A primer on advanced laparoscopy in small animals

By Ashley Villatoro, DVM, DACVS-SA

Veterinary laparoscopy has flourished within the past few decades. Comparable or superior outcomes to the open approach, positive owner perception, and the familiarity and accessibility of equipment have expanded the use of laparoscopy. It is important for the veterinary community to be familiar with these advanced applications to allow for appropriate patient referrals.

Owners who would decline a more invasive surgery might be open to a minimally invasive option if presented to them. Given a choice of an open or laparoscopic procedure in one study, 92 percent of pet owners elected the minimally invasive option, even with a significantly higher price point.¹

Laparoscopy is advantageous due to quicker healing time, smaller incision size with inherent decreased incisional complications, quicker time to discharge, and decreased post-operative pain.^2-5 With expanded usage of advanced imaging in veterinary medicine, an increase in diagnosed conditions with a concurrent rise in need for biopsy and definitive surgical procedures has occurred.

Laparoscopy for advanced biopsy procedures

Laparoscopic liver biopsy

Laparoscopic liver biopsies are commonly performed to further investigate chronically elevated liver enzymes, liver dysfunction, and neoplastic, inflammatory, infectious, or metabolic liver processes (Figure 1). Multiple liver samples can be collected simultaneously via laparoscopy for evaluation by histopathology, heavy metal testing, and bacterial or fungal culture. A cholecystocentesis can be performed concurrently, with direct visualization and evaluation for biliary leakage post-aspiration.

In cases of advanced liver disease, liver function is often compromised, which can affect intra- and post-operative complications, such as delayed healing, hemorrhage, and anesthetic changes.^6-8 An advantage of laparoscopy is the direct visualization of the biopsy site with the ability for hemorrhagic control, as hemorrhage is increased in patients with liver disease. Smaller incision size allows for quicker closure and minimizes anesthetic time.

Limitations of laparoscopically obtained liver biopsies include the inability to target intra-parenchymal lesions not grossly visible during laparoscopy. However, recent literature has described and evaluated laparoscopic ultrasound, showing it to be superior to transabdominal ultrasound in detecting lesions.⁹ Adoption of routine laparoscopic ultrasound combined with laparoscopic procedures allow for even more precise targeting of lesions.

Laparoscopic renal biopsy

Renal disease is commonly encountered in dogs and cats, and different modalities for renal biopsy exist. Laparoscopic renal biopsies offer several advantages over other modalities of renal biopsy. Unlike ultrasound-guided percutaneous biopsies, laparoscopy allows for direct visualization of the kidney cortex and increased planes of biopsy for more targeted sampling. Laparoscopic renal biopsies allow the use of alternate biopsy tools for increased precision sampling of the renal cortex and superior diagnostic samples.

A study comparing 5-mm laparoscopic cup biopsy forceps to the traditionally used core needle biopsy, revealed that there was an increased amount of glomeruli obtained using the cup biopsy forceps.¹⁰ With laparoscopy, larger needle biopsy tools with improved diagnostic quality can be used with less concern for continued hemorrhage.¹⁰ This is due to the ability to laparoscopically place a capsular suture or apply a hemostatic agent to the biopsy site directly if hemorrhage occurs, which is not feasible otherwise.

Renal biopsy can also be paired with therapeutic procedures, such as deroofing or omentalization of renal cysts, which have been reported with favorable outcomes.^11-12

Laparoscopic-assisted GI tract biopsies

Gastrointestinal (GI) biopsies are often required for diagnosis and to develop catered therapeutic management of a variety of GI diseases. Due to the invasive nature of an abdominal exploratory, many owners hesitate to move forward with a surgical procedure that only offers diagnostic information without therapeutic benefit.

Post-operative pain management may be limited as use of opioids or non-steroidal anti-inflammatories can exacerbate the underlying GI disease. Laparoscopy is an attractive method to acquire full-thickness biopsies without a large abdominal approach, which can lead to increased morbidity post-operatively, such as dehiscence, seroma formation, or infection, compared to laparoscopy.

Limitations to the laparoscopic technique include the inability to directly palpate to detect intra-luminal disease in certain portions of the gastrointestinal tract (such as the stomach) and limited visualization of the entirety of the gastrointestinal tract.

Laparoscopic lymph node extirpation

Advanced imaging and the use of fluorescence have enabled the expansion of minimally invasive surgery to procedures previously performed as open surgeries. Recent literature has shown the feasibility of laparoscopic caudal abdominal lymph extirpation using indocyanine green fluorescence, which improves visualization and dissection of the nodes.^13-14 In older and more debilitated patients where two approaches may be necessary, such as with paired anal sacculectomy and caudal abdominal lymph node extirpation, laparoscopy can eliminate the need for a larger incision size and provide a quicker surgical time compared to open (Figure 2).

Laparoscopy for partial or complete organ removal

Laparoscopy has grown to allow for complex complete or partial organ removal. Pairing laparoscopy with other advanced real-time imaging techniques, such as cystoscopy, colonoscopy, or fluoroscopy, can aid in performing advanced surgeries previously only possible via an open approach or with laparoscopic assistance.

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy procedures have become a common surgical approach in small animals, primarily for gallbladder mucoceles but also described for other disease processes, such as cholelithiasis, cholecystitis, and associated masses.¹⁵

Laparoscopic cholecystectomy is typically recommended in elective cases with no biliary obstruction or rupture. However, a recent study that did not exclude patients with possible biliary obstruction or rupture reported a high success rate of 93 percent.¹⁵ The increased use of fluorescence, such as indocyanine green (ICG), has allowed for additional imaging techniques intra-operatively for better visualization (Figure 3). Cholangiography using ICG in combination with laparoscopic cholecystectomy can better illuminate the biliary tree,¹⁶ preventing iatrogenic damage and more precise dissection. Possible complications include the need for conversion in cases of biliary rupture, inability to ligate, or damage to the cystic duct.¹⁷

Laparoscopic adrenalectomy

For smaller-sized adrenal tumors without vascular invasion, laparoscopic removal has been reported to be safe with similar outcomes when compared to an open approach.¹⁸ Laparoscopy allows for excellent visualization of surrounding structures due to magnification. Laparoscopy surgical times are comparable to those of the open approach, pending the laterality of the side of the tumor and the surgeon's experience with laparoscopy.¹⁹

In patients with concurrent endocrine disease and possible delayed healing, smaller-sized incisions allow for less incisional morbidity. In a recent study, the outcome was described as excellent, with a low mortality rate of 9.4 percent in a study involving 100 dogs.¹⁹ Common reasons for conversion were capsular penetration and hemorrhage.¹⁹ If conversion is required, a paracostal approach may be elected for quicker entry into the abdomen, and experience in this approach is necessary. Laparoscopic adrenalectomy may not be possible in patients that are overweight and have larger tumors.¹⁹

Total laparoscopic or laparoscopic-assisted splenectomy

Splenectomy is a common procedure performed for associated masses, torsion, and adjunctive treatment of immune-mediated or infiltrative disease. Owners are often faced with a decision to move forward with a splenectomy for non-hemorrhagic splenic tumors encountered on imaging for a diagnosis. Although fine needle aspiration (FNA) can be performed, true diagnosis of pathology can only be achieved via biopsy. In the face of possible aggressive neoplasia with limited survival time, laparoscopic-assisted (Figures 4 and 5) or total laparoscopic splenectomy is attractive to owners, as it offers quicker recovery time and less post-operative pain.

A study of 136 dogs undergoing laparoscopic splenectomy had a low percentage of major complications, morbidity, and mortality. Conversion rates are reported to range from 0 to 5.9 percent for laparoscopic-assisted splenectomy.²⁰ Single-port laparoscopic splenectomy has been reported and is feasible for smaller masses (3-4 cm) in smaller-sized dogs (<20 kg).²¹ Laparoscopic splenectomy is not feasible for a hemorrhaging splenic-associated mass or larger diameter-sized masses.²²

Laparoscopic partial or total liver lobectomy

Laparoscopic liver surgery outside of biopsies includes partial or total liver lobectomy (Figures 6 and 7). With advanced imaging, appropriate cases for minimally invasive liver lobe resection can now be carefully pre-selected to achieve lower conversion rates and more successful outcomes. Preferred cases include peripherally located and smaller-sized tumors. Central and left-sided liver tumors were noted to be more feasibly removed compared to right-sided tumors;²³ however, recent investigation of a tran-diaphragmatic port can increase success for right-sided liver lobectomy.²⁴ In cases of inability for laparoscopic liver tumor resection, alternative treatment can be performed in a minimally invasive manner, such as microwave ablation.²⁵

Laparoscopic partial cystectomy

Partial cystectomies are indicated for biopsy or resection of bladder tumors, bladder diverticulum, or patent urachus (Figures 8 and 9). With advanced imaging, such as CT, cystoscopy, and fluoroscopy, more specific information on the location of the bladder abnormality and its association with surrounding anatomy allows for better case selection for laparoscopic partial cystectomy.

Resection of the bladder apex is feasible, with bladder closure via intracorporeal suturing alone or in combination with the use of a laparoscopic stapler or bipolar sealing device.²⁶ Laparoscopy only allows visualization of the serosal surface of the bladder, limiting the ability to resect intraluminal tumors. However, the use of cystoscopy concurrently with laparoscopy can allow for a view of the bladder lumen for exact tumor resection and to prevent iatrogenic damage to surrounding structures such as the ureters.

Additional procedures

Pexy procedures

Pexy procedures are performed for prophylaxis and treatment of organ displacement. Laparoscopic gastropexy is commonly performed as a prophylactic procedure to prevent gastric dilatation and volvulus. This procedure is typically performed at the time of sterilization by general practitioners. Unlike in a bitch, where the abdominal cavity is already open for ovariohysterectomy, male dogs require an additional approach for gastropexy. Laparoscopic gastropexy allows for a smaller incision size, which is desired as post-op incisional morbidity can be expected to be higher in a young and more active patient.

Cystopexy and colopexy are often performed in conjunction with perineal hernial surgery to prevent life-threatening herniation of the bladder or colon necessitating emergency surgery. These procedures are also helpful to perform first during surgical correction of a perineal hernia to reduce organs into the abdominal cavity, making visualization in the perineal region easier.²⁷ Laparoscopic cystopexy has been described for caudal pelvic bladder in dogs²⁸ and more recently in a cat.²⁹ Laparoscopic colopexy has also been described as a prophylactic for colonic torsion³⁰ and for rectal prolapse.³¹

Hernia repair

Traditionally, hernia repair of various types is performed via an open approach. With advancements in laparoscopic instruments and port site placement, laparoscopic herniorrhaphy is now a viable option. The use of a new device has been reported as a feasible method for reconstructing diaphragmatic hernias in a cadaveric study, utilizing gasless laparoscopy.³² Previous literature reported the feasibility of repair of experimentally created diaphragmatic hernia measuring 7 cm in five dogs with appropriate healing when re-evaluated after 14 days.³³ Peritoneal-pericardial diaphragmatic hernias have also been reported to be repaired via laparoscopy.³⁴

Hiatal hernial repair can also be performed via laparoscopic esophagopexy, fundopexy, and phrenoplasty.^35-36 Use of video-fluoroscopic studies to evaluate esophageal function with concurrent laparoscopic repair of hiatal hernias revealed improvement between the pre- and post-operative scoring systems.³⁷ Complications can occur with laparoscopy, including the creation of a pneumothorax, need for conversion, hepatic laceration, and continued clinical signs.³⁷ Owner perception of clinical signs improved in all cases in one study.³⁷

Portosystemic shunt ligation

Portosystemic shunt attenuation of congenital extra-hepatic ducts has been reported recently. Certain configurations of portosystemic shunts have been successfully attenuated, including splenophrenic, splenoazygos, splenocaval, and right gastric-caval.³⁸ Concurrent portal pressure can be measured as well as portal angiography for either complete ligation or attenuation.³⁸ Patient size in these cases is smaller due to their underlying disease, but this does not inhibit the ability for a laparoscopic approach. Outcomes from a recent study revealed an average weight of 4.2 kg, with a 100 percent success rate using the laparoscopic approach.³⁸ Complications include pneumothorax due to damage to the diaphragm, and one case of hypernatremia resulting in death.³⁸ Conversion was reported in a third of cases in a previous study.³⁹

Advanced laparoscopic procedures provide a wide range of diagnostic and therapeutic options for small animal patients. The benefits of reduced tissue trauma, improved visualization, faster recovery, and lower post-operative morbidity, make it an appealing option for many patients and owners. By understanding which cases are best suited for minimally invasive techniques and when referral is appropriate, practitioners can help ensure timely intervention and optimized outcomes. As technology and surgeon expertise continue to advance, the range of conditions treatable through laparoscopy will only grow, reinforcing its value as a modern tool in high-quality veterinary care.

Ashley Villatoro, DVM, DACVS-SA, achieved board certification from the American College of Veterinary Surgeons in small animal surgery in 2024. She is currently an assistant professor of General Surgery in the department of clinical sciences at Colorado State University College of Veterinary Medicine and Biomedical Sciences. She is currently a minimally invasive fellow candidate in small animal soft tissue surgery. She has an interest in minimally invasive soft tissue surgery, interventional radiology, surgical oncology, wound management and reconstruction techniques.Ashley Villatoro, DVM, DACVS-SA

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