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In September 2008 an adult female brown bear (Ursus arctos), one of the five brown bears living in the bear area of the Rome Zoological Garden (Fondazione Bioparco di Roma) showed apathy and slight purulent discharge from the reproductive tract. The diagnosed pyometra was approached by laparoscopic ovariohysterectomy. |
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K. G. Friedrich1, L. Pazzaglia2, M. Valente3, G. Costamagna4
1Clinica Veterinaria del Bioparco di Roma, Viale del Giardino Zoologico, 20, 00197 Roma, ITALY
klaus.friedrich@bioparco.it
2Clinica Veterinaria Galilei, Via B. Franklin, 22, 59100 Prato, ITALY
3Ambulatorio Veterinario di Diagnostica Endoscopica e Chirurgia Mini Invasiva, Via delle Tre Madonne, 4, 00197, Roma, ITALY
4Endoscopia Digestiva Chirurgica, Università Cattolica del Sacro Cuore, Largo Gemelli, 8, 00100 Roma, ITALY
Summary
In September 2008 an adult female brown bear (Ursus arctos), one of the five brown bears living in the bear area of the Rome Zoological Garden (Fondazione Bioparco di Roma) showed apathy and slight purulent discharge from the reproductive tract. The diagnosed pyometra was approached by laparoscopic ovariohysterectomy. The access to the abdominal cavity was performed through 4 access ports (trokars) and the organs were manipulated with endosurgery instruments and by moving the animal into the Trendelenburg’s position and laterally. Rapid and exact dissection and haemostasis of the blood vessels in the mesovarium and in the mesometrium was possible with the use of a harmonic scalpel (Harmonic Scalpel LCSC-5, Harmonic Scalpel, Ethicon Endosurgery, U.S.A) and ultrasonic generator (Harmonic Scalpel, Ethicon Endosurgery, U.S.A.). Time of surgery was limited to 51 minutes. The retrieval of the dissected reproductive tract was achieved through one enlarged access port (35 mm) performing a mini-laparotomy. The recovery of the animal was uneventful and the day after the bear was released again in the exhibit. In consequence, the laparoscopic surgical approach can be performed safely not only in healthy animals as described in literature previously, but also in the case of an old animal in critical health conditions. General advantages of minimally invasive surgery are reduced tissue trauma, less pain and short recovery after surgery, with reduced postoperative care requirements.
Introduction
Pyometra is an accumulation of purulent material within the uterus. The uterus is influenced by progesterone produced by the ovarian corpora lutea. Cystic hyperplasia of the endometrium is an abnormal uterine response developing during diestrus (Fossum,t w, 1997). Cystic endometrial hyperplasia in the domestic dog can result in either pyometra, haematometra or hydrometra and many facets of these uterine diseases make the clinical diagnosis difficult. The conditions differ in their systemic effects, since pyometra can be a life-threaten condition that must be recognized, managed and treated expeditiously (Prezter, S D, 2008). In 1997, a Japanese team of surgeons first published the successful laparoscopy assisted ovariohysterectomy in two dogs with pyometra (Minami et al, 1997). Laparoscopic surgery is today well established in human medicine, its use is published also in veterinary surgery and has been developed especially in equine surgery, but limited reports are published on the use of laparoscopic surgery in wild animals and zoo mammals. It has been mainly described for diagnostic purposes, artificial insemination and surgical reproduction control (Bush M, 1978; Bravo P W, 1991; Aguilar R F et al., 1997; Bernhard A et al., 1999; Fowler M E ,1999; Kaandorp S, 1997; Rudnick J C, 1999; Kolata R J, 2002; Maclean R A, 2006). General advantages of laparoscopic surgery for ovariectomy and ovarihysterectomy compared to laparotomy in dogs are reported in literature and include pain reduction, minimal tissue lesion and fast recovery of the animals after surgery (Davidson E B, 2004; Hankock R B, 2005; Devitt C M, 2005; Nickel R F, 2008). Laparoscopy as a minimal invasive technique seems to be still underestimated for many other potential applications in the field of zoo and wildlife surgery, compared to the possible applications, since Cook R A and Stoloff D, published in 1999 a very comprehensive article on “The Application of Minimally Invasive Surgery for the Diagnosis and Treatment of Captive Wildlife” (Fowler M D, 1999).
The present paper reports the successful surgical treatment of a female brown bear (Ursus arctos) with an open pyometra at the Rome Zoological Garden (Fondazione Bioparco di Roma) in September 2008. It was elected to use laparoscopic surgery in this clinical case due to the well known advantages of minimally invasive surgery, taking into account also that a bear would possibly lick the laparotomy wound. The bear’s advanced age, the risk of developing a closed pyometra and the difficulties anticipated in treating a bear without sedation were additional reasons for exploring alternative solutions to laparotomy which would still provide a permanent curative result to the animal’s pyometra. Our previous experience with laparoscopy in this species was at that time based on six laparoscopic surgeries for ovariectomy in brown bears for reproduction control purposes.
Case report
The intact, 30 year old, 140 kg female brown bear (Ursus arctos), was reported as sick by the zoo keeping staff. She was anorectic and lethargic and small quantities (+/-10 ml) of bloody discharge from the reproductive tract had been found on the floor of the bear den. This animal had given birth to two offspring prior to 1998 and lived together with another female and three castrated males in the brown bear exhibit of the Zoological Garden of Rome. On the day of first clinical evaluation, pyometra with an open cervix was considered and the animal was treated with a combination of amoxilllin and clavulanic acid 10 mg/kg body weight (Synulox, Pfizer Italia S.r.l.) and enrofloxacin 5 mg/kg body weight (Baytril 10%, Bayer) administered by blowpipe darts (Teledart, Germany). The date for anaesthesia and following ultrasound examination, radiology and blood analysis was fixed for the day after. To reduce time of recovery and minimize postoperative care requirements, it was decided to proceed by laparoscopic ovariohysterectomy as this would cause minimal tissue trauma and less discomfort to the animal when compared to the 40 cm midline incision required for a laparotomy.
The advanced age of the female and her critical clinical condition, as far it could be evaluated from distance, meant it was important to reduce surgery time as much as possible and we were prepared for a possible conversion to open surgery. Anaesthesia was achieved 20 minutes post administration of 0,05 mg/kg body weight of medetomidine HCl (Zalopine, Orion) plus 2 mg/kg body weight of tiletamine and zolazepam (Zoletil 100, Virbac S.r.l) by blowpipe with 5 ml darts (Teledart, Germany). After evaluating reaction from distance, the animal was approached and moved to the veterinary clinic, where a n° 12 endotracheal tube (length: 50 cm) was inserted and anaesthesia was maintained by oxygen (flow 8 Lit. ) and 1,5% isofluorane (Isoflurane-Vet, Merial). Vital parameters were recorded by a patient monitor (CMS-8000 ,Contec, China). pulse rate was between 60-65/min., respiratory rate was 8-9/min., 89-99 % SpO2 and 32-40 mm Hg PaCO2. Intravenous access was obtained and the blood glucose level determined at 127 mg/dl (Glucose mean reference value in this species and age group: 109 mg/dl, ISIS, Physiological Reference Values,1999). The equipment required for laparoscopy comprised of a complete endosurgery tower with monitor, video processor (Olympus OTV-S7V, Olympus, Germany), light source (Olympus CLV-S30), insuflator (Stryker Endoscopy Insuflator, Stryker, U.S.A.), ultracision generator (Harmonic Scalpel, Ethicon Endosurgery, U.S.A.), electrosurgical device (Ma 400, Martin Electrosurgical Units, Germany), a 10mm/0° Laparoscope (Olympus, Germany) and the following instruments for endosurgery; two grasping forceps (Ethicon Endosurgery, U.S.A), one pair of endosurgical scissors (Stryker, U.S.A.), one Babkock forceps (Karl Storz, Germany), one palpation probe (Karl Storz, Germany), one harmonic scalpel hand piece (Harmonic Scalpel LCSC-5, Harmonic Scalpel, Ethicon Endosurgery, U.S.A) and the following trokars: two Ternamian EndoTip 10 mm trokars (Karl Storz, Germany), two 5 mm trokars (mtp 5,5 mm/ length 53 mm, Karl Storz, Germany), one Verres needle (Karl Storz, Germany) and two Endoloops (Endoloop Ethicon Endosurgery, U.S.A).
Swabs were taken form the vaginal discharge and submitted for bacteriological culture. The animal was positioned on the table and prepared for surgery, a silicon tube was inserted in the uterus through the cervix and a 2% Lotagen solution (Lotagen, Schering-Plough) was irrigated after uterine lavage and aspiration of approximately 100 ml of purulent material. This preparation was done to reduce the volume of the uterus, trying to keep the incision of the abdominal wall as small as possible and extract the dissected uterus and both the ovaries by a single mini-laparotomy.
A Ternamian EndoTip 10 mm trokar was inserted at the umbilical level, after insufflation of the abdominal cavity with a pressure of 12 mmHg of CO2 through the Verres needle. The pneumoperitoneum offered the possibility to obtain an accurate view of the abdominal cavity through the 10mm/0° laparoscope inserted in the first trokar. The second 5 mm trokar was placed, under visual control, 5 cm lateral to the umbilicus and the third 5 mm disposable trokar was inserted 5 cm caudally on the midline. A forth 10 mm Endotip trokar was inserted under visual control, caudally over the bifurcation of the uterus to facilitate the fixation of the uterus during surgery and offer the possibility for triangulation of the instruments. The operation table was moved into the Trendelenburg’s position and the animal tilted at 25° with the head down. At this stage the uterus and the urinary bladder were visualised. On observation, the uterus was a greyish colour and on palpation with the palpation probe the organ showed an abnormal consistency. To identify the ovaries without traction on the suspensory ligament, the bear was placed respectively in a right and a left oblique position.
Two pairs of grasping forceps inserted through the trokars, were used to manipulate the uterus without any laceration of the impaired organ. With the support of an ultracison generator the dissection of the suspensory ligament of both ovaries was obtained and the relative vessels were coagulated without any bleeding. The mesometrium was resected after suspending the uterus at the biforcation with a grasping forceps, inserted in the abdomen through the fourth access port positioned caudally, obtaining an optimal view and keeping out of the way the mesenterial structures. The dissection of the mesometrium was done on both sides of the uterus in craniocaudal direction and parallel to the uterine horns, while coagulating the encountered vessels of the mesometrium. Two Endoloops were inserted over the uterine horns and body and tied caudally to the cervix. Following dissection of the cervix was performed with the support of a harmonic scalpel hand piece and an electrosurgical device. At this point the entire reproductive tract was dissected and the left ovary was grasped with Babcock forceps at the junction between the ovary and the uterus horn and pulled towards the caudal port. The caudal trokar was extracted over the forceps and the incision was enlarged up to 35 mm with blunt ended Metzenbaum scissors to allow the complete extraction of the reproductive tract. Through the enlarged port (35 mm) the left ovary, the left uterine horn, the cervix, the right uterine horn and the right ovary were extracted.
Before reducing the pneumoperitoneum the bear was returned to the dorsal recumbent position, and an accurate visual assessment of the abdominal cavity was performed to evaluate bleeding or lesions secondary to ultrasonic and electrosurgery use. The four incisions were closed in two layers and the skin was closed with tissue glue (Dermabond ©). In this way no external surgical knots were present and the skin completely sealed. Tramadol 2mg/kg body weight (Contramal, Formenti S.r.l) and ketoprofen 1 mg/kg body weight (Vet-Ketofen, Merial) were both adiministered IM once. Ketoprofen was continued by oral administration on the following three days at a dose of 1 mg/kg body weight.
After surgery the bear was transported to its den, connected to a portable gas anaesthesia machine (J.Lewis, IZVG) and monitored during recovery after administration of atipamezol HCl 0,2 mg/kg body weight IM (Antisedan, Pfizer S.r.l.). The animal recovered uneventfully and regained a sternal position within 16 minutes of administration of the antagonist. She was released onto exhibit the day after surgery. Total time of anaesthesia, from the first dart administration to recovery to sternal position, was 136 minutes and total surgery time, from the insertion of the first trokar to the closure of the last access port, lasted 51 minutes. In the days and weeks after surgery the animal was observed by veterinary and keeping staff and showed no signs of pain, wound licking, nor any wound infection. It was possible to visualise the the incisions close up by offering some honey to the animal and stimulating it to stand up in bipedal position and show the abdomen. The animal was treated for other six days SID with a combination of amoxicillin and clavulanic acid 10 mg/kg body weight and enrofloxacin 5 mg/kg body weight administered by blowpipe darts.
Results and discussion
Pseudomonas aeruginosa, Citrobacter freundii and Escherichia coli were cultured from the uterus and histology confirmed cystic endometrial hyperplasia. The choice to perform a minimally invasive surgery in this case had a positive outcome. We were aware from the beginning that conversion to open surgery might be required at some stage, especially if the manipulation of the uterine body had led to laceration and consequent contamination of the abdominal cavity. The advantage of the laparoscopic approach is the short operation time compared to laparotomy and the limited need for large abdominal incisions. In this case it was necessary to enlarge one of the ports up to 35 mm to retrieve the dissected reproductive tract. Laparotomy would require a midline incision up to 40 cm, more time to suture the incision and have much higher risk of pain, wound licking and the possibility of post operative wound infection. Anaesthesia was uneventful and the Trendelenburg’s position and insufflation with CO2, did not influence the quality of the anaesthesia as far as recorded. The familiarity of the surgeons with this procedure and the use of electrosurgery and ultracision coagulation shears, reduced the total time of surgery to 51 minutes. In the case of wild animals such as brown bear, remote injection, security measures and total transport time to and from the veterinary clinic on the zoo ground, obviously resulted in an elevated total anaesthesia time, which would have been difficult to reduce further. The need of prolonged isolation due to postoperative care and observation is limited and this is another important welfare issue to remember.
We conclude that the laparoscopic surgical approach can be performed safely not only in healthy animals as described in literature previously, but also in the case of pyometra in an old animal in critical conditions, if surgery time is kept short, the uterus tissue is not too fragile to risk laceration and if the volume of the uterus is not extended to a point that conversion to laparotomy is mandatory.
Acknowledgements
Special endosurgical equipment was supplied generously by Olympus Europe and made this work possible. We thank especially Mr. Andreas Quistorf and Mr. Frank Drewalowskii from Olympus for their enthusiastic and concrete support.
References
AGUILAR R F, MIKOTA S K, SMITH J, MUNSON L, FREEMAN L J, KOLATA R (1997): Endoscopic ovariohysterectomy in two lions, J. Zoo Wildl. Med. 1997 Sep;28 (3): 290-7
BERNHARD A, EULENBERGER K, ZIEMANN U (1999): Microinvasive Sterilisation beim weiblichen Mantepavian (Papio hamadryas), Tagungsbericht der 19. Arbeitstagung der Zootieraerzte im deutschsprachigen Raum,161-164,
BRAVO P W, SUMAR J, (1991): Evaluation of intra-abdominal vasectomy in llamas and alpacas, J.Am Vet.Med. Assoc. 199(9), 1164-1166
BUSH M, WILDT DE, KENNEDY S, SEAGER S W (1978): Laparoscopy in zoological medicine, J. Am. Vet. Assoc. 1978 Nov 1;173(9):1081-7
DAVIDSON E B, MOLL HD, PAYTON ME (2004) Comparision of laparoscopic ovariohysterectomy and ovariohysterectomy in dogs. Vet Surg. 2004 Jan-Feb;33(1):62-9.
DEVITT C M, COX RE, HAILEY JJ. (2005): Duration, complications, stress and pain of open ovariohysterectomy versus a simple method of laparoscopic-asssited ovariohysterectomy in dogs.J.Am.Vet.Med.Assoc. 2005 Sep 15;227(6):921-7
FOSSUM, T W (1997): Small Animal Surgery, Mosby Edit., 544-549
FOWLER M E (1999): Zoo and Wild Animal Medicine, current therapy, 4th ed., Philadephia,Saunders, 30-40
HANKOCK R B, LANZ OI, WALDORN DR, DUNCAN RB, BROADSTONE RV, HENDRIX PK (2005) Comparison of postoperative pain after ovariohysterectomy by harmonic scalpel assited laparoscopy compared with median celiotomy and ligation in dogs. Vet Surg. 2005 May-Jun;34(3):273-82
ISIS; Physiological reference values,1999,
KAANDORP S (1997): Laparoskopische Sterilisation bei Primaten, Tagungsbericht der 17. Arbeitstagung der Zootieraerzte im deutschsprachigen Raum, 127-130,
KOLATA R J (2002): Laparoscopic ovariohysterectomy and hysterectomy on african lions (Panthera leo) using the ultracision harmonic scalpel, J.Zoo. wildl. Med. 2002 sep;33(3):280-2
MacLEAN R A, MATHEWS NE, GROVE DM, FRANK ES, PAUL-MURPHY J (2006): Surgical technique for tubal ligation in white- tailed deer (odocoileus virginianus), J. Zoo Wildl. Med. 2006 Sep; 37(3): 354-60
MINAMI S, OKAMOTO Y, EUGUCHI H, KATO K (1997): Successful laparoscopy assisted ovariohysterectomy in two dogs with pyometra, J. Vet Med. Sci. 59(9): 845-847
NICKEL R F (2008): Kastration bei der Huendin – Eine Diskussion zur Indikation, chirurgischen Techniken, Nebenwirkungen und Komplikationen, Spektrum Tiermedizin, Veterinaerspiegel Verlag GmbH, 16, 2008, 3 -14
PRETZER S D (2008): Clinical presentation of canine pyometra and mucometra: a review. Theriogenology, 2008 aug;70(3):359-63
RUDNICK J C, BIRKE H, BROSCHEWITZ U, LINKE K, ZIEMANN U. (1999) Endoskopische Sterilisation beim Orang Utan mit anschliessender unilateraler Adnexektomie, Tagungsbericht der 19. Arbeitstagung der Zootieraerzte im deutschsprachigen Raum, 164-171
Dr. med. vet. Klaus G. Friedrich
Head of Veterinary Service
Fondazione Bioparco di Roma
V.le del Giardino Zoologico, 20
00197 Roma
Italy
klaus.friedrich@bioparco.it
info@chirurgiaveterinaria.com
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