Laparoscopy is a low-invasive diagnostic and surgical technique for examining and performing surgical procedures in the equine peritoneal cavity. This article is a case study of a horse with weakly expressed, irregular symptoms of colic occurring over a period of four weeks. Diagnostic laparoscopy was performed, and liver and spleen tissue samples were collected for a histopathological analysis. An endoscopic examination of the abdominal cavity ruled out small intestinal intussusception, and a histopathological analysis supported the identification of the causes of colic

P. Holak, M. Jałyński, Z. Peczyński, Z. Adamiak, M. Jaskólska and W. Pesta*

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128  Pakistan Veterinary Journal ISSN: 0253-8318 (PRINT), 2074-7764 (ONLINE) Accessible at: www.pvj.com.pk    Diagnostic Laparoscopy for Small Intestinal Intussusception in a Horse  P. Holak, M. Jałyński, Z. Peczyński, Z. Adamiak, M. Jaskólska and W. Pesta*  University of Warmia and Mazury, Faculty of Veterinary Medicine, Department of Surgery and Roentgenology, 10-719 Olsztyn, ul. M. Oczapowskiego 14c, Poland  *Corresponding author: piotr-holak@wp.pl   AR T IC LE   H IS TOR Y      ABST RAC T   Received: Revised: Accepted: April 04, 2012 July 02, 2012 July 30, 2012   Laparoscopy is a low-invasive diagnostic and surgical technique for examining and performing surgical procedures in the equine peritoneal cavity. This article is a case study of a horse with weakly expressed, irregular symptoms of colic occurring over a period of four weeks. Diagnostic laparoscopy was performed, and liver and spleen tissue  samples  were  collected  for  a  histopathological  analysis.  An  endoscopic examination of the abdominal cavity ruled out small intestinal intussusception, and a histopathological analysis supported the identification of the causes of colic.  ©2012 PVJ. All rights reserved Key words:  Biopsy Colic Horse Laparoscopy   To Cite This Article: Holak P, M Jałyński, Z Peczyński, Z Adamiak, M Jaskólska and W Pesta, 2013. Diagnostic laparoscopy for small intestinal intussusception in a horse. Pak Vet J, 33(1): 128-130.  INTRODUCTION  Diagnostic  and  surgical  laparoscopy  is  gaining widespread  popularity  in  equine  surgery  (Caron,  2009; Tuohy  et  al.,  2009;  Carmalt  and  Wilson,  2011). Endoscopic imaging of the intraperitoneal space enables an  evaluation  of  abdominal  organs  under  magnification and in real colors which is an unquestioned advantage in the diagnosis of  various diseases.  Laparoscopy supports highly  precise  and  targeted  collection  of  tissue  samples from  any  abdominal  organ  for  histopathological examination, thus expanding the scope and the diagnostic value of the test. Laparoscopy is an effective alternative to conventional  diagnostic  laparotomy  because  it  delivers shorter  convalescence  times  and  a  lower  risk  of complications due to less extensive post-operative wounds (Pader et al., 2011).  History:  A  10-year-old  gelding  of  the  Wielkopolska breed with colic symptoms was referred for treatment to the Department of Surgery and Roentgenology, Faculty of Veterinary  Medicine,  the  University  of  Warmia  and Mazury.  The  horse  participated  in  sports  competitions, and it had been previously treated for an orthopedic injury for three months. An interview with the owner revealed weakly  expressed  colic  symptoms,  decreased  appetite, reluctance to move and body weight drop in the previous four weeks. The physician could not be contacted, and the type  of  treatment  was  not  determined.  According to the owner,  the  treatment  was  effective,  the  horse  had  been reinstated  to  competitions,  it  was  regularly  vaccinated, dewormed and provided with an adequate nutritional regime. During  the  animal’s  stay  in  the  clinic,  weakly expressed  colic  symptoms  were  observed  on  two occasions. In view of the symptoms, the horse’s relatively satisfactory condition and the clinic’s previous experience in dealing with cases of the type, a decision was made to perform  diagnostic  laparoscopy  on  suspicion  of  small intestinal intussusception.  Clinical  examination:  The  results  of  standard  blood morphology  and  biochemistry  tests  did  not  reveal  any irregularities, except for slightly elevated levels of lactate dehydrogenase  (LDH)  and  alkaline  phosphatase  (ALP) activity. Rectal and ultrasonographic examinations did not show any irregularities.  The horse was fasted for 24 hours and premedicated with  0.03  mg/kg  acepromazine  and  0.03  mg/kg  buthorphanol i.v. A mixture of 2 mg/kg ketamine and 0.1 mg/kg  diazepam  i.v.  was  administered  for  casting.  The horse was anesthetized with halothane at a concentration of 1.5% administered with oxygen as a carrier. The patient was positioned in dorsal recumbency, and the operating field  was  set  up  in  accordance  with  the  applicable standards.  The  procedure  was  carried  out  using  a laparoscope with a diameter of 10 mm, working length of 320 mm and 30° angle view.  Pneumoperitoneum with a pressure of 10 mm Hg was created using the Veress needle, and an optical port was introduced in the ventral midline of the umbilical region. The appearance of the parietal peritoneum was assessed, and  starting  from  the  cranial  abdomen,  the  laparoscope was moved from the left to the right side of the abdominal cavity to examine the organs. The laparoscope was further CASE REPORT Pak Vet J, 2013, 33(1): 128-130.  129 manipulated  to  evaluate  visible  organs  in  the  caudal abdomen. Two working ports were inserted in the midline plane  of  the  abdominal  cavity  in  a  triangular  fashion. Babcock  clamps  were  advanced  via  the  ports  to manipulate  and  examine  jejunal  loops.  A  tissue  sample was collected from the right liver lobe tissue using a Tru-Cut  biopsy  needle  inserted  into  the  right  flank  in  the sixteenth intercostal space. Spleen biopsy was performed from the left side in the sixteenth intercostal space. Pneumoperitoneum was  gradually reduced, working ports were retracted and the optical port was withdrawn. Port wounds were closed with two layers of absorbable suture material 2-0. Post-operative analgesic therapy was not  administered;  antibiotic  cover  was  provided  using Penicillin  LA  comprising  6.5  mg/kg  procaine benzylpenicillin and 4.5 mg/kg benzathine benzylpenicillin in deep intramuscular injection.   Diagnosis and differential diagnosis:  The examination of  jejunal  loops  did  not  reveal  any  changes  suggesting intussusception.  The  liver  contour  was  enlarged  with rounded  lobe  edges.  An  enlarged  spleen  was  also observed. Tissue samples were collected from both organs for a histopathological analysis. The collected specimens were fixed in 10% formalin, embedded in paraffin blocks, and  the  resulting  microtome  sections  were  stained  with hematoxylin  and  eosin.  The  histopathological  test revealed  normal  spleen  structure,  and  parenchymatous degeneration of hepatocytes was noted in the liver with focal mononuclear cell infiltration (Fig. 1).  Treatment  adopted:  Based  on  the  results  of histopathological  tests,  the  patient  was  referred  for internistic treatment. Weak colic symptoms were observed on two more occasions in the course of one week, after which they ceased. Increased appetite and greater mobility were  noted  following  changes  in  the  animal's  diet.  The causes  of  parenchymatous  degeneration  of  hepatocytes were  not  determined.  Colic  symptoms  first  appeared towards  the  end  of  the  three-month  pharmacological treatment  of  an  orthopedic  injury,  suggesting  that  the administered drugs had an adverse effect on the liver.  DISCUSSION  Equine laparoscopy is becoming a popular technique in  diagnosing  abdominal  cavity  diseases.  The  most frequent  indications  for  laparoscopy  include:  a  detailed examination of changes diagnosed with the use of other tests (ultrasonographic, rectal examinations) that failed to fully  explain  the  nature  of  the  noted  changes,  tissue sampling  for  histopathological  tests,  chronic  colic  of unknown  etiology,  confirmation  of  neoplastic  changes, peritoneal  inflammations  and  bowel  damage  prior  to euthanasia  (Caron,  2009;  Cribb  and  Boure´,  2010).  As every  method,  laparoscopy  delivers  a  number  of advantages,  but it  also  introduces  certain  constraints on the diagnostic procedure. One of its greatest advantages is the  option  of  performing  the  diagnosis  on  a  standing animal  with  right  or  left  flank  access.  In  this  position, complications  resulting  from  dorsal  recumbency  and general  anesthesia  can  be  avoided,  although  possible movement of the patient during the procedure could lead    Fig. 1:  Parenchymatous degeneration of hepatocytes with small focal infiltrations by mononuclear cells (white arrow). H & E stain.  to certain problems. The advantage of dorsal recumbency is  that  the  procedure  can  be  directly  switched  to conventional  laparotomy,  which  is  not  possible  in  a standing  position,  and  that  the  patient  is  fully immobilized. General anesthesia, pneumoperitoneum and the Trendelenburg position could have an adverse effect on the patient's cardiovascular and ventilatory parameters, which is why a respirator should always be applied when examining  the  patient  in  this  position  (Carmalt  and Wilson, 2011)  Optical port access is created subject to the site of the suspected pathological change, but the point of access can be modified in patients placed both in the standing and the recumbent  position  to  examine  other  parts  of  the peritoneal  cavity  (Cribb  and  Boure´,  2010).  In  the analyzed case, two working ports had to be introduced for advancing  clamps  that  facilitated  the  manipulation  of jejunal  loops.  The  patient  was  placed  in  the  reverse Trendelenburg position (head upwards) for better access to  liver  lobes.  The  right  flank  position  was  adopted  to expose  the  spleen.  The  optical  port  was  placed  in  the umbilical  region  to  control  tissue  collection  from  both organs. The retraction of the biopsy needle from the liver and the spleen resulted in minimal bleeding which soon ceased. The time of the laparoscopic procedure, including liver and spleen biopsy, was 45 minutes.  The applied laparoscope with a working length of 320 mm was adequate for the procedure,  yet in the author's opinion, a longer laparoscope should  be used for better results.  The  30°  angle  view  seems  to  be  optimal  for diagnostic  laparoscopy  because  it  facilitates  precise examination of the organs. Insufflation pressure of 10 mm Hg  was  sufficient  to  lift the  abdominal  integument  and perform the examination The samples collected for histopathological analyses under  laparoscopic  control  constitute  highly  valuable material  because  they  are  collected  from  the  precise location  showing  pathological  changes.  Direct visualization of the biopsy or sampling site supports the determination of the degree of hemorrhaging and enables bleeding  control  which  is  not  possible  in  biopsies performed  under  ultrasonographic  control.  Diagnostic laparoscopy  also  produces  less  extensive  wounds  than conventional  laparotomy.  The  wounds  created  by laparoscopic  ports  are  minimal  which  speeds  up  their healing,  reduces  post-operative  pain,  the  risk  of Pak Vet J, 2013, 33(1): 128-130.  130 complications and shortens convalescence time (Carmalt and  Wilson,  2011;  Pader  et  al.,  2011).  Although  it requires  extensive  skill  and  experience  on  behalf  of surgical  personnel  as  well  as  specialist,  expensive equipment, laparoscopy offers a highly effective and safe diagnostic tool.   REFERENCES       Carmalt  JL  and  DG  Wilson,  2011.  Laparoscopic  cryptorchidectomy-standing or recumbent? Equine Vet Educ, 23: 396-397. Caron  JP,  2009.  Equine  laparoscopic  surgery:  Here  to  stay?  Equine Vet Educ, 21: 301-302.  Cribb  NC  and  LP  Boure,  2010.  Laparoscopic  removal  of  a  large abdominal testicular teratoma in a standing horse. Vet Surg, 39: 131-135. Pader  K,  LJ  Freeman,  PD  Constable,  CC  Wu,  PW  Synder  and  TB Lescun,  2011.  Comparison  of  transvaginal  natural  orifice transluminal endoscopic surgery (NOTES®) and laparoscopy for elective  bilateral  ovariectomy  in  standing  mares.  Vet  Surg,  40: 998-1008.  Tuohy  JL,  DA  Hendrickson,  SM  Hendrix  and  TC  Bohanon,  2009.  Standing laparoscopic repair of a ruptured urinary bladder in a mature draught horse.  Equine Vet Educ, 21: 257-261.  

Diagnostic Laparoscopy for Small Intestinal Intussusception in a Horse

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