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103 Bas.J.Vet.Res.Vol.17, No.1, 2018. ISI Impact Factor:3.461 CYSTOTOMY IN DOGS BY LAPAROSCOPIC AND LAPAROSCOPIC- ASSISTED TECHNIQUES B.T. Abass*; W.H. Karomi**; O. J. Ali* *Departments of Surgery and Theriogenology, College of Veterinary Medicine, University of Sulaimani, Sulaimani, Kurdistan region,Iraq; ** Departments of Surgery and Theriogenology, College of Veterinary Medicine, University of Mosul, Mosul,Iraq. (Received 10 May 2017,Accepted 15 June 2018) Keywords: Canine; laparoscopic, laparoscopic-assisted cystotomy. Corresponding author E.mail: [email protected] ABSTRACT Laparoscopic and laparoscopic-assisted cystotomy techniques were investigated and compared on eighteen experimental dogs, divided randomly into three groups, six for each: group I: Underwent laparoscopic cystotomy closed laparoscopically by titanium clips. In group II: the bladder was elevated by laparoscopic-assisted surgery using grasping forceps and exteriorized through a mini-abdominal incision. The bladder was opened extracorporeally, lavaged, closed with 3-0 polygalactin, in a simple nonperforating interrupted pattern. While in group III: Laparoscopic cystotomy was performed as in group I, but cystotomy was closed laparoscopically with 3-0 polyglactin in a simple full thickness interrupted pattern. The postoperative course, radiography of the urinary bladder and microscopic examination of the urine were favorable and the results were as follow: the post-operative recovery rate from illness in all animals was good and did not show urine retention or incontinence; the radiographic findings at 7, 15 and 30 day, did not show leakage from the closure site; titanium clips was an effective method to provide rapid and secure closure of bladder, but may become nidus for cystolithiasis, as the urine exams microscopically showed accumulation of crystals 30 days after operation. In conclusion, intracorporeal cystotomy closure by suture strands (group III), was a favorable method, because of minimal contamination occurred and no urine crystals was observed. INTRODUCTION Cystotomy is a surgical procedure in which an incision is made into the urinary bladder (U.B.). The procedure can be done for many reasons; the most common is being to facilitate removal of bladder stone or urethral stones. Other indications include; helping to diagnose

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CYSTOTOMY IN DOGS BY LAPAROSCOPIC AND LAPAROSCOPIC-ASSISTED TECHNIQUES

B.T. Abass*; W.H. Karomi**; O. J. Ali*

*Departments of Surgery and Theriogenology, College of Veterinary Medicine, University of

Sulaimani, Sulaimani, Kurdistan region,Iraq;

** Departments of Surgery and Theriogenology, College of Veterinary Medicine, University of

Mosul, Mosul,Iraq.

(Received 10 May 2017,Accepted 15 June 2018)

Keywords: Canine; laparoscopic, laparoscopic-assisted cystotomy. Corresponding author E.mail: [email protected]

ABSTRACT

Laparoscopic and laparoscopic-assisted cystotomy techniques were investigated and

compared on eighteen experimental dogs, divided randomly into three groups, six for each:

group I: Underwent laparoscopic cystotomy closed laparoscopically by titanium clips. In group

II: the bladder was elevated by laparoscopic-assisted surgery using grasping forceps and

exteriorized through a mini-abdominal incision. The bladder was opened extracorporeally,

lavaged, closed with 3-0 polygalactin, in a simple nonperforating interrupted pattern. While in

group III: Laparoscopic cystotomy was performed as in group I, but cystotomy was closed

laparoscopically with 3-0 polyglactin in a simple full thickness interrupted pattern.

The postoperative course, radiography of the urinary bladder and microscopic examination of

the urine were favorable and the results were as follow: the post-operative recovery rate from

illness in all animals was good and did not show urine retention or incontinence; the radiographic

findings at 7, 15 and 30 day, did not show leakage from the closure site; titanium clips was an

effective method to provide rapid and secure closure of bladder, but may become nidus for

cystolithiasis, as the urine exams microscopically showed accumulation of crystals 30 days after

operation.

In conclusion, intracorporeal cystotomy closure by suture strands (group III), was a favorable

method, because of minimal contamination occurred and no urine crystals was observed.

INTRODUCTION

Cystotomy is a surgical procedure in which an incision is made into the urinary bladder

(U.B.). The procedure can be done for many reasons; the most common is being to facilitate

removal of bladder stone or urethral stones. Other indications include; helping to diagnose

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bladder tumor, repairing ectopic ureters and ruptured bladder (1). Traditionally, a cystotomy is

performed through a laparotomy. An excellent view of U.B. can be provided by laparoscopic

surgery (2). Laparotomy is an invasive procedure that can be associated with complications, such

as wound infection, septic peritonitis and the development of abdominal adhesion. Laparoscopy

permits excellent observation of the bladder, is minimally invasive and associated with a low

morbidity (3). Laparoscopy was used to provide a definitive diagnosis, good viewing, easy

access, and a secure repair (4).

The closure of the U.B. laparoscopically by using the standard interrupted suture and external or

internal knotting performed by taking the whole bladder wall extending through the peritoneal

face and coming down to the internal border line, by vicryle 3-0 suture thread (5). Titanium

staples may be an effective method to provide rapid and secure closure of U.B. by laparoscopic

technique, but may cause calculi (6).

The purpose of this study is to evaluate the best method for closure of U.B. by

laparoscopy.

MATERIALS AND METHODS

Animals: Eighteen healthy adult dogs of local bred from both sexes, were used. Their

ages were ranged from 9 months to 3.5 years. The animals were kept under similar managements

and feeding conditions throughout the experiment. The animals were divided equally into three

main groups.

Group 1: Cystotomy was closed laparoscopically by titanium clips.

Group 2: Cystotomy was performed by laparoscopically assisted method. After mini-laparotomy

and mini-cystotomy was performed, the U.B. opening was closed extracorporeally by 3-0

polygalactin by simple interrupted pattern.

Group 3: Cystotomy was performed laparoscopically and closed intracorporeally using needle

holder by simple interrupted pattern 3-0 polygalactin.

For all experimental animals, aseptic surgical operation was performed under the effect of

general anesthesia. Premeditation was performed by atropine sulphate (0.04 mg/kg, I.M.),

followed 10 minutes latter by a mixture of ketamine-xylazine (15 mg/kg – 5 mg/kg, respectively,

I.M.). Maintenance of anesthesia was performed by injection of increments of ketamine-xylazine

mixture. After fixation on dorsal recumbency and aseptic urethral catheterization for evacuation

of urine, a small incision (about 1 cm) was done at the umbilicus. The Verss needle introduced

into the abdominal cavity for pneumoperitoneum, after that from the same site trocar-cannula

size 10 mm was inserted into the abdominal cavity. After that, the trocar was removed and the

telescope introduced into the abdominal cavity according to groups.

Group 1: Three portals were made (Figure 1), for insertion of instruments, i.e., scissor,

grasping forceps and clips applicator. The U.B. was grasped by Babcock forceps and opened by

the scissor. The cystotomy opening was closed by 3-4 titanium clips applied by clips applicator,

(fig. 2).

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Group 2: One portal was inserted in the midline in female dogs and paramedline in male

dogs. Babcock forceps was used to grasp the cranio-ventral region of U.B. A mini-laparotomy

was performed and the U.B. was pulled out of the abdominal cavity for fixation by traction

suture. Cystotomy was performed and closed by 3-0 polygalactin by simple interrupted, (fig. 3)

Group 3: Three portals was made from were all instruments under vision, i.e., grasping

forceps, scissor and needle holder, were introduced. The U.B. was opened by scissor and then

closed by needle holder using 3-0 polygalactin, by simple interrupted pattern (intracorporeal

suturing), (fig. 4).

The animals in either group were observed clinically for 30 days after surgery. Radiographic

examination of the U.B. at 7, 15, and 30 days after surgery by positive or negative contrast

cystography by the use of negative contrast media (air) or positive contrast media (organic

iodide). In addition, urine samples collected from the experimental dogs, before and 7, 15 and 30

days after surgery for microscopicale examination. Postmortem changes on the experimental

dogs were studied by randomly scarifying two experimental dogs at schedules of 7, 15 and 30

days after surgery.

Figure 1: The three portals for insertion of instruments, i.e., scissor, grasping forceps and clips applicator

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Figure 2: The cystotomy opening was closed by 3-4 titanium clips applied by clips applicator.

Figure 3: A mini-laparotomy was performed and the U.B. was pulled out of the abdominal cavity for fixation by traction suture. Cystotomy was performed and closed by 3-0

polygalactin by simple interrupted.

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Figure 3: The U.B. was opened intracorporealy by scissor and then closed by needle holder

using 3-0 polygalactin, by simple interrupted pattern (intracorporeal suturing).

RESULTS No major complications were occurred during surgery in all experimental animals under investigation in 3 groups. In group one, titanium clips was effective to secure cystotomy wounds, but nidus for cystolithiasis at the closure site and higher levels of oxalate salt in the urine samples was found. While, in group two, the laparoscopic assisted method of cystotomy, was easy method, but the rate for occurrence of contamination, was expected to be higher in comparison to other groups. In group 3, the out coming results were the best, but the technique needs skull and time consuming.

The post operative clinical findings in experimental animals in all groups, demonstrated normal posture and appetite, but, pain continued for the next 48 hrs post-surgery during urination with dropping urine. The pain disappeared after that and the urination occurred normally.

The radiological findings at 7, 15 and 30 days post cystotomy did not show leakage of contrast media (positive or negative), (figures, 5 and 6) from the closure site. Titanium clips showed in bladder wall, represent distance between one clips and another.

Microscopical findings of urine samples in animal No. 2, group 1, observed an increase in accumulation of oxalate salt crystals after 30 days. On the other hand, no crystals were observed in urine samples from group 2 and 3.

In necropsy findings, some of animals in group 1 represent adhesion between the sites of closure with large bowel, while no adhesions was observed in group 2 and 3.

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Figure 5: A radiograph at 30 days post cystotomy, show no leakage of positive contrast

media from the closure site.

Figure 6: A radiograph at 30 days post cystotomy, show no leakage of negative contrast

media from the closure site. The Titanium clips used for the cystotomy closure showed in bladder wall.

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Figure 7: Microscopical findings of urine samples in animal No. 2, group 1, observed an

increase in accumulation of oxalate salt crystals after 30 days.

DISCUSSION

Laparoscopic cystotomy produced least complications compared with conventional

cystotomy, because of the small incisions necessary, rapid return to normal function, secure closure and hemostasis, rapid uncomplicated healing (7, 8). Closure of the bladder wall by clips was rapid and secure, but associated with nidus of cystolithiasis when the titanium clips penetrated the bladder mucosa (9). Closure of the bladder wall by extracorporeal suture was an easy method, while intracorporeal suture required time and experience, because it is included within the advanced technique of laparoscopic surgery.

The radiological findings post cystotomy in all animals confirmed excellent secure closures by either, titanium clips (9), or by one layer full thickness (3).

The increased precipitation of oxalate salt and nidus formation at the site of closure with titanium clips observed on microscopical findings in urine samples in some animals in group 1 after 30 days from surgery was due to clips penetration to bladder mucosa that acted as nidus for accumulation of calculi (6). To prevent this, omentum or mesh is applied on the site of closure before clips application as advised by (11). On the other hand, oxalate salts or calculi formation was not observed in the urine samples in group 2 and 3, because closure was performed by braided suture (polygalactin 3-0), that was hydrolyzed and absorbed when being in contact with urine (10).

In conclusion, intracorporeal closure of U.B. wall by laparoscopic method with interrupted suture, produced excellent results, because recovery from cystotomy occurred rapidly, and without complications, such as contamination from outside, as in extracorporeal suturing, and no crystals was observed in urine samples as in closure by titanium clips.

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ACKNOWLEDGEMENT

The authors are grateful for the support supplied by the College of Veterinary Medicine,

University of Mosul, Iraq. As, this study represents a part from the M.Sc. thesis for the second author that proposed and supervised by the first author.

بضع المثانة في الكالب بطرق الجراحة الناظوریة والناظوریة المساعدة

*؛ عثمان جالل علي**؛ وسام حنا كرومي*بھجت طیفور عباس

العراق-أقلیم كوردستان -فرع الطب الباطني والسریریات، كلیة الطب البیطري، جامعة سلیماني؛ سلیماني*

العراق-امعة الموصل؛ موصلفرع الجراحة والتولید، كلیة الطب البیطري، ج**

الخالصة

تم تطبیق ومقارنة الجراحة الناظوریة والناظوریة المساعدة على ثمانیة عشر كلباَ تجریبیاَ قسمت عشوائیاَ الى ثالث

، تم اجراء بضع جدارالمثانة بإستخدام تقنیة الناظور وتم غلق الجدار بكلبسات )١(في المجموعة . مجامیع، ستة لكل منھا

لكن الجدار تم غلقھ من داخل التجویف ) ١(فاجریت عملیات بضع المثانة كما في المجموعة ) ٢(اما في المجموعة . یتانیومالت

البطني بخیاطتھ بطبقة واحدة ضمت جمیع طبقات الجدار بالخیاطة بطریقة المتقطع البسیط بإستخدام خیط البولي كالكتین حجم

خدام تقنیة الجراحة الناظوریة المساعدة ، حیث تم إستخراج المثانة الى خارج الجوف تم إست) ٣(بینما في المجموعة . ٣-٠

البطني من خالل فتحة بطنیة صغیرة وتم فتح جدار المثانة وغلقھا في الخارج بنفس الطریقة وبنفس الخیط المستخدم في

لتثبت من كفاءة غلق جدار المثانة وقوة تحملھا وتم ا. وبعدھا تم إعادة المثانة الى موضعھا في الجوف البطني). ٢(المجموعة

یوماَ على التوالي لكل ٣٠، و١٥، ٧للنضوح البولي بالطرق الناظوریة الثالث بالمتابعة الیومیة ولثالث فترات متعاقبة وھي

رق الجراحة الناظوریة وتم تقییم كفاءة اإللتئام وقوة تحمل المثانة للنضح البولي في المثانات المرممة بط. من حیوانات التجربة

وتم إستنتاج النتائج بطرق التصویر باألشعة . یوما على التوالي من بعد إجرائھا على كل حیوان ٣٠و ١٥، ٧الثالث بعد مرور

.السینیة الملونة بإستخدام الوسط الھوائي السلبي المغایر واإلختبار المخبري العام للبول

وكان معدل الشفاء من . ناظوریة والجراحة الناظوریة المساعدة بنجاح على كل الكالبلقد تم إجراء بضع المثانة بالجراحة ال

وقد أظھرت كل الصور . بعد تلك العملیات جید جدا ولم یالحظ حدوث أي إحتباس بولي أو مضاعفات مابعد عملیات البضع

. الشعاعیة قوة تحمل عالیة للغلق في المثانات بالطرق الثالث

وقد أثبت بأن طریقة . ن بضع المثانة بطریقة الجراحة الناظوریة متدني اإلنتھاك وآمن جراحیا في الكالبوتم اإلستنتاج بأ

وف داخل الصفاق، الجراحة الناظوریة المساعدة كانت األسھل ألنھا زودت أعلى معاینة للمثانة البولیة، وأدنى تلویث لج

على العكس، تنظیر المثانة من داخل جوف البطن وغلقھا . وإستھالك أقل للوقت و غلق آمن جدا وسھل لعملیة غلق المثانة

كانت ٣-٠بطبقة واحدة ضمت جمیع طبقات جدارالمثانة بخیاطتھا بطریقة المتقطع البسیط بإستخدام خیط البولي كالكتین حجم

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بینما، وبرغم غلق المثانة من داخل . لتصاقات لداخل المساریق ولكنھا مسرفة للوقت وتحتاج للمھارةآمنة جدا وخالیة من اإل

.الجوف بكلبسات التیتانیوم كانت آمنة، لكن قد تؤدي لحدوث حصوة المثانة البولیة وحدوث إلتصاقات عالیة داخل المساریق

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