Published in the August 2014 issue of Veterinary Practice News. When Ray Cox, DVM, first took laparoscopy courses in the 1980s, some veterinarians were already performing laparoscopic-assisted ovariohysterectomies. But the procedure took two to three people operating through three ports, and even the best surgeons needed 2.5 hours to complete a spay, so the modality wasn’t practical compared to the traditional spay. But today, Dr. Cox said, even surgeons who take the longest to do a lap-assisted spay need less than 20 minutes. They can also look around inside the animal, basically doing a mini-exploratory during every procedure. In little more than a decade, the lap-assisted spay has become a procedure that can be used often enough for the general practitioner to develop a skill set in rigid endoscopy and make the equipment a practical addition to a clinic. Rigid endoscopy can be used for liver biopsy, prophylactic gastropexy, cryptorchid surgery and cystoscopy, among other procedures, all of which can add to the return on investment. Intrigued by those early courses, Cox began working to refine the procedure. He didn’t know it then, but he would become one of the pioneers of the single-port laparoscopic-assisted spay. Others with whom he developed the procedure were Chad Devitt, DVM; Jim Hailey, DVM; and Markee Kuschel, DVM. A suspended uterus. Cox admitted that for the first couple of hundred surgeries he performed, he was nervous about electrically sealing vessels—a step that presented “a challenge in my first 20-plus years of practice.” He didn’t always trust the seal not to fail. “Originally, we used monopolar cautery,” he explained. “Not only was I worried about how well these vessels were being sealed, but I also was concerned about stray sparks accidentally cauterizing organs and tissues.” In 2003, he found the endoblade, a bipolar cautery instrument that cuts and coagulates using radio frequency power ranging from 70 to 21 watts. “Because this instrument cauterizes only between the paddles, my worries about stray sparks were immediately resolved,” Cox said. “But it left my concerns about how well the vessels were sealed.” Deer Creek Animal Hospital, which Cox co-founded in 1984, started offering laparoscopic-assisted OHEs in 2003. The hospital is in Littleton, Colo. Single port lap-assisted spay. In the ensuing 11 years, Cox has performed about 3,000 lap spays, he estimated, and he and his colleagues have taught the procedure to about 10,000 veterinarians, both at veterinary conferences and the hospital. Only two dogs have died, he said, both because of anesthesia. He’s never had to go back in for a bleeder on the ovarian pedicle, though there were cases in which doctors who suspected a bleed went back in and found nothing. “We have performed the procedure on dogs as large as a 150-pound English mastiff in heat and as small as a 1-pound, 13-ounce Yorkshire terrier,” he said. “Early in this development, the frequency of rigid endoscopy procedures was limited because they were difficult to perform,” Cox said. “But by 2003, newer equipment and easier techniques were being developed.” The same Denver company that found him the endoblade, Biovision Veterinary Endoscopy, worked with Cox to develop a positioning table and instruments “that allowed us to perform the lap spay through a single port,” he said. Complete lap-assisted spay. “We worked with the company until the procedure became practical for the average practitioner,” he added. “And we showed that with experience, a surgeon could single-handedly perform the spay in under 30 minutes.” Years ago, Cox remembered, as endoscopy came to be used in procedures typically performed by general practitioners, laparoscopic spays became a topic at almost every veterinary conference. This trend escalated when Dr. Devitt conducted a study showing that a laparoscopic-assisted ovariohysterectomy was less painful than the traditional open procedure. For just over a year, Deer Creek offered both the traditional OHE and the lap-assisted OHE. “But before long, we felt that the lap-assisted OHE was so much safer and less painful that our clinic converted to offering only the laparoscopic version,” Cox said. That was a relief to Cox, who said the traditional obese mature OHE that the owner would drop off at the reception counter for “just a spay” was threatening his desire to practice. “Over the past 11 years, we have performed thousands of lap-assisted OHEs,” Cox says. “At Deer Creek Animal Hospital, we have taught this procedure to hundreds of veterinarians who are doing laparoscopic surgery for the first time and we have never had a problem with an ovarian vessel not being sealed.” Cox said that while spaying an obese large dog is still not fun, “I no longer lose sleep worrying about bleeding at the ovarian pedicle. This is especially comforting as we continue to teach rigid endoscopy to fellow veterinarians from all over the world with varying skill sets.” A traditional spay. When Deer Creek first began offering lap spays 11 years ago, Cox said, one of its 10 surgeons refused to do them. “This vet just got a job at another clinic in another city,” Cox said. “She told them, ‘If you want me to do spays, you have to buy me endoscopy equipment because I won’t do them any other way.’ She got the equipment.” Today, two vets at the practice say they would stop doing spays entirely if they had to do them the old way, Cox said.
