumentation for examination remotely within the abdomen.
In the 60s and 70s, gynaecological methods were developed, and this is really where the mainstay of laparoscopic procedures, developed, rapidly. In this rather horrific looking picture, laparoscopic intervention, into the uterus of a woman, was used to obtain biopsies and to, and just try to understand infertility issues in, in females. In 1977, the automatic insufflator, massively improved safety.
And then finally, in 1985, the, the computer chip meant that, actual recordings of what was happening within laparoscopic procedures, as well as the digitization of imaging became, the mainstay of, of the advancing, advancement of surgery, and from that point really progressed rapidly. Within the equine field in the 70s, again, just like in the human field, it was really, the reproductive side of, the profession that developed techniques, specific for really diagnostically, trying to evaluate the reasons for infertility in mares, evaluating the ovulation sites specifically in mares. And in the 70s, there's a couple of papers produced, both, titled by Witherspoon.
In which they described the use of a cannula to enter into the abdomen of a mare and evaluate, evaluate the ovulation site, of, of infertile mares. And then, finally, to the actual, probably the mainstay of its use nowadays, the abdominal exploration, and all the accompanying work that followed really started in 1986 by Ted Fisher across in California. In which he described the use of la laparoscopy to diagnose causes of chronic colic in 5 horses and, and reported the successful use of the diag of it as a diagnostic technique, in, in horses suffering from, from that condition.
Then moving into the late 80s and early 90s, it started to, be interestingly used again up in Davis in California. Wilson and Madison described it to be looking at, cryptophic, testes within the abdomen. And finally then in the 90s, when it started to be not just as a diagnostic, but as a tool for actually interventional use surgically to remove, either abnormal testes or even ovaries that were normal or abnormal.
And when we look at it through the 70s, through the 80s, the 90s, and the 70s, there was a couple of papers that were produced, in the 90s, there's 27 papers produced, all describing laparoscopic techniques. And between 2000 and 2010, that nearly tripled when there's 68 papers, produced. They're seeing the fact that laparoscopy, laparoscopic procedures are here to stay and have made, surgery somewhat more exciting within the equine field.
So in terms of, of, of where it's, it's advantages are, as, as everyone knows, it's a minimally invasive surgery and, and used to be thought really as a formally, thought as an advanced surgical training technique really limited to places of academia, research institutions only. However, now, it, it's very much a part. A routine part, both a residency training and now a routine part of most hospitals, that are performing, surgical techniques and horses.
And, and because of its regularity, now, it's just meant that there's been a massive growth in the, both the ability to do, laparoscopic procedures, but also just what we can do with it as we will go through now. And really, the advances are all down to the improvements in the expertise of the, the people doing the work, as well as, a huge, leap forward in the use of equine specific equipment. And obviously that is a huge bearing when we're talking about the difference between a human, or even a, a canine abdomen and the abdomen of a horse, which is obviously much bigger.
And the improved expertise really comes down to the fact that it's a much more regularly used, procedure and technique. Now, therefore, more and more people are using it, more and more things can be done, using the technique. So how do we do it?
Really, it, it, it involves quite a bit of kit, as, as many of you will be aware. The endoscope itself is, is, is usually a 1 centimetre in diameter. It varies in length.
You can have them between 30 centimetres and up to just about 60 centimetres in length, which is quite long and critically important when it comes to evaluating the abdomen of a horse, which is obviously quite large. They come in two different, standard sizes, sorry, standard, angulations. One is a zero degree forward facing camera, and that's easier to use, and there's less hand-eye coordination required.
The, the more commonly used, the endoscope is a 30 degree oblique viewing scope, which increases the field of view and, and enables you to kind of, if you like, look around a corner. So it just, just give you that bit extra vision. The camera usually these days a 4 by 3 former, format standard view.
You have your monitor, you need a light source, and that's, that's really been a, a, a big thing that's been able to be. Help in, in, in just being able to evaluate deeper and into the abdomen. Usually a xenon light source has now replaced most halogen light sources.
And the standard would be 150 to 175 watts with more higher powered units using 300 watts, which ensures a much brighter view. The light cable, obviously, that connects the camera and the endoscope to the, to the, to the light source. And then finally, the insulator, which, uses carbon dioxide to insulate the abdomen.
And yeah, so we look at this. This is your typical kit, really. It, it does involve quite a lot of kit.
And that's before we start talking about instrumentation that's required, to help, either retract or to remove, tissues. Now, insufflation is, is an important part of laparoscopic procedure either under general anaesthesia or standing, and insulation typically is done, as I said, with carbon dioxide. Carbon dioxide has been associated with transient chemical peritonitis and therefore is often attributed postoperative colic, as the blame is apportioned to that.
And, and one of the things that's been looked at more recently was just, to look at the evaluate, to evaluate the effects of carbon dioxide and just really try and demonstrate, does that, pneumo peritoneum result in post-operative pain, no matter how transient. And actually, Whether the abdomen is desufflated following, the procedure or whether it is, not desufflated did not make any difference in the abdominal discomfort. So one of the things that's, that's really changed our thinking, even within the past year, so, is that we don't really need to now spend a lot of time desufflating, the abdomen, for at risk, of, of, of having this post, operative transient pain.
There is still an issue with the chemical peritonitis that the carbon dioxide can result in, in this transient, low-grade discomfort. More commonly, it's seen as a low-grade fever following laparoscopy. It usually resolves within 24 hours or so.
The advantages of laparoscopy really, are, are obvious. It, it's minimally invasive surgery and that automatically then reduces the morbidity associated with the procedure. And because now, in particular, many of the procedures, particularly in the, in the UK, and Europe, less so in the states, many of the procedures are performed standing, there's a cost-benefit and a risk, aversion, from needing to use, general anaesthesia.
Plus, it does provide far better access to parts of the anatomy that previously are difficult to reach or to find, doing traditional laparotomy techniques through the abdomen. The limitations, however, are still present, and they are to do really with, the ability to have that depth perception. So you're looking at a three dimensional structure, really in 2D on a television screen.
And visualisation is the other thing that can be tricky, and that is, made even worse when there's bleeding, the, the lack of light penetration, or indeed fogging of a camera, when particularly on colder days, the abdomen's warm and you get fogging off the end of the camera, these can be issues. However, again, with, the advancement of, of different instruments and, and various techniques, these things have been, much improved. And, and when I remember starting to learn how to do laparoscopy, and I look at what we're using now, it is quite amazing the differences that we get.
It makes it a sheer pleasure to do laparoscopy, where it could often be a quite a frustrating procedure. The reason for that is because we have much better light sources. So like I said before, previously, 150 watts would enin.
Watts would be your, your standard. Now 300 watts means your bright light is much brighter. You can see far, far more, into the areas that you need to be looking at.
The high definition cameras are a major advancement, allowing much better pixelation and much better clarity of the images, plus the alterations of scopes, the different lengths of scopes, and the fact that they are Have higher definition chips in them, mean that we get better clarity and better pixelation as well. And finally, the fact that visualisation is so often occluded by the intestinal content within the abdomen, standing techniques can really help to, to reduce that complication. Access is, is oftentimes a big, pro problem when it comes to laparoscopic procedures.
And, and this has been a major way that over the past 10 years, really, we've been looking to try and help, reduce the, the problems with access. And the reason we have that, obviously, we've got a very large abdomen, and there's a large intestinal volume, as, as I've already said, which does tend to include your visualisation. The fulcrum of the body wall also means that you have this limiting fact to being able to see round corners, and that somewhat helped with a 30 degree scope, but still there are areas of the abdomen that are difficult to assess.
You've got the spleen on the left hand side, which in the horse is very big and can sometimes get in your way. And the scum on the right-hand side is always an issue, especially in horses that are not fasted and can really cause problems in, in, in being able to evaluate, parts of the intestine. And then finally, instrumentation limitations, the instruments and some horses are just too short, and so we, we, we struggle sometimes to actually get tissues that, that we're trying to access.
So, again, when it comes to the access issues, standing techniques as opposed to general anaesthesia techniques have really helped to, to reduce the incidence of, of these issues, especially with regards to, intestinal content getting in the way. Longer scopes mean we can visualise things both from, both deeper into the abdomen, but also we can evaluate both sides from the left side and not have to do, techniques that involve. Of looking, over the split of the sum, angulation of the scope obviously helps.
And then there's been a variety of techniques described, that, that are used, which use laparoscopy to evaluate the structure, but actually then allow the introduction of a hand to help, remove tissue or structures within the abdomen. Again, equine's specific instrumentation has helped massively when it comes to, some of the more traditional. Techniques to remove tissue.
So the complications that we can encounter, really, it's, it's the complications that tend to drive the, the need for advancements in, in technique and or equipment. Bleeding has been a major complication sometimes, with various techniques that have been used, and we'll go into that with specific techniques in just a second. The difficulty of removing tissue or, or dropping tissue in the abdomen is, is also a problem.
Plus the inadvertent intestinal puncture, especially on entry into the abdomen, has also been reported and described, and, and there's obviously a, a very serious complication resulting in, in pertinitis in the horse. We've already talked about abdominal distension, discomfort, and, some of the things that, again, these, complications have been overcome by really come down to the, the fact we've got better instrumentation and better techniques for doing things that would result in bleeding or dropping of tissues or inadventure, inadvertent intestinal puncture. When it comes to the light, the major advancement has been the move from halogen to xenon lights, and still xenon would be the, the most standard, light source used.
You can see here, this is, these are car headlights, but the halogen gives you this sort of yellow, almost sort of warm glowing lights with very little in the way of, of, near field depth. Zenon. Lights, give you much greater penetration and a whiter light, and the LED lights just help, to, to, to, you have a decreased size, but also you have increased penetration and a much greater battery life or LED life 30,000 hours, which makes LED lights somewhat cheaper, in the long run.
In addition, the high definition cameras need less light and a better energy usage. Light is a key thing, and if you can't see what you're doing, then clearly laparoscopy is going to be a very frustrating and probably unsuccessful procedure. So the advancement of, of, of better, increasing the wattage of the lights as well as better, zenin over halogen light sources has been a major, improvement in, in being able to see within the abdomen.
The, the high-definition technology allows 32% wider lateral view to be seen as well as capturing image in a 16 by 9 as opposed to a 4 by 3 format. Now, this means that our image is a lot clearer. The pixelation within the image, is, is a Better.
So you can see the top, the top image here is a slightly, it looks a slightly blurry view, of, of, a piece of, cord, so the scrotal cord here being, having a suture passed through it. And then if you look at the entry of this, cannula into the abdomen in the picture below, you'll see just the, the greater depth perception, the greater quality of picture here, it's a much sharper, much clearer image. This is using the same light source, but with just with the difference between a high definition camera and a standard camera.
It makes laparoscopy, an incredible procedure when you're, when you're using this sort of technology. So as technology has advanced in, in other areas and other fields, so it has helped us to, enabled us to, to make major advances when it comes to visualisation in particular. The depth perception, you know, again, that picture that I shown in the bottom right of the screen here is a three-dimensional picture, 3D image camera versus a 2D image, and you get much better perception, working with a 3D image.
This is a pretty, a pretty standard picture, that you would see, with, with a 150 watt xenon light source. This is a, a same 150 watt Zen light source, but with a 3D camera and HD. Now, one of the major complications has been, puncturing of the intestine, and, and really the trocher, the trocard of what we use to, to enter the abdomen, it is, is critically important, possibly the most important thing, when it comes to laparoscopy.
The reason for that is you have about between 10 or 15 centimetres of muscle to get through between the skin and, the peritoneum. And it's really very difficult sometimes in a in a large source to get, good access confidently, and know that you're not going to puncture intestine. So, therefore, the requirements for a troch are have to be that they, they, they can be placed safely and easily, that they'll stay in position and not slip out of the pertoneal lining.
Therefore, insufflating between the perineum and muscle. They need to maintain the pneumo the pneumoperitoneium whilst instruments are being inserted, and they should be easily cleaned and sterilised. In addition, they have to be smooth sided for the camera that's 10 millimetres in diameter, they, they have to be at least 11 millimetre in diameter.
And the more, most common standard, roars now, have stop cocks for gas installation on either side normally, plus a one-way valve within the centre of the. Within the centre of the roar to prevent escape of insulation when the instrument is is removed. Now, the important thing when it comes to intestinal puncture, obviously, most horses when they're undergoing laparoscopic procedures are fasted for a minimum of 36 hours, sometimes up to 48 hours, that obviously helps reduce the, the gut fill and thereby reduce the incidence of intestinal puncture.
However, there are certain specific operators that are, very useful now, and probably, becoming quite standard for use in, these, in laparoscopic procedures. The blunt tipped operator is pretty much standardised now. A sharp-tipped operator is, is rarely used, given the, the propensity then for it to, to potentially puncture your gut inadvertently.
There's a corkscrew, roar, which you've seen in a previous picture and which is demonstrated here, which has, allows the camera to be inserted or the scope to be inserted down through the, inner tube. And as the camera is advanced, the corkscrew is advanced, you can watch the per being picked up by the corkscrew, and then the camera drops into the abdomen. It's good for keeping the trocar in place and for horses that are less fasted, it's, it's extremely useful.
And then there's a couple of different, systems, the Visiport system and the versa support system that, and, and, and sort of combinations thereof that are, are useful. I'm showing you here the, the, the, the trocar, that's that picture again, here, the trocars being engaged as the peridium, and you can watch the, the peritidium being engaged by the, trocarent and the, and the camera entering the abdomen without, any danger of, of perforating and testing. This is the verse support system, which has, a guarded blade behind a sheath, and the sheath will pop out, the, sorry, the blade will pop out as the, the tissue as the, the trocars advanced through the tissues as soon as it enters a, a cavity, the sheath, snaps over the.
Blades and prevents the, the blade from puncturing anything, in the abdomen. And a similar system here, but just the tissues, has a slightly enlarged, end, that allows tissues to be separated and visualisation potentially as you come down, with the trochar. This is an example of a a system in which the, camera can be placed through C, down and look and evaluate as the, as B is fired, the cutting blade is fired.
The camera can then visualise as this picture shows the different layers being cut through, with a retractable blade until you hit the per fire once and then the camera should enter through without causing any danger there. Our system that we use, is, is a retractable blade system with a corkscrew, and, so you can see here the pictures on the, on the left side of the screen, the corkscrew means that it's maintained in position, doesn't fall out. You've got this retractable blade.
Here, that is, that the sheath covers the blades as it advance, as it, when it pops into the abdomen, but the blade is advanced, pushing back the sheath, when the, the instrument is being pushed through the muscle layers. And this is obviously a, a, a re-sterillizable procedure instrument. The other big issue that we've had, is, is removal of tissue in the equine.
You know, we're not talking about taking 2 millimetre samples out. We're talking about taking sometimes, pieces of tissue that are maybe 10 up to 15 centimetres big out. And obviously, the weight of that plus the fact you're working remotely can make it very difficult instrumentation wise to, to be able to grab that.
There's been big advances in instruments. Basically, any instrument that we have. Using in a laparotomy setting, we can now have an advance of that with a longer, a longer stem and, and used as a laparoscopic setting.
The other thing I point out is the fact that these, these, very useful invention has been the fact that these rotate. And so, you can, you can go in and if your tissue isn't at the right angle, you can rotate it X from outside of the abdomen, rotate the jaws so you can grab it in an appropriate angle. And, and, and really this is, the, the, the tissue removal thing, has the, the various techniques, the hand assisted techniques can help with that.
But mainly what we're talking about is specialised instrumentation, and one thing in particular, which is morselation of tissue, which, enables us to remove large bits of tissue, through, through small, incisions in the abdomen. Lots of different types of instruments have been, now, invented for equine specific use, making the job a whole lot easier when it comes to suturing. Specifically, these, little, clips are, are to prevent you, you don't need to then, use knots in your suture because intracorporal knots tying is, is tricky procedure.
There's, sutures that come already pre-tied with knots that you can use. And then there's these suture passers which, have, essentially got the needle that, fires through suture either side and, and kind of does it as like a shuttle effect between, the tissue and the, and the tissues that you're suturing. Retrieval bags now, you know, pretty common, very useful for, preventing dropping in an abdomen.
They come in all sorts of shapes and sizes. Most of them are too small for equine use and so we have to vary and make them ourselves, but they are useful, as well as, in, in order to prevent dropping of tissues. Stapling devices are, are a huge, advance again, when it comes to control of bleeding and, also when it comes to the use of laparoscopy for things like intestinal biopsies.
This, something like this Covidian device which has Rotating stapling arm that allows up to 3 millimetres of tissue to be, to be stapled safely and with a cutting blade in between, that is useful for intestinal biopsies, although still pretty much in its infancy and not used that routinely within the equine world. Morsation is something I've touched on, what this basically involves is, where normally we would have to have 3 laparoscopic portals. And we would be pulling tissue out of a more of a, a, a, a, a laparotomy portal, so an enlarged laparoscopic portal, maybe 3 centimetres in length.
What a morselation allows you to do is, is to remove the extract the tissue, in one long strand. The way it's done, you're grabbing the tissue in the abdomen and pulling it through, a rotating conical blade that's That's basically chewing the tissue up and making it into a long string as it gets pulled through, the trocar. It's, it's useful for both ovarectomies and for, cryptodiectomies.
And, and it's very useful in terms of reducing the need for, making larger incisions in the, in the para lumbar fossa to remove the tissue. This is an example of it being used, so the, the tissue is, is, is grabbed and, and the morcillating device is, is fired and as the tissue, as that's being fired, the rotating conical blade, the tissue is pulled out slowly whilst being visualised by the laparoscope. So it does reduce incisional complications, which can be fairly high in, in some procedures, in the laparoscopic procedures with horses.
And, you know, and what, the, the, the big issue that we have sometimes when it's removing ovaries or testes or anything from the abdomen is pulling them out through 15 centimetres or so of muscle with, without either tearing them or without dropping them. And this makes that whole process much easier. So the three papers that that really looked at morselation show that there's safe and effective with no significant complications, and these are really in ovarectomy, mares and, and cryptochectomies, but also in the use of granules of cell tumours in mares.
This is typical of what a morselized testes will look like. So a long string of tissue that can be pulled out through a single portal. Bleeding is probably one of the biggest frustrations when it comes to, when it, when it comes to laparoscopic procedures, because, as soon as the structure starts bleeding, two things happen.
One, the surgeon panics, because to try and identify the source of the bleeding or to try and control that bleeding can be quite difficult. And secondly, the, the, the, the bleeding can sometimes be quite far away from the, from the field of view. And it can, as soon as the bleeding starts, the, the concern is obviously that then you lose your picture, and you get this red out, just like with arthroscopy, when the, the picture quickly can become, very, very red and, and actually difficult to see anything with.
The bleeding, really, the, the revolution, for laparoscopic procedures has been the, the, the introduction of the, the vessel sealing device or otherwise known as the ligasure. This really has, revolutionised the ability to, one, control bleeding and to remove tissue without introduction of any other, suture or any other devices to, try and, control bleeding. The vessel sealing devices are, electrosurgical devices.
They coagulate and then they cut. They have this bipolar cauterization that denatures collagen and thus provides a, a seal of the, of the vessel up to 7 millimetres in diameter. And then, once the seal is formed, you can fire a cutting blade across, the tissue, cutting it at the same time.
And the pressure's up to 3 times normal within that vessel have been demonstrated to be controlled, which is pretty impressive. The blade incorporating device cuts with tissue and, and therefore, you get a nice clean cut. With the Ligasure device, there's less postoperative pain, reduced operating time, reduced morbidity, and a far a far greater reduction in blood loss.
It's technically easy to use, and we don't leave any foreign material in situ, and it really is the, the biggest advance from a laparoscopic instrument, that we've had, I think, in laparoscopy in the equine world. If we compare it to things like suture loops or intracorporeal suturing or emasculation techniques, it, it is, it's technically far easier than any of these and results in a far, safer and better seal of the vessel or the tissue being cut. The issue that some people are, that, that was concerning is that they obviously generate quite a lot of heat.
And in fact, a couple of papers looked at that, more recently, and, demonstrated that it, they, they would reach heats of up to 80 degrees when they're being activated. And even at the end of a cycle, still over 64 degrees C. And so, if touching, if, if they are, the tips of them touch adjacent tissue, they can burn a hole quite, quite readily in that tissue.
The adjacent tissue temperatures that are being, exposed to the heat during activation can get up to as high as 54 degrees C. And so therefore, although, the, and therefore, they have to be used with caution. That being said, they are extremely useful and their benefits far outweigh, the concerns with regards to heat, as long as they're used carefully, then there really is no issue with using them.
The other issue potentially, with, looking, that was looked at, more recently again was, was to see, just what happens within the, within the abdomen when it comes to red blood cell count, total protein, and total nucleated cell count. And interestingly, they could, in a, in a study of 30 horses and they compared the, the use of the ligature versus the use of, endoloop sutures to emasculate, testicular tissue. The only real, significant finding was the fact that with the Ligasure, the total nucleated cell count, raised significantly compared to the use of a, endo loop suture.
In one horse, in fact, it went up to 140,000. But after 72 hours postoperatively, pretty much that significance is, is, is lost, and by 4 days postoperatively, there is no, there's no evidence of an inflammatory response within the abdomen. So although initially they do seem to cause, an, a, a, a, a substantial increase in the total nucleated cell count, that increase is not sustained, and therefore their use again is, is safe.
So when it comes to the different techniques that we have, there really are masses of techniques now that we can perform laparoscopically. Under general anaesthesia, described techniques include the cryptoidectomy, bladder stone removal, abdominal exploration and testing biopsies, and internal ring closure. Standard techniques really have superseded most of the, the techniques performed under general anaesthesia.
And really, cryptoidectomy and ovarectomy are far easier standing than they are under general anaesthesia, as is abdominal exploration, intestinal biopsies, and really, the only way of doing, the, the techniques, outlined, neutropexy, nephrosplenic space closure, epilo framing closure, and hysterectomy, are to do them standing. Bladder stone removal also has been used standing also. When we look at, procedural advances, probably one of the most recent procedural advances is, is, looking at epipletic foramen entrapment.
And if you look at the epiloic foramen, or otherwise known as the foramen of Winslow in the horse, and actually, in any species, it is a, it's a small potential space formed by, the caudic process of the liver, the portal vein, and this hebato duodenal ligament. The space goes through, on the, on the right side. And, the, the big concern that usually is about 3 centimetres, up to, up to about 12 centimetres, in circumference.
The concern obviously is intestine that gets trapped in here that then is not able to be released, and it is a, a common, common cause of, of colic in, in, in the horse. It's readily, readily seen by, laparoscopy on the right side of the abdomen. Epiloic foramen entrapment has a very high morbidity and a, and a high mortality rate.
There's only a 48% survival to discharge being reported, and 65% survival discharge of horses that have recovered from GA. So it's pretty, it's, it's one of those, those frustrating conditions, . There are risk factors that are, are very well known now, crib biting, wind sucking, and are typical stereotypical behaviours seen that, that drastically increase the chances of epilera trapping, occurring.
And most commonly, it's small intestine that's trapped from the left to the right of the ileum being involved in over 2/3 of cases. The recurrence rate is quite low, only in about 2 to 14% of survivors, in a more recent study, show the recurrence rate was, was fairly low. However, despite that, still, there is a, a method that, potentially in horses could be used, especially if risk factors are identified.
Horses that crib bite or windsuck have stereotypical behaviours are at much greater increased risk of this condition. So the technique that was developed was really to put a, a, a, a shaped mesh, into the hole, and adhere it to the hole and thereby, close off that space. It was shown to be a fast reliable and safe procedure.
And interestingly, during the process of this, what was discovered is that, between 3 and nearly half of, of the elope foremens that had occurred, that were evaluated post-surgically for horses that had had epilep ramen entrapment, already had evidence of inflammation and adhesions in them. This is the technique that's showed in the paper, so we have the specialised cannula that's made that has the ability to fit down this specially shaped mesh, that's folded in a particular way and twisted to make it almost a diablo shape is what they call it. It's inserted the laparoscopically guided through the cannula, which is then pushed out, with a, with an introducer.
Here's the space again, the framing here, the portal vein aptitude in the ligaments and the caudate process of the liver. The trocar is introduced into the space, and then the, the ablo mesh is pushed into position, and to fill up the hole. And here we have the original picture of the epilo framen.
This is the mesh in place and reduction of the whole 1 month post-surgically, and then 2 months post-surgically, the, the, in, in a, in a postmortem specimen you can see here, the epilo frame completely obliterated by the mesh that's within the, the, the frame in itself. So successful technique for that particular condition. This is just to demonstrate the fact that horses that have epilofra entrapments get adhesions in that area anyway.
Now it doesn't completely close, these are adhesions here and here, and in some cases they will close, but still there's potential here for these horses to have recurrence, although recurrence is low. The second procedure, again, it's a, a closure of a, of a potential space in the horse, involves this cause, again, a very common cause of colic nephrosplenic space, nephrosplenic entrapment. This is when the left dorsal colon, becomes, the, the left, sorry, the left, the colon.
Large colon becomes displaced between the spleen and the left kidney, and the body wall. The nephrosplenic space, is, is, is a space created, between the spleen and the left kidney, and the nephrosplenic ligament connects the two. The colon becomes entrapped by becoming draped over the top of the ligament and thereby pushing the spleen down.
Now the the recurrence rate is, is quite high, so, about a quarter, fifth quarter of horses will have recurrence of this, especially in the more overrepresented breeds. And so that led to really a push to try and close that space. And there's been multiple different techniques, used to close it.
Intracorporal suturing has been reported both, in 2005 by two groups, involving a total laparoscopic technique, and suturing of that. And then those 5 or 44 horses had recurrent colic, but there was a successful, closure in all horses that were, that in which the, procedure was performed. None of the horses that had recurrent colic had nephrosilic space entrapment again.
In the hands assisted laparoscopic techniques is slightly easier technique because, intracorporeal suturing, which is, is tricky, it does not need to be performed. A specialised introducer is used, it's a large, it, it's a 5 centimetre, Larged, trocar that's used really creating quite a large hole into the para lumbar fossa, but through which a around bodypedo can be used to then, perform the nslinic space closure. Again, in this instance, all the, closures were successful.
One of the more recent techniques is the use of this proxxplast prosthetic mesh, and in this instance, the spleen here you can see laparoscopically, er and this probe measuring the distance between the spleen and the body wall. That mesh placement is then, used to adhere, the spleen between the spleen and the body wall, with these tiny titanium helical coils. In 26 of 28 horses, there was a successful closure, sorry, there's a 100% successful closure, 28 of 28 horses, and 26 of 28 horses, there was no recurrence of colic.
So the 38% recurrent colic that was seen was nothing to do with the nephrosplenic space, and you can see here that the tight adhesions formed between the spleen and the body wall as a result of the mesh formation. One of the more recently reported techniques was the use of a knotless barred suture. And in this, the, the, the reason that you don't need knots, and this is because the suture itself has little grips in it that prevents, it from coming out of the tissue.
And this again was presented, at, the, more recently in Glasgow with, with, with, with good success rate, 8 out of 8 cases, but it is technically challenging, and the suture is, is very expensive. And there are other ways of doing it which, work just as well, and don't incur the same expense. Now, the other final closure of a, of a space that, laparoscopically has become the, the preferred technique is, is, is closure of the internal inguinal ring.
And this really scrotal herniation is seen, through the inguinal ring, in, in, intact, male horses. Usually the ilium or the distal regina, it can be seen, coming through the inguinal ring into the scrotum, resulting in a scrotal hernia. However, large colon momentum and bladder have also been reported coming through that area.
And a diagnosis of about 3 to 4% of the horses that are diagnosed with colic, have this issue, much more commonly obvious common in areas where there's more stallions for obvious reasons. It's also seen congenitally in 1 to 4 day old folds, in which these in these hernias are often reducible and usually they're bilateral. The acquired form is in the stallions such as what you're seeing here.
So internal ring closures probably has, there's more techniques to close the inguinal ring, than any other procedure. It can be done standing or under general anaesthesia, and all these different types of things have been, have been described successfully, to, to perform, and close the ring. If we look at the different types of tissue, the two easiest ones to perform are the introduction of a polypropylene mesh, a 6 by 8 cm polypropylene mesh that literally is just rolled up and placed into the internal inguinal ring, and then stapled to the inguinal ring, not the vaginal ring, the inguinal ring.
Barbed sutures have been used just to literally, suture, to suture the ring, the fascia to, the inguinal ring and avoiding obviously the mezorium and the testicular cord as it goes into the internal orbital ring. Intracorporeal suturing is, is also readily performed or more technically more challenging. A peritoneal flap has been described both under the general, both under general anaesthetic by Ross, as well as Hans Wilder Hans, who is, readily performs his standing.
Somewhat more technically challenging, and sometimes access is difficult because we have to get below the level of the, intestinal volume. But here you can see the creation of a peritoneal flap here, and Here with, laparoscopic scissors, the flap here is the testicular cord here. The flap is then pulled across, and then it's sutured or stapled in place across the testicular cord.
The nice thing about this is that the, it's its own tissue, and it doesn't stranggulate the cord as it, as it's been placed over the top, forming a nice natural seal. Finally, in the same paper, Fabrice Ross and all, describes a technique in which, he glues the inguinal ring with, just with, with the sound acrylic glue, glue. And here, this is the, the picture of the glue being introduced.
And it's setting, and then finally, this is 30 days later with a complete seal of the, internal inguinal ring. I've never used this technique, although it's quite, appealing just because of its ease, and, and lack of, lack of difficulty. But yes, it is, it, it certainly described in a valuable technique, especially where more traditional techniques per to the flats and the like are, are more tricky or where there's financial constraints with the use of, a mesh.
Finally, a more recent, study, a couple of years ago now described the use of, of homologous pericardial grafts. These grafts was performed under general anaesthesia, and the grafts were sutured in place successfully, resulting in a good tight seal, after a month. And, again, these, these grafts.
Are, are homologous, so the rejection was not seen, in any of the, in any of the seven horses that were in which it was performed. The grass was stapled in place or sutured in place, and the, it was successfully performed. So, lots of different advances and different ways of doing the same thing to close the inguinal ring.
Some easy, some were tricky, some expensive, some cheaper, but plenty of options. Finally, reproductive system, cryptoidectomy is, is probably the, the, the way that the laparoscopic la laparoscopic procedures have revolutionised the removal of the retained testes. It can also be removed to remove an inguinal testis as well by cutting out of the inguinal ring.
Usually standing nowadays, there's no need to perform a general anaesthesia with these unless for some reason, there's been a mistake that's been made in, in identifying the, the, the, test that's within the ring and it's in the abdomen instead. It's a much easier technique with a horse standing because obviously the test is handed from the dorsal body wall. The use of the liquorsure now is, is routine and standard in, in our practise.
We do not use endo loops or zip ties. Tom Yarborough, he reported on the use of zip ties, leaving them in situ, however, that, did, there was a report further on from, that, that result that reported the revascularization. Of the, of the vaginal tunic and therefore the test is when the test is was left in place.
So really the test is, has to be removed on the basis of that, and the lake assures revolutionised how that's performed. Again, ovarian hysterectomy, these are not advances, and so I'm spending very little time on them because they really are very routine procedures now I've been around for quite some time. But ovarectomy is a routine procedure, hysterectomy may be, less, less, less common now, or rather less well known about, and, and more, recent, procedure.
I think the, the key thing about both of variectomy and the cryptoidectomy is bilateral crypto orchids and bilateral variectomy is being performed from the same side. And, and the, the, the use of the longer, laparoscope laparoscopes, greatly facilitates the ability to pull both ovaries and both, retained testicles out from the same side. And that obviously has great bearing on, the, the morbidity, as well.
So, the Legosure can remove, we can remove ovaries up to 25 centimetres with the use of a ligasure. Combining that with the use of a, a morselator, you can do everything laparoscopically very nicely, without the need for any, large incisions. The ovarian hysterectomy procedure that, we, it's not, it's not commonly performed to performed, to our practise, nice technique that is described here by, Nigel Woodford and Richard Payne, in which the laparoscope is assisting the, removal of the, of the usually pymetric or, or neoplastic, uterus or ovary.
The, The procedure starts as a as a standing procedure with the ligasho being used to transect the mesobarium and the mesometrium, to the most caudal aspects that can be taken, and then the horse is anaesthetized, placed on its back, and a and a small, 10 centimetre midline incision, just cranial to the other is then used to te. The transected uterus, it's then stapled the two lines of staples over sewn and cut out, and has really, it's a, it, it's a remarkably, straightforward procedure, with really great results and has, has really made what was a very, very difficult procedure under usual conditions, much, much more achievable. Other, more reproductive type things that have been reported, are raising of the uterus and multiparous mares, the uterus will often sag, and these horses are, are failing to rebreed.
And so, it was the Schumacher brothers. They described the technique in which they sutured the mesometrium, to the, dorsal body wall, and there, and by allowing 5, horses that had previously failed to be rebred, to be bred, 3 out of these 5 successfully bred, long term. And here you can see the use of the suture, just taking the, the proximal serum muscular layers of the, dorsal uterine body and suturing it to the body wall, and likewise here as well onto it, and these are the adhesions that form after 6 months.
One other advancement when it comes to, more reproductive related, laproscope procedures is the, application of prostaglandin E2 or misoprostol. Horses that, mares that, that are infertile have not been successfully bred for some time, may have this issue when they get, collagen masses that block the oviducts, and, and, and thereby prevent the passage of the, oval down into the uterus. Now, by applying, 1 milligramme of a misoprostol gel, topically onto the oviduct under laparoscopic guidance that can cause contraction, of the opioduct and clear the blockage.
It's been very successful in this particular report, 14 to 15, Byron Mes conceived following the procedure. In my hands, certainly, it's not quite as good as that, but we have seen, horses that have previously failed to conceive, come and conceive, with this very simple procedure. An extension of this procedure was, then used, to, identify, restrictive bands that, that extended from the mesalpis through the mesoarium, and that likely were causing some degree of obstruction of the of the duct.
These bands were then resected, prior to topical PG application. And in 3 years, they were then successfully bred. Bladder repair is, is the other technique that has been moved from being really a laparotomy procedure to laparoscopic, at least a laparoscopic assisted if not a full la laparoscopic procedure.
With a standing repair, the bladder, you get superior visualisation, better access to the bladder, and a, and a dissection that's tension-free. The big problem previously with laparotomy, incisions and, and the exteriorization of the bladder was the exteriorization of the bladder was so difficult under great amounts of tension, to get that bladder out. With the Laparoscopic, assisted techniques, the horse can be anaesthetized and laparoscope can be introduced to identify the best position to bring the the bladder out to remove the, to remove the, the urelith.
In total, laparoscopic procedures, it was demonstrated that a single layer closure was as strong as a double layer closure, thereby reducing time significantly. In general anaesthesia, the two layer closure was performed in a full, and this required a repeat surgery for Ulith as an adult, so that was reported back in 2005. The laparoscopic assisted technique goes something like this where the lap, the laparoscope is, is used to identify the best position for the bladder to come out, of a paraingguinal incision.
And the paragonal incision then can be located ideally right over the bladder. As the bladder is being drawn up to the incision, and that can do something to help relieve tension in the bladder. The fully laparoscopic procedure involves the use of a special, grabber that, that was, introduced into the abdomen, and used to, to remove the urolith as can be seen in these pictures here.
This procedure I've never performed. And then intracorporal suturing used as a double layer suture to remove, to suture the bladder back. I think one additional thing potentially here would be to use the use of a, a bag to, to drop that stone into, because the contamination of the bladder would be significant, given the fact that it's, making a, an incision on the ventral aspect of it.
That being said, this, this horse was successfully operated on, without, with, with minimal complications following the, the procedure. Nephrectomy has been performed, as a, as a hand assisted procedure. Normal kidneys are demonstrated by Keegan in 2003 that, that you could perform, a nephrectomy as a, using a laparoscope to identify the vessels, and then, open the biopy lumbar fossa to remove the kidney.
In unilateral, renal disease and three horses, Rockin described the removal, by a hand-assisted laparoscopic technique with no significant complications. And then in Davis, Hugo Hilton reported in 2008, the removal of a kidney due to renal carcinoma. This is a laparoscopic stapling device was used, the, the, and the renal hilus was, was stapled prior to its, removal, through the para lumbar fossa.
It's an example of a laparoscopic evaluation of the, the renal hillus here, identifying the arteries and the ureter prior to the vein transecttogen removal. And again, this is the per renal fascia that's incised to identify laparoscopically where the kidney is and then it's subsequent removal from the side of the abdomen. So what about the future?
Really, there's so many different, procedures that can be done. Our limitation really is down to, her access still, and the ability to work within the abdomen. It's much, much more difficult in a horse than it is in the, in the human.
But these single incision laparoscopic portals, certainly are something that offer potential for the future. These are dedicated portals that have 3 single portals in through one incision into the abdomen. They can either be 35 millimetre portals or 25 millimetre and a, and a 12 millimetre cannula with a dedicated insulation channel.
They're useful in humans, very useful of minimising the size of the incision and the number of incisions needed for laparoscopic means. The other issue in terms of flexibility and visibility really is now being overcome in sorry, in human use by the means of this four-way articulating endoscope. So much more like a non-rigid endoscope, the endoscope and passing and can be moved around, around corners and, and evaluated.
Plus there's two opposing, channels through which instrumentation can be passed. The final thing which is, is possibly, on the horizon, has been used in horses, once, is this natural orifice transluminal endoscopic surgery, or NOTS surgery. This combines endoscopic and laparoscopic techniques, and eliminates the need in its entirety for abdominal incisions and any complications that exist as a result of that.
It's really talking about entering into the abdomen through other orifices, usually the mouth, the anus, or the vagina. Now in the horse, it's been used to perform a bilateral ovarectomy, transvaginally, in 9 horses, it was performed, it was performed with some difficulty. So the, you can see in this picture here, the, this is the, cannula being placed in the vaginal vault.
And then the laparoscopic portal is being used here to introduce the ligature and the grabbing instruments to remove the ovary. Lack of visualisation and quite severe haemorrhage were the two major, complications of the procedure. And really begs the question as to if it was worthwhile doing it this way when, we have very little issues, I believe, in most cases with incisions, laparoscopically, when we go through the abdomen.
potentially it might be a learning curve, but really, abdominal laparoscopy, we're so used to now, incisionally, we have very few complications and therefore, the risk of the bleeding plus the lack of visualisation in this instance, these instances here makes this technique hard to see how it would replace traditional laparoscopic techniques that already existed. However, it could potentially be used for, the evaluation of uterine torsions, very usefully, which is something we have very little, Ability to diagnose pre, before, before we need to perform any emergency surgery. But maybe it's not use will become popular, I can't see it's use at this point in time being replacing, any of the traditional techniques that we have currently.
And ultimately, if we look at the human field, then where we're going is the robotics, and really where humans are not needed at all. And maybe that is what the future will be like that soon we won't be needed to do any of this surgery, just be programmed computers. And I would like that, I'd like to say thank you and hope you've enjoyed this, presentation.
Thank you very much for that, Jonathan. Thank you. .
As I say, I haven't got an equine veterinary background, so, please do, if you have any questions, pop them in the Q&A box, and I will post we have you have about 2 minutes left, so I can pose them to Jonathan. Hopefully I will show you all great. It was a very in-depth, .
Presentation and hopefully it's giving you some really good ideas about when you go back into practise, some information there that you can go and put into practise that will help you in your day to day work. . Also, while you're thinking of the questions, I'd just also like to highlight that there will be a a short survey popping up at the end of this webinar just asking you for your feedback on this presentation.
So please do take a couple of minutes just to complete that survey because that really helps us develop our programme but also gives a really useful feedback to our presenters as well. So, let's see. Has anyone got any questions?
No, we don't seem to have any questions, Jonathan, so it seems like you've been let off lightly, either that or, either that or you've just, shocked them all into, submission. But you know, I'm sure, I'm sure you've put it's so comprehensive, I'm sure it's covered a lot of the points, . Obviously, you do remember that this webinar is recorded and will be available on our website within the next 24 to 48 hours.
So it'll be there for you to refer back to if there are any points you want clarification on, then you'll be able to refer back to the webinar, shortly. Well, that seems to be it. I say, we don't seem to have any questions, so, thank you very much for joining us.
Thank you to yourself, Jonathan, for putting together such a great presentation. And, thank you to Phil for being on the technical side, supporting us, and I, look forward to, welcoming you all on our webinar very soon. Good night.
