Laparoscopic-Assisted Gastropexy

Gastric dilatation-volvulus (GDV) is a life-threatening emergency in large dogs. The only universally accepted method to prevent GDV is a gastropexy. Other management practices are frequently recommended to reduce the likelihood of gastric dilatation, but a gastropexy is considered the only method to prevent volvulus. This paper describes the author’s recently published technique for an incisional gastropexy with laparoscopic assistance.1 The gastropexy is strong, and the technique is relatively quick and easy for the beginning laparoscopic surgeon to perform.Full-term GDV usually occurs in deep-chested dogs having the typical history of eating a large meal, drinking a lot of water, and having post-prandial excitement or stress. Signs include nonproductive attempts to vomit, drooling, pacing, rapid breathing, distended abdomen, and signs of shock. The combination of a large meal, excessive water intake, and aerophagia produces gastric distention. This gastric accumulation is exacerbated by delayed gastric emptying and decreased fluid absorption in the stomach. Gastric distention results in volvulus or rotation (clockwise rotation, as viewed from both a caudal and ventral view). Volvulus obstructs portal venous blood flow, which produces a combined cardiovascular and toxic shock. Decreased blood flow to the affected viscera produces vascular stasis, gastric ulcers, septic shock, and probably the release of myocardial depressant factors.23Emergency treatment should be simultaneously directed toward relieving the gastric distention and treating the shock. After the initial emergency treatment, many patients are operated to examine the abdomen (i.e., stomach, spleen, and the remainder of the splanchnic organs), reposition the twisted stomach, and secure the gastric antrum to the right side of the abdomen.23 Depending on organ viability, some dogs may require a partial gastrectomy or splenectomy.Postoperative care is as crucial as the emergency anesthesia and surgery. Many cases require a few days of intensive care treatment and all require critical monitoring and treatment for the first 48 hours. Even with excellent surgical and medical care, the mortality of dogs with GDV is high. In a prospective series of 295 dogs operated for GDV, 15% died.4 In contrast, only 1% of dogs with dilatation only, or with a non-confirmed GDV, died.4Prevention of volvulus markedly increases the likelihood that a dog will not die during a bloat episode. The importance of a right-sided gastropexy for prevention of volvulus in dogs at risk for GDV has been well documented.23 Dogs operated for GDV must have a permanent type of gastropexy to prevent recurrence. In a study of dogs treated medically for bloat, 68 survived the initial treatment and were followed for 1 year; 59 (81%) died within 1 year of the initial treatment.5 In another series of cases, of 136 dogs operated for GDV, only 4.3% of the dogs treated with a gastropexy recurred, in contrast to 54.5% of the dogs that did not have a gastropexy during their initial surgery.6 The dogs with a gastropexy had a median survival time of 547 days, as compared to 188 days for the dogs not treated with a gastropexy.6 Several other authors have concluded that dogs treated with a prophylactic gastropexy are at a markedly reduced risk for volvulus.35–8A prophylactic gastropexy should be performed in any dog with a history of bloat being managed medically. Other risk factors for an increased tendency to bloat have been identified in large epidemiological studies.69–11 In a series of nearly 6,000 dogs, of which approximately one-third bloated, risk factors included increasing age, increasing weight, and a thoracic body confirmation with a large chest height/width ratio; purebred dogs were more likely to bloat than mixed-breed dogs, particularly the breeds of Great Dane, Weimaraner, St. Bernard, Gordon setter, and Irish setter.9 The deep chest-to-width ratios and having a relative (particularly a parent) that had bloat were found to be high risk factors in a separate study.11 Splenic torsion as treated by splenectomy has been followed by GDV in two dogs.12 Although risk factors for GDV have been identified and the high mortality of GDV well documented, many susceptible dogs apparently do not receive gastropexies. One factor may be the common practice of an open laparotomy being done to perform a gastropexy. The laparoscopic-assisted technique described here is minimally invasive and produces essentially no complications after surgery.1Several gastropexy techniques have been developed for use during a laparotomy. These include incisional gastropexy, circumcostal gastropexy, belt-loop gastropexy, and tube gastropexy placed either during an open laparotomy or percutaneously using a gastroscope.23 The technique first developed was a tube gastropexy, which can be quickly done during laparotomy GDV treatment.13 Because the tube gastropexy breaking strength is relatively low and potential complications include septic peritonitis, other gastropexy techniques were developed.314–17 The goals for these gastropexy techniques are that they are simple to perform, produce a permanent attachment between the antrum and the right abdominal wall, do not alter gastric function, and have minimal complications.7 A permanent adhesion requires that the mesothelium of the serosa and peritoneum be either removed, cauterized, or incised at the interface of the stomach and body wall.21718 The circumcostal technique is very strong, based on breaking-strength studies, and it results in a low GDV recurrence rate.19–21 Infrequent complications include iatrogenic perforation of the seromuscular site,21 pneumothorax, and rib fractures.22 Other strong gastropexy techniques include the belt-loop and incisional techniques.72324Laparoscopic gastropexies have been developed.25–27 These are done using suturing or stapling techniques performed within the abdomen using laparoscopic techniques. Three trocars and a high degree of laparoscopic surgical skill are required. The laparoscopic-assisted technique described herein only uses the laparoscope to identify and grasp the antrum. Once the antrum is exteriorized, the gastric incision and gastropexy can be simply done by an open technique.Eight research dogs were used to develop this incisional gastropexy technique.1 The dogs were monitored for 1 month postoperatively, at which time they were evaluated by gastrograms, ultrasonography of the gastropexy sites,28 necropsy with histopathology, and breaking-strength testing of the gastropexy. All dogs had normal gastric function after surgery and minimal adverse responses to surgery as evidenced clinically by all dogs eating normally and having normal bowel movements within the first few days after surgery as well as none exhibiting vomiting. Additionally, none of the dogs exhibited fever, abnormal behavior, or had evidence of a significant stress leukogram. Using ultrasonography, the adhesion site could be identified as the site where the stomach was adhered to the abdominal wall. The mean length of the adhesion site was 2.9 cm, and the average tensil strength (i.e., breaking strength) of the gastropexy was 106.5 Newton.1 The adhesion had mature and abundant fibroplasia, indicating a strong scar. These gas-tropexy results indicate that this laparoscopic-assisted technique produces a strong adhesion similar to the strongest gastropexy previously reported. This technique has been applied to client-owned dogs. The dogs have had minimal postoperative complications, and none developed gastrointestinal problems.1Laparoscopy should be performed during general anesthesia and positive-pressure ventilation. Dogs are placed in dorsal recumbency. A trocar cannula for the viewing telescope is placed on the ventral midline 2- to 3-cm caudal to the umbilicus [Figure 1]. After distending the peritoneal cavity with carbon dioxide, a 0°, 5- or 10-mm laparoscopea is placed through the cannula. The laparoscope is connected to a video camerab and a xenon light source.c The second trocar cannula is placed lateral to the right margin of the rectus abdominus and 3-cm caudal to the last rib [Figure 1]. A 10-mm laparoscopic Babcock forcepd is passed through the right paramedian port to manipulate the cranial abdominal organs and then to grasp the antrum of the stomach. The antral site for grasping with the forceps and for the incisional gastropexy is midway between the mesenteric and antimesenteric sides, approximately 5- to 7-cm orally from the pylorus.The Babcock forceps and antrum are exteriorized by removing the right side cannula and extending the cannula’s incision to 4 cm in a direction parallel to the last rib. The antral exteriorization should be viewed via the laparoscope in order to avoid twisting of the antrum [Figure 2]. Traction sutures with a 0 synthetic, monofilament suture are placed in a cruciate fashion, orally and at least 4-cm aborally, at the commissures of the intended gastropexy. An incision at least 4-cm long is made through the serosa and muscular layer of the antrum. The sides of the incision should be dissected from the mucosa to insure that the sutures are not placed through the mucosa and that adequate muscle tissue is exposed for the gastropexy. A simple continuous pattern of 2-0 or 0 synthetic, monofilament, absorbable suture is placed to appose the seromuscular layer of the antrum to the transversus abdominus muscle [Figure 3]. Separate closure sutures are placed on the cranial and caudal sides of the incisions. The oblique abdominal muscles are closed with interrupted synthetic sutures, and the remainder of the incision is closed according to the surgeon’s preference. After viewing the gastropexy for position and orientation [Figure 4], the midline cannulae are removed and the incision is closed.A more complete procedure description has been published. For veterinarians wishing to acquire laparoscopic skills and equipment, they are encouraged to review a recently published textbook29 and to participate in “hands-on” laboratory courses.The authors would like to thank Ms. Allison Wright who prepared the illustrations of the surgical procedure.