laparoscopy assisted nephrectomy in a standing horse suffering from nephrolithiasis

Abstract

ZusammenfassungIn der Literatur werden für die Nephrektomie beim Pferd neben der konventionellen Technik in Allgemeinanästhesie zwei laparoskopische Operationsmethoden am stehenden Pferd beschrieben. Im Rahmen von experimentellen Arbeiten publizierten Marien (2002) eine laparoskopische und Keoughan et al. (2003) SummaryIn the literature several surgical techniques for nephrectomies in the horse are described. In addition to the conventional surgical methods, two experimental studies about laparoscopic nephrectomies in the standing horse have been published. This study presents the first clinical case of laparoscopic nephrectomy of a patient with nephrolithiasis of the left kidney. A 12 year-old warmblood gelding was referred to the clinic with an exercise related haematuria of 8 weeks duration. Presurgical examinations led to a diagnosis of nephrolithiasis affecting the left kidney. No other clinical abnormalities were detected. For the surgical procedure the horse was restrained in standing stocks and sedated with detomidine hydrochloride (0,01 mg/kg iv) and levomethadone (0,05 mg/kg iv) and the sedation was maintained with romifidine (0,01 mg/kg iv) throughout the procedure. Paravertebral anaesthesia was undertaken and lokal infiltration was performed with 20 ml lidocaine 2% at each surgical site in the left paralumbar fossa. A laparoscopic nephrectomy requires 3 separate portals. The first portal for the optic trocar was placed in the 17th intercostal space at the ventral border of the tuber coxae. The instrument portal was created 2-3 cm caudal to the 18th rib again level with the ventral margin of the tuber coxae. Through this portal, the laparoscopic injection needle was inserted and subperitoneal infiltration of the perirenal peritoneum was performed using 20 ml of local anaesthetic (2% lidocaine). The perirenal peritoneum was then incised at the caudo-ventral aspect of the left kidney with laparoscopic scissors. To allow a handassisted surgical procedure at this point a third portal (as a mini-laparotomy) was created 5 cm caudal to the second one. With the inserted hand the peritoneal incision was bluntly enlarged under visual control so that the kidney could be detached from the retroperitoneal fat to expose the ureter and the renal vein and artery. As the renal vein and artery could not be separeted from each other they were ligated manually and using instruments as a bundle in 4 places and transected. The ureter was sutured in 3 places and transected. The mobilized and because of the nephroliths enlarged kidney was exteriorized through the third portal which had to be extended vertically (21 cm). The three surgical sites were closed in multiple layers, the intra-abdominal retro-peritoneal wound was not sutured. A 10 day course of ceftiofur-sodium (2,2 mg/kg im once daily) and flunixin-meglumine (0,5 mg/kg im twice daily) and 10 ml Phytorenal ® (Selectavet) per os once daily was initiated pre-operatively. One day post surgery the horse`s general demeanour was slightly reduced but improved the next day...

Hand-assisted laparoscopic nephrectomy for the treatment of ureterolithiasis and nephrolithiasis in an adult horse

“…A loss of at least 50 % of nephrons is required to cause pathologic changes in serum urea, creatinine or urine specific gravity (Ferguson et al 2007). Therefore, a functional assessment of mixed urine from both kidneys is often unremarkable in unilateral disease (Röcken et al 2005). Although a urine analysis was performed in this case, evaluation of split renal function would have been more valuable.…”

“…Although a urine analysis was performed in this case, evaluation of split renal function would have been more valuable. This can confirm unilateral kidney disease, while at the same time checking the health of the contralateral kidney (Röcken et al 2005). In this case, identification of the right ureteral opening to the bladder on endoscopy was problematic.…”

“…Moreover, the hand-assisted laparoscopy allows surgeons to perform the surgery more efficiently (Keoughan et al 2003). During evisceration of the kidney, manipulation can cause trauma to the abdominal wall and the kidney, and therefore contamination of the abdomen and incisional complications like seroma formation (Röcken et al 2005). In human surgery, renal morcellation before abdominal retrieval is described to significantly reduce post-operative pain and clearly reduce incisional complications (Rijkenhuizen 2008).…”

“…Right ureter, artery and vein were manually freed and triple ligated with extracorporeal knots using 5 metric Polyglactin 910 (Novosyn) under laparoscopic visualisation and transected using a vessel sealing device (Ligasure) 5 . The renal vein and artery could not be separated, as was described in the case of Röcken et al 2005, therefore they were ligated as a bundle. No accessory branches to the renal artery were identified.…”