Good morning. My name is Doctor Carolyn Arnold. I am a large animal surgeon, from Texas A&M.

Today, I'd like to, give my presentation entitled Cryp Orchid Surgery, Surgical Technique and Management of Complications. So very briefly, in an overview, I'm gonna touch on how I work up crypt orchids. I'm gonna touch on two surgical techniques, an equal approach under general anaesthesia, a standing laparoscopic approach, and then finally, management of complications.

So this is a, this is, I think one of the funny things about crypt orchids. We do them in a large number of ways. So many options.

What you see here in the picture on the left is, a colt being a crypt orchid being castrated, at one of our school units. On the right is a donkey at a, wildlife at a wild at sanctuary. So sometimes we do these in the field, and then other times we choose to go into a sterile surgical suite.

So the image on the left is someone doing an inguinal approach, and there on the right is our standing surgical, suite for laparoscopic surgery, as we're getting that horse ready. And so I think what these images bring up is such an array of choices that veterinarians have for how to do the procedure. And so, I think that brings us back to the question, how do you pick a method?

Which one do you choose? And in the 20 some odd years I've been doing this, I kind of have found that I tend to ask 4 questions, and those guide me. So the first question is, has this horse, this crypt orchid, been operated on before?

Is there actually a testicle in this horse? Where is that testicle? Is it abdominal?

Is it inguinal? Is it in the scrotum? Where is it?

And then which approach do I choose? So we're gonna work through those four questions. So the question of previous surgery, I think is really important.

Here's a horse in dorsal recumbency. This was a bucking horse that meant he did not wear a halter. He was run through a cattle chute.

I was told to go castrate this horse early on in my career, and you will see that there are actually 5 different incisions on the bottom of his belly. 12345. So clearly things had not gone well.

All right. This horse had an unknown castration history. When we laid him down, we saw two incisions.

Therefore, we made our incisions in other places, and this is really what you want to avoid, . So the question, has anyone ever operated the horse before? The owner might say, no, I've learned to ask a second question.

How long have you actually owned the horse? And so if the answer is, I bought it at a sale, I got it off the internet, they might They might interpret that first question is, they have never tried to operate the horse, but sometimes knowing that the horses had this unknown history makes us think a little bit harder about which method we would choose. The second question, does this horse actually have a retained testicle?

All right. So, maybe there is a shaky history in regards to surgery. Maybe, you don't palpate scars, maybe you do.

Maybe the horse has continued masculine behaviour. And so sometimes in order to answer. That question, you end up doing hormonal assays, OK?

And you have a wide range to choose from. You can measure testosterone, you can measure oestrogen sulphate. Those tests are good, but they are also dependent on age of the horse.

So if it's a 2 or 3 year old in the winter or fall, they may not be as reliable. I think the HCG skin test is, which is where you do a baseline testosterone, you give HCG and then you measure testosterone again in 24, 48, and sometimes even 72 hours. More recently, measurement of anti-Mullerian hormone or AMH has been really useful and has provided some really good indications whether you have a stallion, a crypt orchid, or a gelding.

All right. So all of those can be used. And sometimes we actually resort to doing that before we go to surgery.

So, if we had decided there is a testicle in the horse, I think this is kind of my number one determinant of what method I'll pick or or a big part of it. Is where is that testicle located? And there was a really nice paper that came out of EVJ about 11 years ago or so that described a non-invasive method, for ultrasounding along the abdomen and the flank and finding that testicle, and that would help you choose.

So if it's abdominal, to me, that means I need to, do one of two approaches. If it's inguinal, I'm typically gonna go the inguinal method. So here's my little flow diagram.

Which approach, so number one, where is the testicle? Let's go down the inguinal branch for the first time. If it's inguinal, I will almost always choose an inguinal approach, so the horse and dorsal recumbency under general anaesthesia, because 99 times out of 100, I can get them for that approach.

I think it's somewhat less invasive than a standing laparoscopic surgery. And our hospital pricing structure means it's half the cost of a standing laparoscope, all right? And the clientele that I have, a lot of times money is their overriding factor, all right?

If, however, ultrasound shows me that that testicle is indeed in the abdomen. My next question is, will he stand for a standing laparoscopic surgery? So is this horse halter broke?

Is he of a behaviour that I think we could sedate him well enough? And if the answer is yes, in that case, I very much prefer a standing laparoscopic method, right? If owner finances preclude that, then we're gonna go with an in approach.

And if that ultrasound shows anything unusual about that testicle, say, size, maybe there's got an abscess in it, we'll usually choose an approach on the ventral abdomen. All right? So very quickly, an inguinal approach.

So this is done with the horse and dorsal recumbency, for our horses in our school teaching herd or at sanctuaries. This is usually done under GKX. Sometimes this is done in the field.

In our hospital, this will always be done in our surgical suite, all right? It's the approach that I like for something called a high flanker, where the test is and the epididymis is actually within The inguinal canal. All right.

In the case of a partial crypt organ, and this is a nice diagram here, so the horses, you know, here's his abdomen right here. Here's his inguinal canal. We've got part of the epididymis through that inguinal canal, and then we simply need to track it back and pull it out through to get the testicle.

All right. So the inguinal approach is great for either partial or complete crips, depending on their finances. And because I am in a hospital setting, I usually choose to close this ring or at least ablate that space on my way out, right?

So, again, here's a horse and dorsal recumbency. This is generally where you find that inguinal ring. You can take your hand and feel both the cranial and caudal edge.

This horse would have his penis sewn into his prefuse, to be clipped and draped in a sterile fashion. And then for a high flanker, you simply cut, make an incision directly over the ring, come through the sub-Q with some nuts and bombs, and then typically it's right there and you can pull it out with sponge forceps. All right?

If it's in the canal, I typically don't close the ring. I may or may not close the incision, depending on what kind of environment the horse is going back to. So for a partial or complete for a partial crypt orchid, here's a nice little cut out.

All right. Here's our superficial inguinal ring. Here's our internal inguinal ring.

Here's a little bit of the tail of the epididymis. All right, sticking through. All right, we can usually make that approach, grasp that little vaginal process, make a slight incision in the tunic, and then simply Pull the epidymitis and the testicle out through it.

Sometimes there will be a little bit of a constriction, and you'll need to actually run your hand down that ring and maybe enlarge it digitally. But those, that's, that's just a really nice method for something that's right there. And like I said, in our hospital, that's really half the price of a laparoscope.

So we have many owners that choose that. The difference between a partial and a complete crypt, again, here's your superficial ring, here's your internal ring. This is a little window in the peritoneum of the abdomen.

I will enter my hand down through that superficial inguinal ring, and then I kind of curl around, bluntly dissect through the peritoneum, and you can reach down and pull the testicle and epididymis up through it. All right? So for those horses, both partials and complete, I usually close.

The superficial inguinal ring with viral and then do a subcular and skin. All right. If the decision is made, that we have a complete crypto orchid, meaning both epididymis and testicle are inside the abdomen, I like to do a standing laparoscopic approach.

This has, become kind of popular with our clientele as well. Generally, I think people that have a little bit more budget to spend in our hospital, it's about $1200 to $1500. I also think there's a little bit of a misconception along, amongst the public.

Sometimes I think they, when they hear minimally invasive surgery, they equate that to mean there is less or no risk with that surgery, and that's actually not true. And, and that's part of our client education is to say, look, it's still surgery. Things can go wrong.

You can still have a sick horse afterwards. There are some risks. I also like to have a backup plan if that horse won't stand, if surgery isn't going well.

And I talked to the owner about that as well. All right. So here is a testicle that was removed.

This was the descended testicle. Here is, the abdominal testicle, and you can see this configuration of the epididymis, both in terms of the head that's in the tail, as well as the ligaments, is really, quite a bit longer than this normal one, which can make them hard to get out. So basically, for the laparoscopic surgery, we've got the horse standing, sedated.

I have a catheter in them. We clip and prep the parallelmbar fossa, and then we basically are making three portals in that parallelmbar fossa, 12, and 3, and you enter the body wall with a blunt trocar. I then insufflate CO2.

Confirm that I'm actually into the abdominal cavity and then insufflate so I can see the viscera. The instrumentation used, I usually use a 30 degree laparoscope, which is here. Here's the camera attached to it, and then we need both traumatic and a traumatic grasping forceps, as well as this ligature.

This instrument I have found to be particularly valuable. It both seals and cuts vessels up to 7 millimetres in diameter, and that makes it a lot more comfortable for the patients. So there's good control of hemostasis.

All right. So, I'm gonna play a little bit of a quick video here about entering the abdomen, with a cannula. We've already got the scope in this horse.

We are on the left side. So what you're looking at is the cannula with a blunt operator is about to be passed through the body wall and into the peritoneum. You can see that the peritoneum is somewhat.

It's very easy to strip the peritoneum off the body wall, which can make it hard. There's a really nice shot. And so we're watching with the scope in the cannula that we have already made.

Video, I'm gonna show you a quick video, and what it is, we've got the laparoscopic camera inside the abdomen, and then we're watching, make, we're watching ourselves make a portal. And this is just kind of a demonstration, if you will, of what it looks like inside the abdomen. And before you insufflate how close everything actually is.

So there's the peritoneum being pushed away. I, I'm gonna speed it up just a little bit. And so we're trying to find that nice balance between using enough force to get through the peritoneum.

And not hit the viscera. And so that's a little bit of a learning curve. I think we're through there we are.

And so we advance the forceps. There's part of the epididymis. We've got to be really careful not to grab anything like bowel with that, that's the traumatic.

And there we pull the epididymis. And then we can see the testicle underneath. So there it is.

So good exposure. So this horse was actually a little bit of an incomplete crip, meaning I think that testicle was sitting right there at the inguinal ring, and part of the epididymis has gone through into the canal, but we're able to retract it. All right, great.

So, what could possibly go wrong? Management of complications. I think this is a saying, I, I forget who said it, and someday I'll figure out who to quote, but it says good judgement comes from experience and a lot of that comes from bad judgement.

So this is a rather gruesome slide. That first image on the left is a horse with peritonitis, after a, inguinal approach to cryptorchid. The horse in the middle is hissing his body wall again after an inguinal approach, and then here's a horse that let out following laparoscopic surgery, ugly pictures and hopefully very rare events.

So one thing I've learned is that in general, a lot of what goes wrong doesn't happen necessarily because of surgical mistakes. Instead, it's the choices that are made due to various factors such as the horse, Owner's wishes or time frames. Sometimes people aren't patient.

They don't listen to what we think, you know, the right time frame might be, or to, you know, change a horse's diet before laparoscopic surgery. Sometimes you're very limited by your facilities, sometimes you're limited by your staff. Sometimes you're limited by the owner's finances, and sometimes it's your time and your schedule.

So this is an image of our standing, a laparoscopic suite, right when laparoscopy was kind of first introduced to Texas A&M. And you can see the horses wearing a drape, the cords are up high. We now drape things differently, but you can see all those people in the room, and the whole thing makes me feel claustrophobic at times, and I have to think the horses feel that way too.

So to go over some of these factors, I am a firm believer that not all horses are meant to endure a standing surgery. This, image is a view from a university bus. We had a patient who was unloading into the hospital.

It was a 2 year old who had had very little handling. When they went to bring him in through the doors, he just freaked out and ran away. A horse like this, I would never even attempt to do a standing procedure on.

He's barely worn a halter, he's got a huge flight risk, and the thought of putting him in a standing surgery room with all those people and equipment, I just don't think. It would work. So that is a great horse to lay down and do an inguinal approach, no matter where the testicle is located.

Here's some other patients that we tend to get. Here's some donkeys. Donkeys have become really popular for us.

They are aggressive and they fight a lot if you don't castrate them. Oftentimes, people get them from rescues from various and as sundry places, or they're found roaming the streets. And so there's an unknown castration history.

But these are really not good patients to do a standing laparoscopic surgery on. I've also found they're not great patients to do recumbent laparoscopic surgery on because I can't, they're so short that it's hard to get them in a true Trendelenburg location. So for me, I much prefer doing these small unhandled courses in, in a surgical suite and dorsal recumbency with an inguinal approach.

This is a horse that is just mean. He's bitten a couple people, the image on the right, he's broken someone's arm. We're not gonna put him through a standing laparoscopic surgery or us.

And then sometimes you get horses, very athletic, but not used to people, very athletic and used to people. And sometimes these horses just have a temperament that I honestly think it's safer to anaesthetize them, than to do a standing surgery. If we're not sure about the horse, if the owner really wants the minimally invasive or laparoscopic surgery, sometimes we'll test them out.

I'll have my technicians, run them into the standing suite. I'll have an old drape. They put the old drape on their back.

They kind of rattle around the instruments, make it busy, and just do a test run and see. This is a colt, who was extremely attached to this little miniature horse. And the owners told me there's absolutely no way you can separate the horse from his little friend.

And I thought for sure we could. So, you know, being a little bit stubborn, I decided to try to separate them, and it was a disaster. The horse did fine.

He sedated beautifully as long as that little guy was at his head. So those were the technicians dressing that little miniature up in sterile gear as we got ready for this horse's surgery, kind of making fun of. Making fun of my hardheadedness and not willing to listen there.

I do think it's important, especially in standing surgery, that you have good control over the OR environment. The person at the head of the horse is very, very important and can make the procedure go well, or it can really affect the procedure and have it go poorly. Sometimes when horses get sedate, they tend to cock a leg, rest their hip, and that makes the laparoscope really hard.

Also, I've learned to pay very close attention. We do a rough prep outside the room. That means less prep ends up on the stall, or, or I'm sorry, on the floor of the OR, which makes it less slippery.

I've also learned to cast. These horses. You're usually giving them some alpha 2s for sedation.

And I do think that having urine not all over the floor is, is another factor in how well these horses do and handle the anaesthesia. For our anaesthesia protocol, here's an example of things that go wrong. This was a draught horse, and he was a crypt orchid, and he got a little bit over sedate and decided to lay down during the procedure.

Thankfully, he lay down on the side that we hadn't put the laparoscope in. But I'm very acutely aware that when a horse lays down during laparoscopic surgery, it can have a pretty catastrophic event. So every horse that goes into our surgical suite will have a catheter, with a 30-inch extension set.

We're very careful about the degree of sedation. You want them sedate enough to accept it, but not to sedate that they slip, they fall, or they decide to lay down like this guy did. And this is our protocol, for a lot of our standing procedures, not just crypt orchids.

So there's the catheter wrapped in. We usually give a loading dose of dittoidine and then a CRI. We usually also combine that with a loading dose of morphine and a CRI.

Also helpful is something called a ketamine stun. So that's maybe a painful part. Maybe the horse is getting anxious, and you just need that thing to stand quietly for a couple minutes, and we try not to do that every more than 30 minutes, but that protocol has been very successful for us.

I did mention that we do a lot of crips under anaesthesia. We do those both under GKX as well as inhale it. I have learned to be careful of breeds like this, Frisians, or some type of draught horses.

It's a rare event, but I've had a couple develop what they call a post-anesthetic myylaia or paralysis of the hind limbs after kind of a short anaesthetic period typically healthy horses. I've also had some troubles in recoveries, not a lot, cause this tends to be a fairly young population, but we're pretty cognizant about the horse's attitude. So not every horse that goes in for crypto orchid surgery, many of them recover on their own in a darkened room, as opposed to using head and tail ropes, because their temperaments are just such that they can't tolerate it.

So we also talked about for laparoscopic surgery. I do feel that there are a small number of horses that either, I think they're gonna be OK, but it turns out they're not. They can't take the activity, the claustrophobia maybe of the standing surgery, or perhaps they're intolerant of having the carbon dioxide is deflated into their abdomen.

There are also times when we decide to use the ligature to transect a structure such as a large testicle, with a laparoscope, but we know it's too big to remove from a flank. And so there are times when we deliberately say we're gonna start standing, close our portals, and then finish the job under GKX or under some kind of general anaesthesia. So all these things, there's just so many ways to do crypt orchids, so many factors to consider.

All right. The other thing, and one of the four questions I had talked about in the beginning was, where is the testicle. The other thing that we're learning to pay attention to is not assuming that every testicle is normal.

All right? So when you're there looking for the testicle with the ultrasound, it's also a great idea to characterise how big it is. Does it look like it has a normal rama, right?

Here are 3 images of testicles that are not normal, right? One is an abscess. All right.

Here is a testicular tumour that was in a cryptorchid testicle. And then here is a horse that just had, this was actually the remaining down testicle. This wasn't intraabdominal, but this horse had just a tremendous amount of perioitis and was quite sick.

All right. So sometimes, here's another cryptorchid testicle. This is a cyst and so these are very deceiving.

Here is the actual testicle. Here is the head, the body, and the tail of the epididymis, and he's got this huge system here. Right, this isn't going to pull out nicely from an inguinal approach, and if you're using a laparoscopic approach, you probably need to make a little bit bigger hole to get this out.

Also, here's another good image showing how deranged sometimes the length and the association of these ligaments to the testicle and the scrotum are, right? So sometimes it helps to pick these up on ultrasound. Here's that horse that I think I showed in the beginning of the presentation, the bucking horse that couldn't be haltered or, you know, handled normally.

When he got turned upside down, in the, you know, after sedation in the cattle chute, we found these two incisions. I really wish I had been able to do more of a workup on him. This is what came out of this horse.

So here was, One of the, one of the testicles that was crypt orchid, but here was the second. All right. So initially, I had made a inguinal approach, and I could feel part of the testicle, but it felt too big.

We then kind of converted it to a pair of inguinal, and again too big. We finally ended up taking that thing out through a ventral midline. So it's a little bit more proper planning and workup, I think we would have had a lot nicer experience.

All right. Here's another complication. Thankfully, it doesn't happen often, evisceration.

I have only had this happen after routine castration. I've never had it happen with a crypt, knock on wood. If I am in our hospital OR, I will choose to close, that superficial inguinal ring and also do a sub 2 and the skin.

But there's a lot of horses that we castrate, are teaching herds or, horses that don't have a lot of value that crypto orchids get done in the field. And I don't play suture. I leave those horses open, all right?

I have learned that sometimes horses would Really large inguinal rings, say, susceptible breeds, like draught breeds or standardbreds. I will definitely palpate their ring size. And if I feel like it's really large, or God forbid, you feel bowel there, those are great ones to not do in the field and to simply refer in.

All right? Peritonitis, I've had this happen in two cases after cryptoin surgery. Once with the laparoscope and once with an immunal approach.

This is a, this is doing a belly tap, the image on the left. That horse had about 300 or 400,000 nucleated cells and a total protein of 5 in its abdomen. I don't, you know, when we are in the hospital, we're very careful.

We use aseptic technique, we glove, we mask, we're in full surgical guard when we go into an abdomen. But every once in a while, I think if you do enough of these, you're going to find that there is the odd horse that gets a parititis. This is what that horse's bowel looked like.

At surgery, so this was a horse that we went back into surgery to, see what had happened, if there was a leak in the bowel, had bowel been transected. It turned out there wasn't. The horse just got a septic abdomen following peritonitis.

Way back in 1988, there was a really nice study that I think explained why some horses do this. Essentially they took 20 or so normal horses, and they did belly taps before and after, . Castration, and they found that some horses had a very pronounced inflammatory response to a normal castration, so a a castration where the horse didn't become febrile, didn't have excessive swelling, but they did serial taps on those horses after castration and found that even in some cases there was 100 to 70,000 nucleated cells per microliter in that peritoneal fluid.

So I think that there are some horses that develop an inflammatory response that can lead to peritonitis. Regardless of the method that's used a routine castration, an inguinal crypt, or a laparoscopic crypt, I have learned that I think providing a broad spectrum antimicrobials, helps certainly in all cases. So my horse.

Will get at least a dose of PPG and genicin before and a dose of penicillin afterwards. If I feel like there was any prolonged haemorrhage, if I feel as though we were in that horse's abdomen for a long time with the scope, having to do a lot of dissection, maybe having to do a lot of ligature, I typically will leave them on for a course of 3 days. Other antibiotic combinations that you could choose would be, certainly exceed combined with gentamicin, but I do think you get better coverage when you combined some form of beta lactone with an anaemic glycoside.

We've learned to be really careful when we're in the abdomen with the laparoscope. It is very easy, that licature gets hot and it's very easy if you're up against a mesentery or a piece of bowel to put just a small nick in it and develop a peritonitis, to traumatise the bowel or to get adhesions. And finally, the other thing that we have learned is that, sterilisation of instruments is important.

So for many years, what you see here, this is literally, I think, a, pipette, an AI pipette that's cut in half, and we use it as a shield when we block the, pedicle to the testicle. So what you see here is a long needle being inserted, and we would put the AI pipette in. Run the needle through it and then we would put lidocaine in before we use the ligature to transect the cryptorchid testicle.

And at one point, our OR nurse said, you know, maybe part of our problem is I'm not sure we're sterilising those pipettes the right way. And so when we changed that, we kind of attributed that to one of those peritonitis. So it's, it's really just being careful and being adherent to good surgical technique, I think that helps.

And then sometimes a little bit of luck, you know, I don't do, I don't operate horses that have fevers. I don't operate them if they've been sick recently, strangles, pigeon fever, outbreak of respiratory disease, kind of choose your battles. So I mentioned the damage that can be done with the ligature.

I'm going to show you a video. So we are in the abdomen, and I believe this actually might be an ovarectomy, but it will kind of demonstrate the same principle. Yes.

All right. So we have put the scope in the abdomen. We have not fully insufflated yet.

And as we're looking around and getting our bearings, we're gonna notice a little bit of haemorrhage at one point. So there's the uterine horn in the background here. And sometimes you get a little bit of cloud over the scope, and that's because the inside of the horse is quite a bit warmer than the inside of our surgery room.

We'll run this forward just a little bit. All right, so we've gotten a little bit better look. We've cleaned the edge of the scope off.

And we're waiting for the abdomen to instate so that we can see the structures that we need. Another instrument in. All right.

Here is blocking the pedicle. So I had talked about this earlier. There's a needle that runs through the cannula.

We're going to, there's insulation of lidocaine right there, that tissue kind of blanchees. And there's been some nice work done that shows that if you can't get the pedicle blocked, you can simply apply lidocaine topically to either the testicle or ovary, whatever you're trying to loose her off, right? So there's also some topical lidocaine being dribbled on it.

We're going to Take the needle one more time and go come into that pedicle. And I will typically use about 20 cc's of lidocaine to block a crypt orchid pedicle. And then we're just spreading the rest on it.

I'm gonna advance a little bit. OK. So this is a good example right here.

When we put the first cannula through and we're doing it blindly, Got a little bit aggressive and caused just a little bit of damage there. So that's why you want to be very careful. It's a fine act between placing your cannula across the wall and not stripping the peritoneum and then finding, whoops, went a little bit too far and actually hit that ovary.

Right. This is an ovary. It was just a great example of some damage that you can do inadvertently.

And next, we are showing the literature in action. So I'm gonna let that run a little bit. So this is the ligature.

It's got two paddles. You grasp the tissue. Lock it And then you kind of hit the button that applies the thermal cautery that does the seal and the coagulation.

You wanna try to stay close to that structure and not get back behind the rotorchid or behind this ovary, there's gonna be the small colon esentery. You can see it peeking in just there to the left. And you wanna make sure that you're very, very careful with that instrument not to burn a hole inadvertently in other structures, cause it does generate heat.

Also be aware if you've got a normal, you know, say cryptor in a small testicle, it doesn't take a whole lot of heat to transect it. If you've got a bigger structure like this granulosa cell tumour, oftentimes you need to come across with multiple bites, and that generates a little bit more heat. You can kind of see the small colon peeking in the background, and we're quite close to it, even though we've insufflated the abdomen.

So you just wanna be a bit careful. All right, let's see what else we've got. This is kind of the cauterised edge that you'll leave on the tissue.

OK. So, If you do, if you do find that you've got a peritonitis, I do think early identification is the most important thing. Oftentimes, what these horses will show you post-surgery is a fever that initially isn't all that important.

Maybe it's 101, 102, but it becomes a sustained progressive fever. All right? I think the ultrasound is a great tool.

To look at horses and look, especially at their site of surgery. So sometimes it's not a full-blown peritonitis where the guts are sitting in, you know, litres of fluid on the, and floating in the abdomen. Sometimes what you will see is kind of a focal collection of kind of hyperchoic fluid on the ultrasound, right at the surgical site.

And I think oftentimes that can be managed, with both abdominal lavage and continued antibiotic therapy. Right? We do, in, in the cases I've had with peritonitis, we do a lot of abdominal lavage via, these chest strains.

They're essentially 32 gauge French drains that we placed in the abdomen. And then we'll hang, say 10 to 20 litres of sterile saline or LRS . In you know, kind of an ingress portal and an egress portal.

Here's the egress portal on the ventral. Sometimes we'll put an ingress portal kind of at the parallel bar fossa where we made one of the trocar incisions, and then you can simply run 20 to 30 litres of saline into the ingress and lavage that abdomen without having necessarily to go to surgery or doing it, you know, maybe a post-surgical exploration. So I, I am very cautious.

It's, it is not unusual to have a small fever maybe the day or two after a laparoscopic procedure, but it should go away and it should come down. I, I don't often find fevers in my horses that I do, in, Cryptor is with, and I think part of the difference is the CO2 causing a little bit of a chemical peritonitis in their abdomens. All right, body wall complications.

I've had some of these. This horse is a crypt orchid that was done in the field, within about 48 hours, he became very depressed, febrile, and actually started sloughing his, Inguinal incision. This horse had developed a clostridial infection.

We could not save this horse. As you can see, he has just continued to dehis along his ventral abdomen. He developed a necrotizing fasciitis, .

Thankfully, this owner, the veterinarian who performed this crypt orchid in the field, had actually asked the owner to come into the hospital and thought it would be better. The owner had turned that down just, because of finances, and then we had this catastrophic outcome. Thankfully, I, I've only seen that once in my career, but it is a A great indication of if the horse is of a certain value and the owner is willing to provide a better level of care.

I do think it's nice to be in a hospital if you're going to go into the abdomen. With the laparoscope, I think, we have some other issues that make it a little bit more complicated with body wall issues. When you're first learning laparoscopy, it's easy to have trouble to get across, the body wall, the peritoneum, and into the abdomen.

Sometimes what happens if you're not, I don't wanna say aggressive. If you're not conclusive enough when you enter the abdomen, you might actually be stripping the peritoneum and then find yourself insufflating carbon dioxide in between the peritoneum and the muscle as opposed to inside the abdomen. .

There are some horses that confirmationally I think are a lot more difficult. Thoroughbreds are typically, young thoroughbreds are a lot nicer to work on than some of the fat older quarter horses. I get, they don't have as much of a, a waist or a para lumbar fossa.

This diagram here is kind of, this is our tuber coxate, this is our last rib. The, this would be a portal portal here, third portal. Once the testicle is transected, we tend to connect, these two portals and, and bring the testicle out through the abdomen.

. Also, sometimes you find you haven't quite made your portals in the right place and it's hard to get done what you need to do. And so that's also, I think a part of, you know, I typically warn owners, we'll start laparoscopically. Usually we get the job done, but every once in a while, you know, I might need to close this horse and then make another approach under general anaesthesia.

All right? This is a good example of body wall problems. This was actually a mare that had a septic ovary.

In our coral horse population, we have a lot of assisted fertility techniques. This mare had undergone aspiration of oocytes from her ovary over time and had developed this lovely little ovarian abscess. The surgeon working on her had attempted to bring it through a normal portal.

It ruptured, causing Her to have a septic peritonitis, and again, kind of a necrotizing fasciitis. You can see, this, this mirror was in a life-threatening situation when she came to us. There is really nothing between here and the abdomen, and we don't have a whole lot to do other than to place drains, and try to debride dead tissue.

We ended up putting stents over this. This mayor went on to develop a septic track that ran through her body wall behind her ribs. In the end, this is, what that track looks like on the laparoscope.

We could at some point feed the laparoscope through this tract. We ended up having to resect two small portions of rib, remove this dead tissue and put a wound back on her after she resolved her peritonitis. So the complications are there, you know, thankfully they don't happen often, but it's, when they do happen they can be pretty scary.

Along with body wall complications, we have found horses that have been operated previously, who sometimes adhere a piece of bowel, to their body wall or to other structures. Let's see if I can play this video here. All right, so we're in the abdomen.

This is a crypt orchid that somebody had made an inguinal approach on, but could not quite get all of the testicle out and so abandon it. And as we're looking here, There's a part of the epididymis available in the background, and you can see that there is adhesions of that testicle and epididymis to the body wall. I'm going to fast forward it just a little bit.

We're going to get, there's a nice view of the adhesion. All right. Here is a grasping forcep, atraumatic.

We've introduced it to the abdomen and we're going to put it on that testicle. In a second. Let's see if I can advance that just a little bit.

All right, so we're grasping it. There's the testicle, there's the epididymis, and we get a nice bite and look. Whoops, we're stuck.

All right. So that's not gonna come out through any normal approach, right? And what we're gonna have to do is go in with the ligature and actually kind of ligature it off the body wall and pull it through.

Let's see if I can get you a picture of that. There's We're blocking there. Trying to numb it up before we get our ligature, trying to grasp away.

Actually using shears there. To kind of remove that adhesion so that we can free that testicle up and make him go. And they bleed quite a bit, which does kind of inhibit your visualisation.

So really just stripping the peritoneum, you know, that adhesion off between the peritoneum and the testicle. In the lower image on the right side of the screen, there is a horse that got peritonitis, post inguinal approach that had an adhesion of his small bowel to his inguinal area. When that horse, got his bowel full and tore that adhesion, he leaked in his abdomen, causing a peritonitis, and clearly that's a, a cropsy specimen there.

All right, let's see. I think we've got one more topic to cover, colitis. I've had this happen in, patients that go through either an inguinal approach or a laparoscopic approach.

I do think that this is a patient population that can be stressed. Oftentimes they're young horses unhandled. We bring them into a hospital environment.

We give them antibiotics. In the case of the laparoscopic surgery, we modify their diet. When I first started doing laparoscopic surgery, I, I think I was a bit nervous about it and I just chose to really empty them out.

And I would starve them for, sometimes I would take their hay away for 48 hours, and then they concentrate away for 24. I don't, and while that was nice, I think I added a little bit of stress to these horses' lives, and I would So I would get horses that had colitis. So what we've learned is kind of a balance with a fasting protocol.

I oftentimes have their owners at home, remove hay from their diet and switch them over to a, a complete feed such as equine senior, maybe a day or two before, to bring the horse into the hospital so that they're fasted really before they ever get to the hospital. And that has worked out a little bit better. I don't know if there's ever a safe antibiotic protocol.

I think you can get a colitis, related to antimicrobial use from all antibiotics, but I found at least in our geographic area, the use of, penicillin and genicin, has been a safer protocol. And again, most horses get a dose, one dose of genicin and a dose of penicillin before and after surgery, and that's it. We're also pretty aware that if we do think that we're getting a colitis, we're pretty quick to DC the antibiotics and start some things like probiotic, Some of the Other things that you can, you know, give like yoghurt with oh gosh.

This is, yeah. Anyways, we, we're pretty quick to hop on them if, if we think they're developing a colitis. So, and we also try to limit stress.

So sometimes that's the horse goes out for walks. The horse, you know, goes in a barn that's maybe a little quieter. Sometimes the ones that know they're a stallion, they get really ramped up if they're around mares.

So we just, you know, are a little conscientious about what we can do. Well, that is the end of my presentation. Thank you so very much for your attention.