A New Experimental Laparoscopic Stapled Gastropexy in the Dog Combined with Intracorporeal Knot Tying
*Sanchez Margallo, Francisco M, SORIA GALVEZ, Federico, Uson Gargallo, Jesus
*Centro De Cirugia De Minima Invasion, Avda. Universidad s/n
A number of procedures designed to permanently adhere the stomach to the body wall have been experimented in veterinary medicine. The main clinical application of this surgical procedure is the prevention of GDV (gastric dilation-volvulus syndrome) relapses in the dog. Recently, several authors have indicated laparoscopic surgery as an alternative to the conventional surgical abdominal approach to this disease in the dog. As a contribute to this subject and convinced of the positive potential of laparoscopic surgery in the treatment of GDV in dogs, the authors propose a technique of laparoscopic gastropexy with combined stapler and intracorporeal knot tying in three normal dogs.
Three healthy male dogs were used (18,16+3,55 Kg). The dogs were placed in dorsal recumbency and a technique of four-trocars was used. After obtaining the pneumoperitoneum, the abdominal cavity was explored and the gastric antrum was located. The antrum was grasped with a laparoscopic Babcock forceps, the hepatogastric ligament was transected with scissors or laparoscopic hook. A seromuscular incision was made in the antral region and a 3 x 4cm tunnel was obtained. The pressure of inflation was reduced to 10-12 mm/Hg, to avoid the induction of subcutaneous or intramuscular emphysema during the peritoneal and muscular wall incision. Using hook scissors, the incision was made in the peritoneum and muscular layer of the abdominal wall, 3 cm caudally to the last rib and 10 cm laterally to the ventral abdominal midline. The two tunnels were apposed and the stapler device (Endo-GIA) was activated and extracted. An incisional gastropexy resulting in the adhesion of the peritoneal layer of the abdominal wall with the gastric serosa was obtained. By gastroscopy, the stomach was inflated to rule out a perforation of the gastric mucosa. The fistula resulting from the anastomosis of the two tunnels was closed with an intracorporeal simple, interrupted suture pattern of 2/0 or 3/0 non-absorbable suture material. The pneumoperitoneum was resolved and the trocars were extracted. The incisions in the abdominal wall were closed routinely in double layer. The dogs were clinically evaluated 30 days after surgery. After 30 days of surgery, post-mortem examination was performed in all cases.
In the three cases here described the laparoscopic surgical procedure lasted 73"b10,53 minutes. No particular intraoperative difficulties were encountered. The complications reported for laparoscopic gastropexy, including gastric or splenic perforation, splenic puncture and subcutaneous emphysema, were not observed in the three dogs considered. Patients showed a normal alimentary habit after surgery and their body weight and clinical conditions remained normal during the study. The results of this study are similar to that obtained by other authors with laparoscopic gastropexy. The functional studies of the gastropexy showed a satisfying fixation of the operated area and, macroscopically, a permanent adhesion of the antrum to the area to the body wall was present in all cases. The extension of adhesions in the laparoscopic technique is similar to that obtained in the open gastropexy. Advantages of laparoscopic incisional gastropexy are avoiding the penetration into the gastric lumen, and the creation of a strong fibrous connective tissue between the muscular layer of the abdominal wall and the antrum. At post-mortem examination, gastropexy appeared as a strong permanent adhesion between the stomach and the abdominal wall in all three dogs. A connective tissue layer indicating complete scarring covered the area of suture.
As concluded by other authors and considered the low incidence of postoperative complications and the prompt recovery of patients, we think that laparoscopic gastropexy could be considered as a valid alternative to the traditional prophylactic open gastropexy. The similarity of results in this and other studies suggests that the strength of the adhesion allows prevention of gastric rotation. A disadvantage of this procedure is the longer operating time, mostly related to the need of training in the technique of intracorporeal suture. More experimental and, mostly, clinical studies are needed to confirm the efficacy of laparoscopic incisional gastropexy versus the conventional open technique. Furthermore, the clinical application of laparoscopic gastropexy requires that conditions such as an appropriate patient's clinical status and death risk, together with surgeons experience with the technique, are present. It should be kept in mind that the laparoscopic technique requires longer operating time and that high risk patients would benefit of shorter anaesthesia and surgery time.