Small Animal Laparoscopy and Thoracoscopy. Группа авторов

with 360° wound edge retraction, protect wound edges from contamination, and facilitate laparoscopic‐assisted procedures [10]. Wound retractors improve surgical exposure by applying even, outward circumferential pressure to the wound margins, transitioning a linear incision to a circular opening with improved working space. This improved surgical exposure is achieved without the need for lengthening the incision and enables the surgeon to insert at least one finger into the abdomen, providing palpation and haptic feedback during exploration [11]. Benefits of using a wound retraction device include atraumatic circumferential wound retraction, barrier protection of the body wall and skin against contamination by bacteria and/or neoplastic cells, and improved extracorporeal intestine exposure without compromising vascular supply [11–13]. Reports in human medicine demonstrate a significant decrease in the occurrence of surgical site infection in patients undergoing major intestinal surgery when wound retractors are utilized [12, 13].

Wound retractors are available in a variety of sizes to match the surgeon's desired incision length and range from 2.5 to 25 cm. The smaller sizes (2.5 cm) are most frequently used in small animal MIS. The authors often use a SILS port through a 2.5 cm wound retractor for laparoscopic‐assisted abdominal exploratory and visceral biopsy. The use of wound retractors has been reported to facilitate a number laparoscopic and thoracoscopic procedures in veterinary medicine including abdominal explore and biopsy [14], gastrointestinal foreign body removal [10, 15], resection and anastomosis [16], splenectomy [17], cysterna cyhli ablation [18], pulmonary surgery [14, 19], and many hand‐assisted MIS procedures (Figures 4.29, 4.31–4.34).

Wound retractor placement is achieved by compressing the inner ring (internal ring) between the thumb and index finger creating an oval (Video 4.3). The compressed ring is inserted into the incision until the entire ring is positioned within the cavity and compression released. A finger is used to palpate the inner ring's position within the cavity to ensure that there is no entrapment of viscera between the inner ring and body. External traction is then applied to the outer ring (external ring) by the surgeon and assistant. The outer ring (external ring) is then rolled outward (similar to rolling down a tube sock), causing a shortening of the polyurethane sleeve relative to its original position. This rolling is easiest to perform with an assistant and is completed when the outer ring (external ring) is in contact with patient's body wall, entrapping the body wall snugly between the inner (internal) and outer (external) rings (see Figure 4.33).

Figure 4.28 (A). A suction irrigation device has many fenestrations in the tip for effective suctioning. (B). Commercial units are surprisingly cost effective and include a pump, tubing, and a handpiece for regulation of suction and irrigation actions. (C). Use of irrigation and suction.

Figure 4.29 Use of a wound retractor in abdominal minimally invasive surgery.

Figure 4.30 A wound retractor applies centrifugal force on the incision, greatly facilitating exteriorizing of intestines.

Figure 4.31 Wound retractor in the chest.

      Figure 4.32 The wound retractor facilitates exteriorizing of organs while protecting the wound edges.

A wound retractor can also be used with a laparoscopic cap (Figure 4.34), which enables a laparoscopic approach before and after specimen retrieval.

Morcellators

Morcellators are specialized surgical instruments used to divide larger tissue resections into smaller pieces to facilitate extraction through a laparoscopic port or small incision. Electromechanical morcellators (Figure 4.35) are commercially available and commonly used in human laparoscopy.

      Mechanical morcellators debulk large tissues using a sharp cylindrical blade, which shaves off tissues into layered strips, that are exteriorized though a hollow tube or shaft inserted in a cannula [3, 4, 6]. Typically, grasping forceps are inserted through the morcellator device to handle the tissue of interest and withdraw the tissue into the hollow cylindrical lumen of the morcellator and into contact with the rotating circular cutting blade. In order to minimize potential contact of tissues within the abdomen during morcellation, this technique can also be performed with the tissue enclosed in a specimen retrieval bag. The FDA issued a recommendation to not use power morcellation in patients with suspected or confirmed cancer due to the risk for tumor cell seeding without the use of a tissue containment system [20]. A systematic review of laparoscopic morcellator‐related complications underscored the need for surgeons' safe practices associated with its use [21]. The authors recommend any morcellation of potentially harmful tissues in veterinary patients to be performed within specimen retrieval bags.

      Morcellators are considered to reduce operative time and decrease the risk of incision site hernia formation [6]. In humans, morcellation is most commonly performed during laparoscopic hysterectomies, myomectomies, and splenectomies [3, 4, 6]. In veterinary medicine, morcellators are most commonly reported for the removal of reproductive tumors in equine patients [22, 23]. Recently, laparoscopic falciform fat morcellation in dogs was found to be a safe and effective approach to the harvest and isolation of adipose‐derived mesenchymal stem cells [24]. Risks associated with the use of power morcellation include iatrogenic tissue damage, seeding of cancerous or infected tissues, and decreased ability to perform histopathologic cancer staging [6, 21, 25].

      

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