BSAVA Manual of

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BSAVA Manual of Canine and Feline Endoscopy and Endosurgery

Canine and Feline

Endoscopy and
Endosurgery

Edited by
Philip Lhermette
and David Sobel

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/ 5/2 3 12:30
:4
 BSAVA Manual of
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Canine and Feline

Endoscopy and
Endosurgery
Editors:

Philip Lhermette
BSc (Hons) CBiol MIBiol BVetMed MRCVS
Elands Veterinary Clinic, Station Road,
Dunton Green, Sevenoaks, Kent TN13 2XA
and

David Sobel
DVM MRCVS
Metropolitan Veterinary Consultants, 65 Greensboro Road,
Hanover, New Hampshire 03755, USA

Published by:

British Small Animal Veterinary Association

Woodrow House, 1 Telford Way, Waterwells
Business Park, Quedgeley, Gloucester GL2 2AB

A Company Limited by Guarantee in England.

Registered Company No. 2837793.
Registered as a Charity.

Copyright © 2013 BSAVA

First edition 2008
Reprinted with corrections 2013
Reprinted 2015

All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in form or by any means,
electronic, mechanical, photocopying, recording or otherwise without
prior written permission of the copyright holder.

Illustrations 3.11, 3.12, 4.12, 4.14, 4.16, 4.18, 4.21, 4.36, 5.1, 5.5, 5.9, 5.10,
5.12, 5.13, 6.9, 6.11, 6.13, 6.14, 7.1, 7.2, 7.3, 7.4, 7.5, 7.6, 7.7, 8.1, 8.10,
8.11, 11.5, 11.13, 11.15, 12.9 and 12.14 were drawn by S.J. Elmhurst BA
Hons (www.livingart.org.uk) and are printed with her permission.

A catalogue record for this book is available from the British Library.

ISBN 978 1 905319 02 2

e-ISBN 978 1 905319 57 2

The publishers and contributors cannot take responsibility for

information provided on dosages and methods of application of drugs
mentioned in this publication. Details of this kind must be verified by
individual users from the appropriate literature.

Printed in India by Imprint Digital

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Printed on PEFC Accredited paper made from sustainable forests

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 Other titles in the
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BSAVA Manuals series:

Manual of Canine & Feline Abdominal Imaging
Manual of Canine & Feline Abdominal Surgery
Manual of Canine & Feline Advanced Veterinary Nursing
Manual of Canine & Feline Anaesthesia and Analgesia
Manual of Canine & Feline Behavioural Medicine
Manual of Canine & Feline Cardiorespiratory Medicine
Manual of Canine & Feline Clinical Pathology
Manual of Canine & Feline Dentistry
Manual of Canine & Feline Dermatology
Manual of Canine & Feline Emergency and Critical Care
Manual of Canine & Feline Endocrinology
Manual of Canine & Feline Fracture Repair and Management
Manual of Canine & Feline Gastroenterology
Manual of Canine & Feline Haematology and Transfusion Medicine
Manual of Canine & Feline Head, Neck and Thoracic Surgery
Manual of Canine & Feline Musculoskeletal Disorders
Manual of Canine & Feline Musculoskeletal Imaging
Manual of Canine & Feline Nephrology and Urology
Manual of Canine & Feline Neurology
Manual of Canine & Feline Oncology
Manual of Canine & Feline Ophthalmology
Manual of Canine & Feline Radiography and Radiology: A Foundation Manual
Manual of Canine & Feline Rehabilitation, Supportive and Palliative Care:
Case Studies in Patient Management
Manual of Canine & Feline Reproduction and Neonatology
Manual of Canine & Feline Surgical Principles: A Foundation Manual
Manual of Canine & Feline Thoracic Imaging
Manual of Canine & Feline Ultrasonography
Manual of Canine & Feline Wound Management and Reconstruction
Manual of Canine Practice: A Foundation Manual
Manual of Exotic Pet and Wildlife Nursing
Manual of Exotic Pets: A Foundation Manual
Manual of Feline Practice: A Foundation Manual
Manual of Ornamental Fish
Manual of Practical Animal Care
Manual of Practical Veterinary Nursing
Manual of Psittacine Birds
Manual of Rabbit Medicine
Manual of Rabbit Surgery, Dentistry and Imaging
Manual of Raptors, Pigeons and Passerine Birds
Manual of Reptiles
Manual of Rodents and Ferrets
Manual of Small Animal Practice Management and Development
Manual of Wildlife Casualties

For further information on these and all BSAVA publications, please visit our website:
www.bsava.com

ii

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 Contents
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List of contributors v

Foreword vii

Preface viii

1 An introduction to endoscopy and endosurgery 1

Philip Lhermette and David Sobel

2 Instrumentation 11
Christopher J. Chamness

3 Flexible endoscopy: basic technique 31

Edward J. Hall

4 Flexible endoscopy: upper gastrointestinal tract 42

Edward J. Hall

5 Flexible endoscopy: lower gastrointestinal tract 73

James W. Simpson

6 Flexible endoscopy: respiratory tract 84

Diane Levitan and Susan Kimmel

7 Rigid endoscopy and endosurgery: principles 97

Philip Lhermette and David Sobel

8 Rigid endoscopy: rhinoscopy 109

Philip Lhermette and David Sobel

9 Rigid endoscopy: otoendoscopy 131

Laura Ordeix and Fabia Scarampella

10 Rigid endoscopy: urethrocystoscopy and vaginoscopy 142

Alasdair Hotston Moore and Gary England

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11 Rigid endoscopy: laparoscopy 158

Eric Monnet, Philip Lhermette and David Sobel

12 Rigid endoscopy: thoracoscopy 175

MaryAnn Radlinsky

13 Rigid endoscopy: arthroscopy 188

Rob Pettitt and John F. Innes

14 An introduction to laser endosurgery 220

David Sobel and Jody Lulich

Index 228

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 Contributors
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Christopher J. Chamness DVM

Karl Storz GmbH & Co., 175 Cremona Drive, Goleta, Santa Barbara, CA 93117, USA

Gary England BVetMed PhD DVetMed DVR DVRep DipECAR DipACT ILTM FRCVS
School of Veterinary Medicine and Science, University of Nottingham, College Road,
Loughborough LE12 5RD

Edward J. Hall MA VetMB PhD DipECVIM-CA MRCVS

Division of Companion Animal Studies, Department of Clinical Veterinary Science,
University of Bristol, Langford House, Langford, Bristol BS40 5DU

Alasdair Hotston Moore MA VetMB CertSAC CertVR CertSAS MRCVS

Division of Companion Animal Studies, Department of Clinical Veterinary Science,
University of Bristol, Langford House, Langford, Bristol BS40 5DU

John F. Innes BVSc PhD CertVR DSAS(Orth) MRCVS

Small Animal Teaching Hospital, Leahurst Campus, University of Liverpool, Chester High Road,
Neston, Cheshire CH64 7TE

Susan Kimmel DVM DipACVIM

The Center for Specialized Veterinary Care, 609-5 Cantiague Rock Road, Westbury, NY 11590, USA

Diane Levitan VMD DipACVIM

The Center for Specialized Veterinary Care, 609-5 Cantiague Rock Road, Westbury, NY 11590, USA

Jody Lulich DVM PhD DipACVIM

Veterinary Clinical Sciences Department, College of Veterinary Medicine, University of Minnesota,
1352 Boyd Avenue, St. Paul, MN 55108, USA

Philip Lhermette BSc (Hons) CBiol MIBiol BVetMed MRCVS

Elands Veterinary Clinic, Station Road, Dunton Green, Sevenoaks, Kent TN13 2XA

Eric Monnet DVM PhD FAHA DipACVS DipECVS

Department of Clinical Sciences, Colorado State University, 300 West Drake Road, Fort Collins,
CO 80523, USA

Laura Ordeix DVM DipECVD

Carrer Tragi 4, 08003, Barcelona, Spain

Rob Pettitt BVSc CertSAS MRCVS

Small Animal Teaching Hospital, Leahurst Campus, University of Liverpool, Chester High Road,
Neston, Cheshire CH64 7TE

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PDFLibrary.Net

MaryAnn Radlinsky DVM MS DipACVS

Department of Small Animal Medicine and Surgery, College of Veterinary Medicine,
University of Georgia, Athens, GA 30602, USA

Fabia Scarampella DVM DipECVD

Studio Dermatologico Veterinario, Via Sismondi 62, 20133 Milano, Italy

James W. Simpson SDA BVM&S MPhil MRCVS

Royal (Dick) School of Veterinary Studies, Easter Bush Veterinary Centre, Roslin,
Midlothian EH25 9RG

David Sobel DVM MRCVS

Metropolitan Veterinary Consultants, 65 Greensboro Road, Hanover, NH 03755, USA

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 Foreword
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The BSAVA Manual of Canine and Feline Endoscopy and Endosurgery has been written to help
practitioners learn skills in minimally invasive diagnosis and surgery. Today in veterinary medicine,
‘minimally invasive’ usually refers to flexible endoscopy for diagnosis and rigid endoscopy for both
diagnosis and surgery, largely reflecting the practices of minimally invasive procedures performed in
human medicine. The availability of advanced imaging modalities such as ultrasound, CT and MRI
enables more precise targeting of affected tissues in veterinary medicine. Reasonably priced surgical
tools for tissue cutting and coagulation, such as diode lasers, bipolar electrocautery devices and the
harmonic scalpel, are now available to improve surgical precision. New endoscopic tools will facilitate
more therapeutic procedures being performed with flexible endoscopy in the future. The magnification
and visualization provided by endoscopic approaches makes diagnosis and therapy possible in areas
of the body that were previously inaccessible. Though veterinarians still, and will continue to, utilize
open surgery, current trends suggest that less invasive procedures are here to stay.

If we take a lesson from human medicine, when new procedures are facilitated by new technology,
demanded by patients, produce equivalent or better outcomes, and are cost-effective, they most surely
are adopted as a new standard of care. Having worked in the field of minimally invasive surgery since
the early 1990s, I have seen tremendous advances in instrumentation, techniques, procedures, and
in our ability to teach these techniques to others. We are witnessing a growing demand for minimally
invasive procedures from clients who see the excellent outcomes from friends and family members
undergoing these procedures and who want the best care for their animals.

By first giving an introduction to the instrumentation, and then focusing on the endoscopic application
in subsequent chapters, the authors present a clear treatise on minimally invasive approaches to
common problems seen in veterinary medicine. The editors, David Sobel and Philip Lhermette, are
very experienced in minimally invasive surgery and are able to present the material in such a way that
is easily read and assimilated into small animal practice. The editors, along with the authors, have
worked diligently not only to demonstrate equivalent or better clinical outcomes, but also to show the
cost-effectiveness of these procedures in a practice setting.

Although veterinarians are still in the early phase of adoption of minimally invasive procedures, I
believe that we are poised for endoscopy and endoscopic surgery to be a vital element of the future
veterinarian’s armamentarium. I anticipate even greater utilization of flexible endoscopy for therapeutic
procedures and perhaps even combinations of flexible and rigid endoscopy to diagnose and treat
diseases that are now only accessible by open surgery.

Lynetta Freeman DVM MS

West Lafayette, IN
March 2008

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 Preface
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‘The second millennium has brought with it a new era of modern surgery. The
creation of video surgery is as revolutionary to this century as the development
of anesthesia and sterile technique was to the last one.’

Marelyn Medina MD
Rio Grande Regional Hospital (McAllen, TX)
Society of Laparoscopic Endosurgeons Public Relations Committee

inimally invasive techniques, or ‘keyhole surgery’ as they are commonly known, have become the
standard in human healthcare over recent years. eterinary surgeons have been slow to exploit fully
these new techniques, partly due to the high cost of instrumentation in the early days, and partly through
natural conservatism. With the availability of equipment at a reasonable cost, these techniques have
become cost-effective in general practice and provide several advantages over conventional surgery.

This Manual has been written as a hands-on guide for general practitioners interested in pursuing this
fascinating branch of veterinary surgery. It is intended as a guide for those starting out in this interesting
field – and sub ects covered range from the purchase of equipment to basic techniques, with a few
references to more the advanced techniques to whet the appetite of more ambitious surgeons.

e have tried to make the anual as practical as possible, drawing from our own experience, to
give hints and tips that we find useful both in surgical technique and on purchase of instrumentation
without breaking the bank – and without compromising quality – in order to maintain high surgical
standards. It is not meant as a substitute for qualified practical tuition, and we would urge the reader
to take practical ‘wet lab’ courses with qualified instructors before embarking on these techniques for
the first time. ndoscopy is a very practical skill and requires adequate training both in the use of the
instrumentation and in working within a two-dimensional video environment. Having said that, most of
what is contained in the Manual is relevant to general practice and any competent surgeon with good
hand-eye coordination can, with practice, carry out most of these procedures.

In a world where minimally invasive techniques have become commonplace in human surgery, people
expect to have keyhole surgery themselves and are coming to expect the same level of treatment for
their pets. The advantages are the same in animals as they are in humans. Recovery is much shorter,
allowing day surgery where previously recovery would take days or weeks. Reduction in perioperative
pain is a ma or benefit for all patients. t a time when the profession is becoming more and more
aware of the need for postoperative pain relief, should we not give some thought to causing less pain
and trauma in the first place In the words of Hippocrates ‘first do no harm.’

e are extremely grateful to the authors who have given up their time so generously to contribute to
this anual. They are, without doubt, leaders and pioneers in their field and bring not only a depth of
knowledge and experience but also an unbridled enthusiasm for their work that will hopefully inspire
others to continue to develop techniques in the future.

Philip Lhermette
David Sobel

December 2007

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 Chapter 1
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An introduction to endoscopy
and endosurgery
Philip Lhermette and David Sobel
Introduction
Endoscopy is derived from two words: the Greek
endo meaning inside and scopein meaning to look
at or view. Over the past few years there have
been major advances in the ability to ‘look inside’
patients and to perform quite complex operations
through tiny incisions. This has given rise to the term
keyhole surgery.
But endoscopy is not new. Mankind has seemingly
always possessed an innate curiosity to peer inside
body cavities. The first reports of endoscopy come
from Hippocrates (460–377 BC), who described the
use of a rectal speculum. Roman, Greek and Arab
physicians all made use of various primitive specula
for peering into body cavities, indeed three- and four-
pronged vaginal specula (not dissimilar to modern
instruments) were unearthed at the ruins of Pompeii,
dating from AD 79. However, these devices used only
natural light and no lenses or optics of any kind. No
real advances on these initial attempts were made
until the 19th century.
Endoscopists have had a difficult time throughout
history convincing the critics. The modern era of
endoscopy really started in the early 19th century with
the introduction of the Lichtleiter (Figures 1.1 and 1.2)
or light conductor, by Philipp Bozzini (Figure 1.3) of
1.1
Restored light
conductor with
attached four-part
light-carrying
tube. (Courtesy of
Magister E Krebs)
Ch01 Endo.indd 1
An introduction to endoscopy and endosurgery
1
Frankfurt in 1805. The breakthrough was the addition
of a light source to improve visualization. The
Lichtleiter utilized a beeswax candle as a light source,
reflecting the light down a hollow tube using a mirror.
The operator peered through a hole in the centre of
the mirror. This device was used for looking at the
rectum, vagina and urethra via a selection of different
specula. However, visibility was still poor and the
procedure was uncomfortable or even painful for the
patient (with the additional risk of burns), so the device
did not gain popularity at the time. Added to this, when
Bozzini demonstrated his device to the Academy of
Medicine of Vienna in 1806, he was ostracized for his
‘undue curiosity’, and his invention described as ‘..but
a magic lantern’. He died a few years later, in 1809,
but his work inspired some to continue in this field.
1.2 Attachable light-carrying tubes. (Courtesy of
Magister E Krebs)
1.3
Philipp Bozzini
(1783–1809).
(Courtesy of the
Collections of the
Medical University,
Vienna)
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 Chapter 1 An introduction to endoscopy and endosurgery

Half a century later, in 1853, French surgeon

Antonin Desormeaux (Figure 1.4), another urologist,
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designed the first functional cystoscope. This device

used a Gazogene lamp, burning a mixture of turpentine
and alcohol and was based on the Lichtleiter. This
had all the drawbacks of Bozzini’s apparatus, but
prompted Desormeaux to write his monograph ‘De
l’endoscopie’ in 1865, which greatly increased interest
in endoscopy and resulted in the early commercial
production of endoscopes in the USA.

1.5 Maximilian Karl Friedrich Nitze (1848–1906).

(Courtesy of the Collections of the Medical
University, Vienna)

1.4 Antonin Jean Desormeaux (1815–1822).

(Courtesy of the Austrian Urological Society)

Up until then most attention had focused on cysto-

scopy and the urogenital tract. In 1868, a Desormeaux
endoscope was used by Adolf Kussmaul in the first
attempts to explore the oesophagus and the stomach.
Since this device was essentially a hollow rigid tube, it
was somewhat difficult to introduce into the stomach,
especially in a conscious subject, so it was probably
no coincidence that the ‘patient’ used for his demon-
stration was a professional sword swallower. Although
visualization was limited using this apparatus, the
principle of gastroduodenoscopy was born.
When Thomas Edison invented the light bulb in
1879, it was immediately seen to be the answer to
many of the problems of poor illumination in the early
endoscopes. In the same year, Maximilian Nitze
(Figure 1.5) and Josef Leiter (Figure 1.6) produced a
rigid cystoscope with a built-in light source made from
electrically heated platinum wire. The endoscope itself
incorporated a working channel and a multi-lens sys-
tem, and the whole apparatus was water-cooled, much
to the relief of their patients. They followed this up with Josef Leiter (1830–1892). (Courtesy of the
1.6
a crude gastroscope based on the same pattern. Collections of the Medical University, Vienna)

Ch01 Endo.indd 2 4/3/08 09:38:11

 Chapter 1
In 1887, Nitze and Leiter improved the design by
moving the light bulb to the distal end of the device,
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improving illumination still further. The rigid nature of
these devices limited the range of view and required
great care and skill on the part of the endoscopist to
prevent iatrogenic damage. The limitations caused by
blind spots were partly overcome by the introduction
of a gastroscope with a flexible lower tip. This was
developed in 1898 by George Kelling in Dresden, and
was controlled with a system of wire pulleys operated
from the proximal end. However, this instrument did
not prove popular and was superseded by a modifica-
tion of an earlier rigid instrument, a triple tube gastro-
scope, originally invented by Theodore Rosenheim in
Berlin in 1896.
This consisted of: an inner tube containing a
number of short focus lenses; a middle tube containing
the lighting system, derived from a water-cooled
platinum wire loop; and an outer sheath with a scale
of measurement. This was modified by Elsner in 1911
to include a rubber tip for introduction, and became
the standard gastroscope for the next 20 years.
The first attempt at an endoscopic examination of
the abdominal cavity was carried out by Dimitri
Oskarovich Ott of Petrograd, Russia in 1901. He used
a head mirror and speculum to peer through an inci-
sion made in the posterior vaginal wall. In the same
year George Kelling of Dresden, Germany, performed
the first true laparoscopy on a dog. He used a Nitze
cystoscope and insufflated the abdomen by injecting
air through a sterile cotton filter. He published this
work in 1902, terming his procedure celioscopy.
Working separately, Hans Christian Jacobaeus
from Stockholm, Sweden, published his initial series
of endoscopic examinations of patients with ascites
and coined the term laparoscopy. He went on to apply
this technique to the thorax, and performed thoraco-
scopic lysis of pleural adhesions and chest drainage
under local analgesia in a tuberculosis sanatorium.
By 1912 Kelling and Jacobaeus had reported 160
examinations and described liver pathology, neoplasia
and tuberculosis. In 1912 Victor Darwin Lespinasse,
working in Chicago, performed the first endoscopic
neurosurgical procedure: intracranial intraventricular
endoscopy and coagulation of the choroid plexus for
the treatment of hydrocephalus in two children. Walter
Dandy went on to improve the technique in 1932 with
results similar to craniotomy. In 1911 the first laparo-
scopic procedure was carried out in the USA by
Bertram Bernheim, and the diagnostic use of laparo-
scopy expanded rapidly amongst internists and
gynaecologists, but general surgeons lost interest as
the therapeutic value appeared limited.
Over the following 20 years, many modifications
to instrumentation and technique were made to
facilitate exploration of the abdominal cavity. Sharp-
tipped pyramidal trocars were introduced in 1920,
and insufflation by syringe was supplanted by a
manual insufflator operated by a foot pump, introduced
in 1921 by Goetze. A move to carbon dioxide as
the insufflation gas was made popular in 1924 by
Zollikofer in Switzerland, as it was less flammable
and more rapidly absorbed, and therefore less likely
to result in embolism. Other major advances were the
Ch01 Endo.indd 3
An introduction to endoscopy and endosurgery
introduction of a rubber gasket by Stone in the USA,
which dramatically reduced gas leakage through the
trocar, and the introduction of a new needle for
induction of pneumoperitoneum by Janos Veress
from Hungary in 1938. The Veress needle was
originally designed for induction of pneumothorax
prior to thoracoscopic treatment of tuberculosis, but it
was quickly adopted by laparoscopic surgeons. It
comprised a sharp needle containing a spring-loaded
blunt trocar to minimize trauma to intra-abdominal
organs, and is still widely used today.
Up until the 1920s endoscopes had been almost
entirely rigid instruments, often with an arrangement
of angles and mirrors to negotiate around corners. In
1920, Rudolph Schindler, a physician from Munich,
modified an old Elsner gastroscope by adding a
channel for air insufflation, which greatly improved
the image and reduced smearing of the lens with
gastric contents and mucus. The rubber tip was
inserted using a rigid inner tube that was then
withdrawn and replaced with the lens and lighting
system. In 1932 Schindler, in collaboration with
George Wolf of Berlin, replaced the lower third of the
gastroscope with a flexible bronze spiral covered in
rubber. A system of short focus lenses in the inner
tube could be bent in any direction to an angle of 34
degrees without visual distortion, thus heralding an
era of semi-flexible endoscopy, which remained
dominant until 1957.
Schindler was an inspirational teacher and
groundbreaking researcher, introducing photography
and microphotography to his work and publishing
widely. He became a world authority on endoscopy
and inspired a medical student, Heinrich Lamm, to
suggest that a bundle of flexible glass rods might
conduct light and images better than the system of
lenses traditionally used. John Logi Baird, renowned
as the inventor of the television, coincidentally
patented the idea of using curved glass rods to carry
light around a curve at about the same time, but failed
to develop his idea. Lamm spent 2 years developing
his prototype and in 1930 was able to photograph
writing on a piece of paper placed in the stomach. In
1934 Schindler, a Jew, was arrested by the Gestapo
and sent to Dachau concentration camp, where he
remained for 6 months until the combined efforts of
colleagues in the USA and Germany managed to get
him released. He travelled to Chicago where, as a
visiting professor, he established Chicago as the new
world centre of endoscopy and was responsible for a
renewed and serious interest in the manufacture of
endoscopes in the USA.
By the 1950s antibiotic therapy had largely
replaced the use of thoracoscopy in the treatment of
tuberculosis, and over the next 20 years thoracoscopy
developed as a mainly diagnostic procedure. It was
still used in the management of pleural effusion and
also for the management and biopsy of primary and
metastatic tumours. It was not until 1954 that flexible
endoscopes as we know them today were first
conceived. Harold H. Hopkins, who invented the
zoom lens in 1946, was a mathematician and
professor of applied physics at the Imperial College of
Science in London. In 1929 Hopkins had thought of
4/3/08 09:38:11
 Chapter 1 An introduction to endoscopy and endosurgery

the idea of using flexible plastic rods, coated with a at the distal end. These had a much improved image
low refractive index material and outer layer of black quality as they did not produce the pixelated image,
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paint, to transmit undistorted images from one end of which results from fibreoptic transmission.
the bundle to the other. Even at this late stage, endoscopy was largely
Instrument maker Karl Storz had suggested to used by internists in a predominately diagnostic role.
Hopkins the idea of optical fibres to transmit light, Minor procedures, such as intestinal polyp removal,
coupled with a rod lens system within an optical biopsies and bladder stone retrieval, were being
shaft to transmit images. These improvements performed but general surgeons were still rather dis-
allowed a much clearer, brighter image than had interested. The stimulus for advances in laparoscopy
been possible before, with a more natural rendition and endosurgery came from German gynaecologist
of colours. An additional advantage was that the light Kurt Semm (Figure 1.7), widely acknowledged as the
source was removed from the tip of the instrument, father of modern laparoscopy. Semm developed an
decreasing the risk of burning the patient. Storz pat- automatic carbon dioxide insufflator to monitor intra-
ented this idea in 1965, and this principle is still used abdominal pressure during laparoscopy, as well as
today in most rigid endoscopes, giving a wider field tissue morcellators, suction/irrigation systems and
of view and better light transmission with a smaller various techniques for laparoscopic haemostasis.
diameter of insertion tube than when using tradi- Above all he was an enthusiastic teacher and innova-
tional thin lenses. tor, and, with the assistance of Karl Storz, developed
Hopkins was also interested in transmitting the the pelvi-trainer, a laparoscopic model which enabled
image via optical fibres, and together with his post- surgeons to practise the vital hand–eye coordination
graduate fellow Narinder Singh Kampany, a physicist and suturing techniques necessary for successful
studying advanced optics, he researched ways of interventional laparoscopy.
coating optical fibres and arranging them in a coher-
ent bundle so that the spatial arrangement of fibres
remained unchanged along the length of the bundle.
In this way an image could be transmitted even if the
bundle were bent through 360 degrees. In 1954
Hopkins and Kampany published a report of success-
fully transmitting images through fibreoptical bundles
in Nature entitled ‘A flexible fibrescope using static
scanning’. A cardiology registrar at the Hammersmith
Hospital in London, Timothy Counihan, had read this
paper and mentioned it to a colleague, Keith Henley.
Henley was a gastroenterologist, and Counihan,
rightly as it turned out, suggested that this might have
a practical application in gastroenterology. A short
while later, Henley was in the USA and discussed the
idea over lunch with a fellow gastroenterologist Basil
Hirschowitz, a South African who trained at the Central
Middlesex Hospital in London. Hirschowitz was con-
ducting research into a miniature camera that could
be used to take diagnostic images of the gastric
lumen, and he immediately saw the potential of this
idea and contacted Kampany in London. The discus-
sion convinced Hirschowitz that these techniques
could be applied to endoscopy, and on his return to
the USA he collaborated with two physicists from
Michigan, C. Wilbur Peters and Lawrence T. Curtiss,
to produce the first working flexible fibreoptic endo-
scope in 1957. This was manufactured commercially
in 1960, and in 1962 a controllable directional tip was
introduced following a suggestion by Liverpool gastro- 1.7 Kurt Karl Stephan Semm (1927–2003).
scopist Robert Kemp. Over the following 10 years or (Courtesy of L Mettler, University of Kiel)
so further modifications were introduced, with the
addition of water and air insufflation channels and
provision for suction and passage of instruments. However, laparoscopy was still widely viewed with
Another leap forward came with the development considerable scepticism; indeed, it was variously
in 1969 of the Charged-Couple Device (CCD) by Bell thought of as unethical, reckless and even downright
Laboratories in the USA. This device is common dangerous. On one occasion Semm was in the
today in digital still and video cameras, and middle of a slide presentation on ovarian cyst
revolutionized endoscopy. CCDs are small, light, and enucleation by laparoscopy when suddenly the
very sensitive to light, and are ideal for capturing projector was unplugged with the explanation that
endoscopic images. By 1983 the first flexible video- such unethical surgery should not be presented.
endoscopes were being introduced with a CCD chip When he was appointed to the chair of the Department

Ch01 Endo.indd 4 4/3/08 09:38:11

 Chapter 1
of Obstetrics and Gynaecology at the University of
Kiel in 1970, Semm introduced laparoscopic surgery
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into his department and, at the request of co-workers,
had to undergo a brain scan because colleagues
suspected that only a person with brain damage
would perform laparoscopic surgery.
Upon requesting that surgeons at the University of
Kiel in the years 1975–1980 perform laparoscopic
cholecystectomy, Semm was greeted with laughter.
Despite all this he persisted with his vision. In 1983
Semm performed the first laparoscopic appendectomy,
making the first move from diagnostic to therapeutic
laparoscopy. When he later told a surgical meeting
what he had done, the President of the German
Surgical Society called for his suspension. But the
seed had been set.
Erich Muhe of Germany carried out the first chole-
cystectomy in 1985, amidst severe criticism from the
German Surgical Society. These procedures were dif-
ficult and awkward to perform as the surgeon had to
hold the endoscope in one hand and peer through the
oculus. Then came the development of the CCD tele-
vision camera. For the first time, cameras were small
enough to clip on to the eyepiece of an endoscope
and transmit a magnified image to a monitor. Not only
did this greatly increase the diagnostic and surgical
ability of the endoscopist, it also allowed other mem-
bers of the surgical team to view the procedure.
Surgical assistants could operate the camera and
endoscope, freeing the surgeon’s hands to enable
more delicate procedures to be carried out using two
hands, and the maintenance of a sterile field was
greatly enhanced. The first video-assisted chole-
cystectomy was carried out by Philippe Mouret of
Lyon, France in 1987, and was rapidly followed by
others. Despite the early scepticism, the advent of
video-assisted endoscopy heralded a major paradigm
shift in the view of general surgeons worldwide, and
by 1991 there was an explosion of new techniques
unparalleled in surgical history. In 1993 the National
Institutes of Health held a consensus conference,
which declared laparoscopic cholecystectomy the
treatment of choice for uncomplicated cholelithiasis.
Laparoscopic techniques were applied to almost
every aspect of abdominal and thoracic surgery, as
well as arthroscopic exploration of joints. After experi-
encing years of ridicule, Kurt Semm’s vision had
finally been vindicated.
Surgeons quickly appreciated the benefits of fewer
abdominal adhesions, faster return of bowel function
after surgery, and fewer wound complications and
postoperative infections. Patients were up and about
more quickly, freeing hospital beds, and there was
much less postoperative pain and scarring. This led
to an added impetus from patients themselves,
demanding minimally invasive procedures, and
hospital authorities were quick to appreciate the
benefits too. Laparoscopic hernia repairs and
antireflux surgery were quickly followed by techniques
for removal of solid organs, such as the spleen,
adrenal glands, liver lobes and kidney. This not only
benefited patients with organic disease but also
increased the donor pool for transplantation, since
donor organ removal became less traumatic. Initial
Ch01 Endo.indd 5
An introduction to endoscopy and endosurgery
procedures to resect colon cancer met with scepticism
and worries that it might increase wound recurrence
through seeding at the operative site. However, these
fears have not been realized and indeed rates of
recurrence have been similar or less with laparoscopic
techniques, whereas return of bowel function and lack
of adhesions have been greatly enhanced.
Veterinary surgeons have also pioneered
minimally invasive techniques since the early 1970s,
but uptake has been slow, due in part to the
considerable cost of instrumentation and the same
scepticism that so inhibited the early pioneers in the
human field. Flexible endoscopy was the first to gain
acceptance in the veterinary field with the obvious
benefit that these instruments give in the exploration
of the tubular structures of the body, in particular
the respiratory and gastrointestinal (GI) tracts. The
first reports of bronchoscopy in small animals
appeared from O’Brien in 1970 and were followed
by flexible endoscopy of the GI tract by Johnson et
al. in 1976. Biopsy samples could be taken and
foreign bodies removed without resorting to open
surgery, and these procedures rapidly gained
acceptance. Rigid endoscopy has taken longer to
become established, despite the first reports from
Dalton and Hill (1972) and Lettow (1972), working
separately, on the use of laparoscopy for evaluation
of the liver and pancreas.
Many veterinary surgeons were taught at college
that ‘wounds heal side to side, not end to end; make a
big hole’, the aim of which was to give the surgeon
optimum visualization of the surgical field. Video-
assisted endoscopy has completely superseded this
opinion by giving the surgeon a considerably
enhanced, magnified and well illuminated view of
almost the entire abdominal or thoracic cavity through
a tiny 5 mm incision. It has enabled veterinary
surgeons to visualize areas, such as the urethra and
nasal cavity, which were previously impossible to
access adequately, and even carry out endosurgical
procedures without the need for any surgical incisions.
The benefits to the patient are obvious and, much as
has been the case in human surgery, the impetus for
veterinary minimally invasive procedures may well
become client driven, at least in part. As the cost of
equipment has come down in price, it has become
economically viable to convert to minimally invasive
procedures, and human surgical equipment
manufacturers have formed veterinary divisions.
Manufacturers are also producing equipment
exclusively for the veterinary market with modifications
that suit veterinary patients and techniques, as well
as our pockets.
Incorporating endoscopy into
veterinary practice
The decision to incorporate minimally invasive surgery
and diagnostics into a companion animal practice is a
complicated one, taking into account practice
demographics, economics, staffing, physical plant
considerations, practitioner interests, and relative
proximity to similar practices.
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 Chapter 1 An introduction to endoscopy and endosurgery
Make no mistake – endoscopic equipment is
expensive. It is expensive to purchase, expensive to
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maintain and expensive to operate. For the purchase
of instrumentation, both the used secondary
equipment market and the new equipment market are
viable sources.
In the USA, where human healthcare is largely in
the competitive marketplace, the market for used
medical equipment is thriving. At top US hospitals,
when new and improved instrumentation becomes
available, there is often a race to procure the latest
and greatest in technology. The resultant excess,
high-quality equipment ends up on the secondary
market, where it is either exported overseas or sold on
to the veterinary market. In the UK, current NHS regu-
lations make it difficult for individual NHS hospitals to
dispose of excess or redundant equipment to the vet-
erinary community. The government does maintain a
resource database of available used medical equip-
ment, but it is limited, and navigating the NHS bureau-
cracy to obtain medical equipment can be frustrating.
That being said, having a good working relationship
with personnel in the operating theatres and store-
rooms of your local NHS hospital can be helpful.
Surplus equipment from the NHS and private sector is
often sold off at medical auctions, and this can be a
useful source for the veterinary surgeon. However, it
is a case of ‘buyer beware’ since the equipment is
sold with no guarantee and it can be difficult to assess
functionality in the auction environment.
The used medical equipment market, whilst
variable in inventory and quality, can be an excellent
place for the veterinary practitioner to obtain
endoscopic equipment. However, there are some
important qualifiers for navigating these resellers. It
should be borne in mind that all of the human
equipment sold on the secondary market was not
designed for small animal use. The veterinary surgeon
must have a solid understanding of what procedures
they will be performing and on what patients. For
instance, buying a very inexpensive 12 mm
sigmoidoscope will be of limited value for the feline
practitioner looking to perform small bowel endoscopy.
Taking careful stock of what equipment is needed for
the most common procedures intended to be
performed is critical prior to going shopping.
Equipment history is difficult to obtain from the
secondary market. How, where and for what
procedures the equipment was used, and if there is
any relevant repair history, all affect the potential
resale value of the equipment. Resellers often obtain
the equipment in bulk lots and have little information
to pass on to their customers. As such, warranty
information is often unavailable or limited in duration
or scope. Purchasing a 10-year-old video camera
system without a warranty can be a risky proposition,
especially if spare parts have gone off the market. It is
wise to enquire from the secondary reseller as to
whether they provide on- or off-site service, the
service costs, and spare part and repair availability. A
service contract may be available to purchase; the
cost of the contract must be evaluated in light of the
age and value of the equipment relative to its
replacement cost.
Ch01 Endo.indd 6
With the used equipment market thriving in the
USA, more and more high-quality endoscopic
equipment is making its way across the Atlantic. This
has made it much easier for practitioners to purchase
instrumentation and reduced the costs in the
secondary market. However, it is prudent for the
European veterinary surgeon to carefully evaluate the
electrical and video compatibility of North American
equipment with those available in their countries. The
electrical supply in the USA is based on a standard
110 volt power source with country-specific mains
power supply cords. Often a power converter or phase
transformer is needed to make the equipment usable
in other countries. In addition, the video standard
used in the USA is NTSC. It can be difficult to use
NTSC video cameras with monitors and video
recording apparatus using the standard European
PAL video format. Often converters are needed,
decreasing image quality, complicating set up and
increasing costs.
In response to the burgeoning need for endoscopic
instrumentation in the veterinary market, new
equipment, much of it specifically engineered for
companion animal practices, has become more
readily available. In the UK and worldwide, there are
now many companies that specifically work with the
veterinary community. New equipment almost invari-
ably costs more. However, skilled representatives
from these companies can provide advice as to the
best equipment for the particular species and
procedure. Often these companies provide excellent
warranties and service plans, guaranteeing a high
degree of ‘up-time’. In addition, continued professional
development (CPD) and installation training to
facilitate the integration of endoscopy into the practice
are often available from these companies.
Financing the purchase of endoscopic equipment
is beyond the scope of this manual. Suffice to say that
creative financing options, including leases with low-
cost buyouts, and many other options are available.
This discussion should be held with tax advisers and
other business professionals to make sure that the
best financial option is explored for the individual
practice. As competition increases, the cost of new
equipment falls, and a basic set of rigid endoscopy
equipment, including camera and monitor, now costs
roughly the same as an ultrasound machine. However,
the cost of the equipment is an abstract number
without adequate planning and prediction of the
number of procedures to be performed and the
revenue expected to be generated.
Once a general figure for the start-up costs has
been determined, it is possible to calculate the fees
needed to be generated to justify the equipment pur-
chase. It is a good idea to keep a log of the instances
in which the surgeon would consider performing an
endoscopic procedure. For example, when presented
with a sneezing dog, a note should be made that this
patient may be a potential rhinoscopy case. Similarly,
when presented with a giant-breed dog for an ovario-
hysterectomy, a note should be made of the laparo-
scopic spay and gastropexy that might be performed.
This information can then be extrapolated to come
up with a prediction of how many of each type of
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 Chapter 1
procedure might be performed over the course of the
fiscal year. These basic calculations can give a very
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rough approximation of the client costs of each pro-
cedure, being sure to account for an appropriate
profit margin. Does this number correlate well with
the fees generated by similar traditionally performed
procedures in the surgery currently? Does it allow
endoscopy to be a cost-competitive alternative to
traditional approaches?
Consideration of the demographics of the human
and animal clientele is also important. Analysis of the
clientele in terms of income, education, proximity to
large urban centres and proximity to advanced human
healthcare are all somewhat predictive of a clientele’s
likelihood of availing themselves of advanced
veterinary care. Careful observation of the type of
pets seen in the practice is also important. Is the
practice an urban small dog/cat/pocket pet practice?
Is the practice a ‘green belt’ large dog suburban
practice? Is the predominant pet the farm dog or
stable yard cat? These observations play a role in
determining the type of procedures to be performed,
the equipment needed and the numbers of cases
likely to be seen.
Another important factor to be considered is the
physical plant. Whilst most practices do not have a
dedicated endoscopy suite, it is truly wonderful if this
can be accommodated. Having a dedicated room to
perform endoscopy is a huge benefit. Indeed, having
a dedicated room for non-sterile endoscopy and a
separate theatre for surgical endoscopy would be the
best of all. In reality, it is helpful to have a theatre of
adequate size to allow for movement of the equipment
in and out of the room, and space in a non-sterile area
of the building to perform non-sterile endoscopic pro-
cedures. A wet sink table is very beneficial when per-
forming rhinoscopy, cystoscopy and colonoscopy. The
ergonomics of the workspace need to be examined to
allow for adequate access of the anaesthetist to the
patient, adequate visualization of the video monitor
and adequate room to perform the procedures appro-
priately and comfortably. These factors are covered in
the appropriate procedure chapters.
Another factor worthy of consideration is the
practitioner’s commitment to learning and perform-
ing endoscopy. Virtually all of the techniques
described in this Manual can be performed with
expertise by most practitioners. Aside from the finan-
cial commitment, the veterinary surgeon needs to
evaluate their interest in spending the requisite time
to learn and perfect the skills needed to become a
competent endoscopist. Certainly in the initial phases
of learning, procedures will take more time; frustra-
tion level can be high. But with practice and persist-
ence endoscopy will become easier and more
time-efficient. Does the practice allow for enough
time to learn these new techniques? Is the volume of
consultations and surgical procedures so great that
it makes introducing new procedures difficult? These
questions must be answered by each practice indi-
vidually, assessing the particulars of the desires of
the veterinary staff and the time constraints placed
on each veterinary surgeon.
Ch01 Endo.indd 7
An introduction to endoscopy and endosurgery
Marketing the minimally invasive surgery pro-
gramme to the clientele and veterinary community
should be an integrated component of any scheme to
establish a successful endoscopy practice. The vet-
erinary support staff of receptionists and nurses are
often the first line in introducing these procedures to
clients. When phone calls come in to the surgery, staff
should be well trained in identifying the patients for
whom a particular endoscopy might be appropriate.
The practice should be identified to the client as offer-
ing the most advanced diagnostics or treatments for
the given problem. Staff should be equipped with the
ability to answer questions regarding the superiority
of endoscopic intervention compared with traditional
approaches, including the benefits of speed of recov-
ery and less pain to their pet. When the consultation
with the veterinary surgeon is scheduled, additional
time should be allotted to allow for adequate discus-
sion of the appropriateness of endoscopic interven-
tions. Surgeons should be cautioned against
overplaying the ‘gee whiz’ factor of endoscopic sur-
gery, but rather should focus on the very real physio-
logical benefits to minimally invasive approaches.
Observations of the author [DS] over the last 10
years, from practising in both the UK and the USA,
have given the firm impression that when it comes to
medical technology, the general public is quite savvy.
Virtually every week clients come in for a consultation
and enquire as to whether the particular procedure
can be performed in a keyhole (or Band-Aid, USA)
fashion. Even on those occasions when it might not
be appropriate, it is very interesting to note how aware
clients are of the advances in surgical procedures.
When clients are presented with surgical options that
might realize less pain and trauma, and improve
recovery of their pets, they are often very keen to
explore those possibilities.
Client education brochures and pamphlets are
very helpful in disseminating information to pet
owners. Full colour glossy productions, highlighting
the unique offerings of the practice and the advanced
level of care the patients receive, will be read carefully
by owners and often distributed to their friends and
colleagues. Many practices will have open house
days at the surgery to allow the public to come in and
see for themselves the impressive level of care that
advanced endoscopic techniques will allow. Video
presentations and tours of the endoscopic theatre are
all very impressive to the general public.
Many practitioners are keen to use endoscopy
and endosurgery to augment or establish a referral
component to their practice. For the existing referral
practitioner or specialist, the introduction and
marketing of endoscopy is of critical importance. The
referring veterinary clientele are expecting their
referral and specialist sources to have access to the
most current state-of-the-art techniques. They will be
looking to the referral practitioner to allow access to
these modalities for their patients. For the first opinion
practitioner, endoscopy offers a unique opportunity to
break into the referral market. The first question for
the practitioner to ask themselves is ‘do I have the
requisite degree of expertise to offer referral services?’
Initially, it may be the case that a limited offering be on
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 Chapter 1 An introduction to endoscopy and endosurgery
the menu. Additional procedures can be added as the
practitioner gains experience with different and more
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advanced procedures. It is important for first opinion
practices to have firm and well publicised policies
regarding their referral practices. Often competing
local practices will be reluctant to send referrals to
their competitors who also provide first opinion
services, for fear of losing the client. Each practice
must make this decision, but careful consideration
must be given to developing a policy that will
encourage referrals for endoscopy and alleviate fears
of losing clients.
Many practices will put on small informal CPD
programmes to introduce their services to veterinary
surgeons in the local area. Often equipment or
pharmaceutical manufacturers can be encouraged to
help sponsor such CPD. This low key informal way of
educating and marketing new referral services is a
fun, easy way of answering questions and encour-
aging local participation in the new services from
the practice.
Patient assessment and stabilization
The initial assessment of each patient presenting for
an endoscopic or endosurgical procedure is based on
the clinical history and general haemodynamic
stability of the individual, as well as the stability for the
specific procedure being considered. Careful history-
taking should be performed:
• Diet and ho sin sho ld be estioned
• atin and drin in patterns sho ld be e al ated and digital radiography are virtually always the first
and examined in the consultation room if possible
• rinary and defecatory patterns sho ld be well as the peritoneal space. Positive and negative
evaluated
• D ration of the clinical problem and the owner s frequency than prior to endoscopy. Ultrasonography
perception of the progression of clinical signs are
important
• n iries re ardin animal ho semates and or and are commonly employed prior to endoscopy.
littermates should be made.
For any endoscopic procedure, consideration
must be given to the relative safety of general anaes-
thesia. The first consideration is haemodynamic sta-
bility. Careful auscultation of the heart and lungs is of
paramount importance. Many endoscopic procedures
have the potential to decrease ventilatory efficiency,
so it is critical that the patient has an acceptable
cardiovascular status. Ideally, resting SpO2 should be
evaluated. In addition to the standard series of bio-
chemistry analysis and complete blood count (CBC),
blood gases (arterial if possible) should be evaluated.
Thoracic radiographs should be obtained if clinically
indicated, and, if there is any clinical or historical indi-
cation of cardiac disease, an echocardiogram (ECG)
performed. The patient’s hydration status should be
evaluated both via clinical pathological analysis
(packed cell volume, PCV; total solids, TS; urine spe-
cific gravity, USG) and clinical assessment.
A good general physical examination is indicated.
The tendency to focus exclusively on body parts or
organ systems related to the presenting problem
Ch01 Endo.indd 8
should be avoided. However, special attention obvi-
ously needs to be given to the systems directly related
to the presentation, as well as to the cardiovascular
status, as noted above. A review of the previously per-
formed clinical pathology needs to be undertaken,
and, if indicated, appropriate completion of the diag-
nostic work-up prior to endoscopy. The underlying
principle for any surgical or anaesthetic intervention is
to perform the least invasive intervention needed to
diagnose and manage the presenting problem.
The first order of business is to stabilize the patient
in preparation for subsequent intervention. Supportive
management of hydration status via intravenous fluid
therapy should be dictated by clinical assessment
and clinical pathology. Cardiovascular status needs
to be monitored and maintained. Monitoring and
correction of blood gas abnormalities, thoracocentesis,
pericardiocentesis and abdominocentesis (as well as
appropriate fluid analysis of all samples) should be
performed if clinically indicated and needed to improve
haemodynamic stability. Therapy for secondary or
concomitant disease states should be undertaken,
including managing infectious diseases, vomiting and
diarrhoea, and endocrinological anomalies. Nutritional
support in the form of total or partial parenteral
nutrition, force-feeding or tube hyperalimentation
should be considered.
In spite of the advent of endoscopy in veterinary
practice, traditional diagnostic modalities have not
been abandoned. Indeed, the ability to perform mini-
mally invasive surgery has increased the use of other
imaging and diagnostic modalities as well. Traditional
imaging techniques for evaluating both the pleural as
contrast studies are still performed, albeit with less
and echocardiography and excellent techniques for
examining the internal structure and size of viscera,
Ultrasonography is very helpful in determining the
size and structure of organs such as the liver, spleen,
pancreas, bowel, adrenal glands, kidneys and bladder.
The presence and location of free peritoneal fluid can
easily be assessed. Echocardiography is ideal for
evaluating the morphology and structure of the heart,
determining both cardiovascular stability and disease
state of the heart and surrounding structures. Thoracic
ultrasonography is helpful in examining the pleural
space, although its role in assessing pathology of the
pulmonary parenchyma is less consistent.
When available, computed tomography (CT) and
magnetic resonance imaging (MRI) are also very val-
uable. MRI is excellent for examining pathology of the
nasal passages and sinuses, and CT is very helpful in
evaluating the abdomen. However, limitations of
access and cost make these modalities less fre-
quently used. This situation is rapidly changing with
an increase in the number of units in veterinary use
both in both private practice and teaching hospitals.
The endoscopist must give constant consideration
to the potential for the need for open or traditional
surgical approaches. In spite of the author’s [DS]
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 Chapter 1
keen interest in performing as much surgical and
diagnostic work as possible using endoscopic
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techniques, there are significant limitations as to what
can be accomplished endoscopically. If during the
diagnostic work-up it becomes apparent that an
aggressive surgical intervention will yield more
complete and timely information or therapeutic results,
the veterinary surgeon must remain open to the
possibility that endoscopy may not be the most
reasonable approach. The best interests of the patient
must always be the guiding principle.
Flexible versus rigid endoscopy
The flexible endoscope is essential for examining
tubular structures that have a tortuous course, such
as the GI tract or lower airways. Long flexible
endoscopes allow structures deep within the lungs
and digestive tract to be seen, and for biopsy samples
to be taken, without the need for invasive surgery.
This has obvious benefits for the patient. Their
limitations, apart from expense and the problems of
cleaning and maintenance, are due to light
transmission and instrumentation.
Flexible endoscopes are complex instruments
with channels for suction/irrigation and passage of
instruments, as well as light guide fibres and optical
image fibres, and guidewires for the angulation of the
tip. This complexity accounts for the initial expense of
the instrument and high maintenance costs, and also
gives rise to numerous nooks and crannies where
bacterial contamination can reside, making adequate
cleaning difficult but essential. The majority of flexible
endoscopes on the veterinary market are fibreoptic
endoscopes. In a fibreoptic flexible endoscope, the
image is transmitted down a bundle of optical glass
fibres to the eyepiece. This results in poorer light
transmission than a rigid endoscope and a pixelated
view of the operative site, since the final image is a
composite of a large number of smaller images
transmitted down each individual fibre.
In addition, the glass fibres are very fragile and
easily damaged, leading to black spots within the
image representing broken fibres. This further
degrades the final image. These problems have been
largely overcome by the newer video-endoscopes,
which have a digital camera chip at the business end,
but at a significant cost penalty since essentially a
separate camera is purchased with each endoscope.
As the cost of equipment comes down this will be less
of a problem, but at the moment the price premium is
not inconsiderable. Video-endoscopes are also
subject to size limitations since miniaturization of
CCDs does not currently permit the manufacture of
insertion tubes much below 6 mm in diameter.
Instrumentation for a flexible endoscope has to
pass down the instrument channel, which limits its
size and requires it to be long and flexible. In particular,
biopsy samples are necessarily small and it is
sometimes difficult to biopsy to an adequate depth to
ensure obtaining representative pathological tissue.
This is particularly true where the mucosa overlying
an area of pathology is inflamed and thickened.
Ch01 Endo.indd 9
An introduction to endoscopy and endosurgery
Rigid endoscopes are simpler in construction with
no moving parts. Light transmission and image qual-
ity is much better than with a fibreoptic flexible endo-
scope, and cleaning, sterilization and maintenance
are relatively simple. Initial cost is also considerably
less. Instrumentation for rigid endoscopy can be
larger since it does not always need to be passed
through an instrument channel. It can be passed
alongside the endoscope or indeed through a sepa-
rate operative portal. This allows larger instrumenta-
tion, which not only enables the use of a variety of
instruments akin to the normal familiar day-to-day
surgical instruments, but also allows larger tissue
samples to be taken, which can result in a higher
diagnostic yield. Rigid endoscopy also enables instru-
ments to be inserted in several ports, spaced apart,
and triangulated to the operative area. This can allow
easier surgical manipulation than a strictly linear flexi-
ble endoscope would permit, so that many of the sur-
gical operations that are currently performed through
open surgery may become possible endoscopically
with appropriate instrumentation.
The advantages of this are obvious to the patient;
smaller wounds mean less trauma and reduced
postoperative pain, rapid healing and fewer sutures to
take out. Much of the operative time in open surgery
is taken up closing the wound made in the first place.
Surgical operating time is often shorter for endoscopic
examinations, so the price differential with conventional
open surgery need not be enormous despite the
increased cost of instrumentation.
In some areas there may be overlap in the use of
rigid and flexible endoscopes. Although flexible endo-
scopes are used widely in the respiratory and GI
tracts, rigid endoscopes may be useful in some situa-
tions. Rigid endoscopes are used in tracheoscopy,
where a view down as far as the carina is possible in
most patients. Rigid instrumentation is more robust
than the smaller forceps that must be passed through
the instrument channel of a flexible endoscope and,
therefore, may be better suited for removing some
foreign bodies from the trachea or oesophagus. Rigid
biopsy forceps are also larger in size, for the same
reason, and may result in a more diagnostic sample
in sites such as the colon. Although rigid access is
limited to the descending colon, most colon pathology
is fairly diffuse and representative samples can usu-
ally be obtained from this site. Conversely, although
rigid endoscopes are more commonly used in the
nose and bladder, small flexible endoscopes can be
used to access the sinuses and the male urethra.
Future advances in endoscopic
surgery
Flexible endoscopy of the GI tract is limited to some
extent by the length of the insertion tube. Wireless
endoscopic CCD camera systems have been
developed, which can be swallowed in a capsule and
controlled from outside the body. Propulsion devices
attached to the capsule are being developed to allow
its movement to be controlled by the surgeon. In this
way, images of the entire GI tract can be obtained
4/3/08 09:38:12
 Chapter 1 An introduction to endoscopy and endosurgery
and, eventually, with the incorporation of biopsy,
cautery or laser instrumentation, minor procedures
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may be carried out without the need for any traditional
insertion tube.
Flexible endoscopes have also been developed
with zoom-enabled magnification of up to 100 times,
allowing extremely detailed mucosal analysis for the
diagnosis and management of mucosal disorders,
such as coeliac disease. The incorporation of
ultrasound devices into the tip of the flexible endoscope
enables detailed examination of structures such as
the pancreas and hepatic portal system.
There is currently a great deal of research being
carried out on endoluminal or natural orifice surgery.
Natural Orifice Transluminal Endoscopic Surgery
(NOTES) involves passing a dual operating port
flexible endoscope via the mouth and through the
gastric wall into the peritoneal cavity to carry out
laparoscopic surgery, without making any external
incision. An appendectomy has been carried out on a
human patient in India with the appendix removed via
the mouth and the gastric mucosa repaired from
within. More recently, in April 2007, at the University
Hospital of Strasbourg, the first transvaginal
cholecystectomy was performed. Various other
procedures, from splenectomy to hernia repair, have
been described in the pig model. With the advent of
improved optics, endosurgical sewing machines and
electrocautery devices, NOTES is likely to become
commonplace in future years.
Advances in surgical glues may render sewing or
stapling redundant, and greatly facilitate endosurgical
procedures; the advent of electrosurgical instruments,
such as Ethicon’s harmonic scalpel™ and Tyco’s
LigaSure™, have already improved haemostasis and
reduced the length of surgical procedures.
The use of robotics has revolutionized many
aspects of laparoscopic and thoracoscopic surgery.
In 2001, Marescaux used the Zeus robot to perform a
cholecystectomy on a patient in Strasbourg, France
with the surgical team located in New York; whilst in
Italy, in May 2006, the first surgery was performed
entirely by a robot with no human assistance. The
50-minute operation for atrial fibrillation was carried
out on a 34-year-old patient in Milan. The Da Vinci
robotic system is used in heart and prostatic surgery,
and is being applied to many other laparoscopic
procedures. There are many advantages of robotic
devices:
• he binoc lar endoscope pro ides hi h-definition cholecystectomy. Journal of the American Medical Association 269,
full colour, magnified, 3D images of the surgical
site to the surgeon who sits at a remote console
• he s r eon s hands are attached to Sircus W (2003) Milestones in the evolution of endoscopy: a short history.
manipulation controls, which have 7 degrees of
freedom movement to mimic the natural flexibility
of the human hand and wrist
10
Ch01 Endo.indd 10
• As the s r eon mo es their hands the operati e
arm of the robot mimics the movement, and the
addition of filters (similar to those employed as
‘shake’ filters in modern digital camcorders)
eliminates tremor, which can be a problem at
high magnification. This allows extremely precise
manipulation of tiny instruments for intricate
vascular and neurosurgery.
The ability to record procedures into the computer
memory, coupled with the integration of MRI and CT
scans of the patient, enables simulations to be carried
out for training purposes complete with tactile
feedback, much as an airline pilot practises in a flight
simulator. A surgeon is able to carry out ‘dummy’ runs
before performing a complex procedure on a live
patient, and the superimposition of coloured MRI
scans on live video-endoscopic images allows the
surgeon to visualize enhanced borders of abnormal
tissue to facilitate dissection.
The limits of minimally invasive surgery are being
continually expanded as technology advances. The
modern era of laparoscopy and minimally invasive
surgery, championed by Kurt Semm and others, has
revolutionized human surgery and is set to do the
same in the veterinary world. In the words of Dr
Paul A Wetter, chairman of the Society of Laparo-
endoscopic Surgeons
“Someday in the future, people will look back at a
regular surgical incision as something archaic and
barbaric. We have Kurt Semm to thank for that.”
References and further reading
Dalton JR and Hill FW (1972) A procedure for the examination of the liver
and pancreas in dogs. Journal of Small Animal Practice 13(9),
527–530
Doglietto F, Prevedello DM, Jane JA Jr., Han J and Laws ER Jr. (2005) A
brief history of endoscopic transsphenoidal surgery: from Philipp
Bozzini to the First World Congress of Endoscopic Skull Base Surgery.
Neurosurgery Focus 19 (6), E3
Harrell AG and Todd Heniford B (2005) Minimally invasive abdominal
surgery: lux et veritas past, present and future. American Journal of
Surgery 190, 239–243
Johnson GF, Jones BD and Twedt DC (1976) Esophagogastric endoscopy
in small animal medicine. Gastrointestinal Endoscopy 22, 226
Kalbasi H (2001) History and Development of Laparoscopic Surgery.
Official Journal of the Association of Iranian Endoscopic Surgeons
1 (1), 45–48
Kaushik D and Rothberg M (2000) Thoracoscopic surgery: historical
perspectives. Neurosurgery Focus 9 (4), 10
Lettow E (1972) Laparoscopic examination in liver diseases in dogs.
Veterinary Medicine Review 2, 159–167
NIH Consensus Conference (1993) Gallstones and laparoscopic
1018–1024
O’Brien JA (1970) Bronchoscopy in the dog and cat. Journal of the
American Veterinary Medical Association 156(2), 213–217
Journal of the Royal College of Physicians (Edinburgh) 33, 124–
134
Tuffs A (2003) Obituary: Kurt Semm – a pioneer in minimally invasive
surgery. British Medical Journal 327, 397
4/3/08 09:38:12
 Chapter 2 Instrumentation

2
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Instrumentation
Christopher J. Chamness

Introduction may be used for gastroscopy but not duodenoscopy.

When most veterinary surgeons hear the term
endoscopy, they think of a flexible endoscope being
used to examine the upper or lower gastrointestinal
(GI) tract. In reality, the general term endoscopy
means ‘to look inside’, and refers to an almost endless
number of applications that make use of both flexible
and rigid endoscopes. To name a few, GI endoscopy,
bronchoscopy, cystoscopy, rhinoscopy, arthroscopy,
laparoscopy and thoracoscopy are all endoscopic
procedures performed by doctors and veterinary
surgeons using flexible or rigid endoscopes,
depending upon the anatomy, available equipment
and preference of the surgeon.
Flexible endoscopes are most useful in anatomical
regions where access requires an optical instrument
that is able to turn corners, such as the GI, respiratory
and urinary tracts. It should be noted that under
certain conditions these procedures may also be
performed using rigid endoscopes, but that visual
access may be limited. For example, a rigid endoscope
The same may be used for colonoscopy but only to
examine the distal portion of the colon. Rigid endo-
scopes are preferred for cystoscopy in females but a
flexible endoscope is needed for transurethral
cystoscopy in male dogs. Either flexible or rigid endo-
scopes may be used for tracheobronchoscopy; how-
ever, a small-diameter flexible endoscope enables
the operator to reach deeper into the bronchial tree.
Flexible endoscopes
Most flexible endoscopes contain three regions
(Figure 2.1):
• The insertion tube is the part of the endoscope
that enters the patient
• The handpiece contains the manual controls and
working channel port (if present)
• The umbilical cord plugs into the light source.

Air/water valve
2.1
Suction valve
A flexible
Deflection control knob (up/down) Deflection control knob (left/right)
video-
Deflection lock (left/right)
Instrument channel cap endoscope
with 4-way tip
Instrument channel
deflection.
Programmable buttons (©Karl Storz
Insertion tube GmbH & Co.
Deflection lock (up/down) KG)
Video cable connection

Pressure Distal tip

compensation valve

Light post
Bending section

Air inlet

Connection for Irrigation bottle connection

suction pump

Tight cap for video

cable connection Distal tip
Objective lens

Light guide lenses (2)

Insufflation nozzle
Irrigation nozzle
Instrument/suction channel

Umbilical cord

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Ch02 Endo.indd 11 30/04/2013 09:06

 Chapter 2 Instrumentation

Some flexible endoscopes have no umbilical Deflection control

cord, such as the fibrescope shown in Figure 2.2. A The deflection control knobs are located on the
PDFLibrary.Net

simple light-transmitting cable, like those used for handpiece (Figure 2.4). When rotated, they cause the
rigid endoscopes, attaches to the light post of the shortening or lengthening of cables within the
handpiece. insertion tube, which deflects the distally located
bending portion of the insertion tube. The larger inner
control knob controls up/down deflection and is
operated using the left thumb. The maximal deflection
of a typical gastroscope is in the up direction, and
should be at least 180 degrees. Deflection capabilities
in the other three directions (down, left and right)
should be at least 90 degrees. The smaller outer
control knob controls left/right deflection and may be
operated using either the right hand or the thumb of
the left hand. Each deflection control knob also
Fibrescope (2.7 mm diameter, 100 cm long) contains a locking lever, which may be used to fix the
2.2
with 2-way tip deflection. (©Karl Storz GmbH &
Co. KG) deflection of the tip in any given position. Care should
be taken never to attempt deflection of the endoscope
Structure when either locking lever is in the locked position.
The flexible endoscope most commonly used by
veterinary surgeons is the gastroscope, sometimes
also referred to as a multi-purpose flexible endoscope,
since it has applications in both small and large
animals. It can be used in the GI, respiratory and
urinary tracts, depending upon patient size.
Gastroscopes have a 4-way tip deflection (i.e. up/
down and left/right) as shown in Figure 2.3. This
deflection capability is very important for the
successful manoeuvring of a gastroscope through the
small intestine, and particularly for the fine
manoeuvres required to traverse the pylorus.
Video-gastroscope handpiece. (©Karl Storz
2.4
GmbH & Co. KG)

Insufflation, irrigation and suction

Other mechanical functions of a gastroscope include
insufflation, irrigation and suction. Insufflation is
required to expand the viscus and create a space
between the distal lens of the endoscope and the
mucosa to obtain a clear image. Irrigation is needed
to clean the distal lens of the endoscope when mucus,
(a) debris or fogging obscures the view. Suction is applied
to reduce insufflation as needed and also, in some
cases, to remove fluid which may otherwise interfere
with visibility. Each of these mechanical functions is
activated by touching or depressing one of the valves
on the handpiece of the endoscope.

Instrument channel
Gastroscopes also contain an instrument channel,
the opening of which can be found at the distal end of
the handpiece. A variety of instruments, including
biopsy forceps, foreign body graspers and cytology
brushes, may be placed through this channel until
they exit the tip of the endoscope. Care should be
taken when passing instruments through the deflected
tip of an endoscope, as forceful passage of any
instrument could cause damage to the inner lining of
the instrument channel. It should be noted that the
instrument channel also serves as the suction channel
(b) for the endoscope. This means that suction will be
Tip deflection in a gastroscope. (a) Up/down significantly reduced or stopped when an instrument
2.3 is in the channel. This also means that suction will not
deflection. (b) Right/left deflection. (©Karl Storz
GmbH & Co. KG) be effective if the instrument channel cap is open.

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Ch02 Endo.indd 12 30/04/2013 09:06

 Chapter 2 Instrumentation

Insertion tube and umbilical cord

Both the insertion tube and the umbilical cord of a
PDFLibrary.Net

flexible endoscope contain glass light fibre bundles.

This is true for both fibrescopes and video-endoscopes
(see below), since light fibre bundles are used to
transmit light from the light source to the tip of the
endoscope to illuminate the area being examined.
Accordingly, the entire shaft of any endoscope should
be handled with care, avoiding banging, crushing or
tight coiling. The distal tip of an endoscope should
also be carefully protected as it contains glass lenses
and tiny nozzles for the exit of air and water.
The umbilical cord of a gastroscope contains the
connector to the light source as well as fittings for
insufflation, irrigation and suction. The insufflation
and irrigation of a gastroscope are both driven by an
air pump, which either is integrated into the light
source or is a self-contained unit that is connected via
a piece of tubing. Gastroscopes come with a small
plastic bottle that provides the water for irrigation,
which should always be demineralized or distilled in
order to prevent the channel from clogging with
mineral deposits from hard water. A fluid line on the
2.5 Leakage tester. (©Karl Storz GmbH & Co. KG)
bottle cap connects directly to the water connector on
the umbilical cord. A standard hospital suction unit is
connected to the suction connector. endoscopy. Any gastroscope used for respiratory
On video-endoscopes only, a video cable endoscopy should be sterilized prior to use. Depending
connector is located at the distal end of the umbilical on manufacturer’s recommendations, this may be
cord, for connection to a video processor which achieved either with ethylene oxide gas sterilization
transmits the image to a monitor for viewing. or by soaking in an approved cold sterilant solution
A pressure compensation valve is also typically (see below).
found at the distal end of the umbilical cord. This Since gastroscopes are typically 8–10 mm in
valve is used for leakage testing as well as pressure diameter, there is a need for smaller diameter flexible
compensation under high pressure conditions, such endoscopes to examine the respiratory and urinary
as ethylene oxide gas sterilization and shipment in tracts of dogs and cats adequately. Smaller diameter
aeroplanes. By attaching the pressure compensation ( mm) flexible endoscopes (see igures 2.2 and
cap or leakage tester to this valve, the inside of the 2.6) typically deflect only in one plane (i.e. up/down or
endoscope is opened to the external air. It is therefore up only). They also lack the dedicated insufflation and
critical that neither of these items is attached to irrigation channels of a gastroscope. However, a
the valve when the endoscope is immersed in fluids small instrument channel is typically included, which
for cleaning. can be used for the passage of instruments, suction,
and even irrigation or insufflation when needed.
Leakage testing
Endoscopes must be watertight in order to prevent
damage by fluids leaking into the inner workings,
which could corrode deflection cables and/or stain
glass fibre bundles causing brittleness and breakage.
It is therefore highly recommended that a leakage test
be performed before and after every endoscopic
procedure. The leakage tester (Figure 2.5) is attached
to the pressure compensation valve and the bulb on
the tester is squeezed until the endoscope is
pressurized to the appropriate level. The pressure
should remain stable if no leaks are present. The cost
of repairing a leak caught early is usually much less
than for a leak that has been allowed to go undetected
for a period of time.
Fibrescope (5.2 mm diameter, 85 cm long) with
2.6
2-way tip deflection. (©Karl Storz GmbH & Co. KG)
Other
Gastroscopes can also be used for bronchoscopy in
patients large enough to accept the diameter of the Video-endoscopes versus fibrescopes
gastroscope in the respiratory tract (i.e. medium- and Flexible endoscopes can be divided into two
large-breed dogs). Sterility of the endoscope is a categories: fibrescopes and video-endoscopes. Both
greater concern in bronchoscopy than it is for GI types of endoscope utilize fibreoptics for the

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 Chapter 2 Instrumentation
transmission of light from the light source to the tip of
the insertion tube in order to illuminate the area of
PDFLibrary.Net
examination. However, they use different methods for
transmitting the image from the tip of the endoscope
to the eyepiece or video monitor.
A fibrescope image is transmitted via a fibreoptic
image bundle from the objective lens at the tip of the
insertion tube to the ocular lens located in the eyepiece.
Transmission of that image to a video monitor requires
the attachment of an endoscopic video camera to the
eyepiece of the fibrescope (see below).
A video-endoscope, on the other hand, has no
image fibre bundle and no eyepiece (Figure 2.7). The
image is transmitted electronically through wires from
a sensor located just behind the objective lens at the
tip of the endoscope, along the length of the entire
endoscope directly to the video processor, and finally
to a television monitor. The sensor at the tip of the
insertion tube is a semiconductor or chip, analogous
to the one found in the camera head of endoscopic
video cameras, which attaches to the eyepiece of
fibrescopes or rigid endoscopes. For this reason,
video-endoscopes are sometime referred to as distal
chip endoscopes or chip-in-the-tip endoscopes.
Video-endoscope attached to a video
2.7
processor, light source and irrigation bottle.
(©Karl Storz GmbH & Co. KG)
The quality of a fibreoptic image is determined by
a number of factors, including the number, size,
quality and cladding of glass fibres in the image
bundle, as well as the optical technology and quality
of lenses used at the proximal and distal ends of the
image bundle. When that image is projected on to a
television screen, other critical factors determining
image quality include illumination and endoscopic
video camera and monitor technology.
Fibreoptic images may appear pixelated (i.e. a
honeycomb pattern is seen) to a greater or lesser
degree, depending on the previously mentioned
factors. It should also be noted that over time
individual glass fibres of the image bundle will
inevitably break, appearing as black spots in the
image (Figure 2.8). These individual broken fibres
can only be repaired by replacing the entire image
bundle of a fibrescope, which typically costs as
14
Ch02 Endo.indd 14
Fibreoptic image with broken fibres. (©Karl
2.8
Storz GmbH & Co. KG)
much as 50% or more of the price of a new endo-
scope. However, fibrescopes have one significant
advantage over video-endoscopes in that they cost
significantly less in the first place (i.e. they are
approximately half the cost of a video-endoscope).
The higher cost of video-endoscopes is justified,
in some cases, by the improved image quality,
reduced incidence of repair and longer lifespan of the
endoscope. However, due to the size of the distal tip
sensors required, video-endoscopes are not widely
available under about 5–6 mm in diameter. Until
manufacturers succeed in further miniaturizing these
sensors, there is no choice but to use fibrescopes for
examination of small anatomical spaces, such as the
urethra of dogs and the respiratory system of cats.
Selection
Selecting a flexible endoscope for small animal prac-
tice can be a daunting task, given the vast array of
endoscope models and sizes available, both new and
used. Given the assumption that any consumer wants
to get as much as possible for their money, the
following priorities are worthy of consideration:
• Size: is the endoscope of appropriate diameter
and length to perform the desired procedures?
• Optics: does the endoscope provide adequate
image quality to perform the desired tasks with
ease?
• Dependability: does the endoscope supplier
provide adequate warranty, service and loans in
the case of instrument failure?
• Ease of use: is the endoscope comfortable in the
operator’s hand and easy to set up, take down,
clean and store?
• Future integration: can the endoscope system be
upgraded and/or integrated with other types of
endoscopes as the practice expands in the
future?
• Cost: what is the endoscope system likely to cost
over the next 5–10 years?
Size
The most versatile endoscopes for small animal
use are <10 mm in diameter, >125 cm in length, and
have 4-way tip deflection. The small diameter and
extended length enables the small animal practitioner
30/04/2013 09:06

to examine a wide range of patients from cats and
puppies to giant-breed dogs. Some veterinary
PDFLibrary.Net
gastroenterologists prefer an endoscope 9 mm or
less in diameter, and 140 cm in length. Attention
should also be paid to the diameter of the instrument
channel, which should be at least 2 mm in order to
procure diagnostic biopsy samples. Smaller diameter
fibrescopes for respiratory and urinary endoscopy
are also available in extended lengths for veterinary
use, which is important to reach the bladder of
large-breed dogs or the distal portions of the
bronchial tree.
Optics
The optical quality of an endoscope is very difficult to
judge from specifications alone. Ideally, an objective
and ‘blinded’ comparison of the endoscopes under
consideration should be performed side-by-side in a
real patient. In addition to optical resolution, particular
attention should be paid to illumination or brightness
of the endoscopic image, especially when viewed on
a video monitor, bearing in mind that brightness will
be inversely proportional to the size of the viscus
being examined. In other words, an endoscope
system may produce a beautiful image in the palm of
your hand while being unacceptably dark in the
stomach of a dog.
Dependability
In addition to the reputation of the manufacturer, the
level of service expected from the vendor is critical.
Any new endoscope should include at least a one-
year warranty. Occasional repairs of flexible endo-
scopes are inevitable. Reputable vendors will provide
either reasonable repair turnaround times or loan
instruments in the case of extended repairs.
Ease of use
The endoscope should be handled by the potential
buyer, deflection control knobs and focus rings turned,
instruments passed through the channel, and a
thorough understanding of set up and disinfection
options obtained. For example, an endoscope that
can be entirely immersed and gas-sterilized may be
much more desirable than one that cannot.
Future integration
In the author’s experience, one endoscope is never
enough for the practice that seriously adopts this
technology. The components of a system may or may
not be compatible with other types of endoscopes.
Particular consideration should be given upon initial
investment to whether the light source, camera and
other devices are compatible with future expansion.
Cost
The overall cost of owning an endoscope may not be
directly related to the purchase price. For example,
the income-generating potential of the endoscope,
which may vary considerably for different models,
must be taken into consideration. In addition, the
cost of repairs, longevity of the product and potential
integration of the endoscope system with future
Ch02 Endo.indd 15
Chapter 2 Instrumentation
products should be taken into account. For example,
approximately half the cost of a flexible endoscope
system lies with the light source and video camera.
Ensuring that these items will function optimally
with other endoscopes as a practice progresses
may be a significant factor in determining overall
cost for endoscopy.
There is a seemingly endless supply of used
endoscopes available on the market, either online or
through second-hand dealers. Most of these
endoscopes come from the human medical field.
Buyer beware – there is a reason these endoscopes
were retired. It would behove the prudent consumer
to identify any shortcomings before making such a
purchase. In some cases, a second-hand endoscope
can be purchased in good working order at a very
reasonable price. In other cases, what appeared to
be a good deal can turn out to be money wasted on a
product that is unusable, unserviceable, or not
appropriate for the vast majority of procedures
performed by veterinary surgeons.
In addition to noting the points previously
mentioned, selection of a used endoscope should
include a rigorous examination to include leakage
testing, passage of instruments through the channel,
judgement of optical quality both through the eyepiece
and on a television monitor, light bundle integrity,
deflection of the tip and examination of the rubber
covering the bending tip of the endoscope. If at all
possible, a minimum 30-day money back guarantee
should be negotiated with the vendor of a second-
hand endoscope, which would allow several trials
in patients.
While purchasing a new endoscope direct
from the manufacturer requires more cash up front
than purchasing a second-hand endoscope, it may
cost less in the long term. The value of product
quality, full warranty, serviceability, veterinary-
specific design and the relationship between buyer
and seller should not be underestimated. Just as the
veterinary profession needs medical instrument
manufacturers to develop products specifically
suited to veterinary medicine and surgery, the
manufacturers need veterinary surgeons to invest in
their products in order to fuel that development. Only
through such collaboration will the profession be
able to benefit, as medical doctors do, from highly
advanced and cost-effective technology specifically
suited to their patients.
Instrumentation
A wide variety of reusable and disposable instruments
(Figure 2.9) is available for passing down the channel
of flexible endoscopes. Some of those commonly
used in veterinary practice include:
• Biopsy forceps
• Foreign body graspers
• Cytology brushes
• Bronchoalveolar lavage tubing
• Stone retrieval baskets (also used for foreign
bodies)
• Polypectomy snares (also used for foreign
bodies)
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30/04/2013 09:06
 Chapter 2 Instrumentation

Biopsy forceps
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Snares

Round jaws
35 mm
Large
Round jaws with pin

Oval jaws 30 mm
Medium

Oval jaws with pin

Grasping forceps
30 mm
Hexagonal
Alligator jaws

Alligator jaws, round

Universal (spoon-shaped, serrated jaws)

25 mm

Alligator jaws with teeth 40 mm

60 mm

Rat tooth

Crescent
Two-prong, 1 x 2 teeth
Cytology brush

Two-prong, 2 x 2 teeth
With protective tube

Two-prong, serrated Coagulating electrode

Unipolar or bipolar
Three-prong, sharp

Injection/aspiration needle
Three-prong, blunt

With retractable tip

Dislodger
Scissors

With four-wire basket

2.9 Flexible instruments. (Reproduced from Tams (1999) with permission from the publisher)

Although reusable instruments cost more, they
tend to last longer, and are designed for cleaning and
multiple uses. After thorough cleaning, it is
recommended that flexible instruments be oiled or
soaked in instrument milk to keep them well lubricated
and functioning properly.
It is critical that the instruments selected are of
appropriate diameter and style for the endoscope
being used. Instruments should always be passed
carefully through the channel, in a closed position,
and never forced against resistance. If the position
of an instrument requires deflection of the endo-
scope tip, it is always best to pass the forceps
through the un-deflected tip until the instrument can
be seen in the field of view, before bending the
tip with the deflection control knobs. Instrument
channel tears due to aggressive passage of instru-
ments or inappropriate instrumentation are among
the most common causes of damage to flexible
endoscopes.

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Rigid endoscopes
PDFLibrary.Net
Like flexible endoscopes, rigid endoscopes come in a
variety of sizes (Figure 2.10), making them useful for
a number of minimally invasive diagnostic and
surgical procedures. In contrast to flexible
endoscopes, rigid endoscopes are simpler, less
expensive and can last a lifetime if not dropped or
banged. Although they cannot manoeuvre around
corners through a tubular structure, like flexible
endoscopes, rigid endoscopes offer unsurpassed
optics and a rigidity that allows them to be more easily
manoeuvred inside non-tubular structures, such as
the abdomen, thorax, urinary bladder and joints. Rigid
endoscopes are therefore preferred for laparoscopy,
thoracoscopy, and arthroscopy, and for cystoscopy in
females. They are also commonly used for otoscopy
and rhinoscopy. For some surgeons they are the
endoscope of choice for oesophagogastroscopy,
tracheobronchoscopy and colonoscopy.
Rigid endoscopes (telescopes). (©Karl Storz
2.10
GmbH & Co. KG)
Structure
The highest quality rigid endoscopes are actually
telescopes, consisting of a series of rod lenses
arranged in a specific linear sequence to maximize
light transmission, magnification and resolution.
Figure 2.11 shows the HOPKINS rod lens system in
comparison with a traditional optical system. Rod
lens telescopes are capable of transmitting
considerably more light and producing a wider field of
view than traditional telescopes. Surrounding this
tube of lenses are numerous glass fibres, much like
those found in a flexible endoscope, which transmit
light from the light post of the telescope to the distal
tip of the endoscope, where the subject is illuminated.
One end of a fibreoptic light cable is connected to the
light post of the telescope and the other end is
connected to a remote light source. The image
produced through a rigid endoscope can be viewed
directly at the ocular or eyepiece of the rigid
endoscope, or transmitted to a television monitor by
attaching an endoscopic video camera to the
eyepiece. Since rigid endoscopes contain glass
lenses and glass fibres, it is important to handle them
with care. Banging or dropping them could cause
damage to the lenses or fibres, reducing image quality
and/or light transmission. A rigid endoscope may
contain one or more dislodged or cracked lenses,
which do not completely obscure the image but
reduce the quality of the image.
Ch02 Endo.indd 17
Chapter 2 Instrumentation
Conventional
optical system
Rod lens
system
HOPKINS rod lens system and a conventional
2.11
optical system. (©Karl Storz GmbH & Co. KG)
Rigid endoscopes are available in a variety of
viewing angles. The viewing angles of the telescopes
most commonly used in veterinary practice are 0
degrees and 30 degrees (Figure 2.12). A 0 degrees or
forward-viewing telescope has a field of view centred
on the axis of the telescope. A telescope with a 30
degrees viewing angle has a field of view where the
centre is offset by 30 degrees from the axis of the
telescope. Acute viewing angles enable the operator
to visualize a greater area simply by rotating the
telescope on its longitudinal axis. Although telescopes
with increasing angles of view enable examination of
a wider area, they also present a challenge to the
novice endoscopist with regards to spatial orientation,
particularly when using instrumentation through
additional ports, such as during laparoscopic and
arthroscopic surgery.
(a)
(b)
Telescope viewing angles. (a) 0 degrees.
2.12
(b) 30 degrees. (©Karl Storz GmbH & Co. KG)
Most rigid endoscopes are relatively simple in
structure (see Figure 2.10) and designed to be used
with various sheaths or cannulae. However, others
are more specialized and contain an integrated
working channel (Figure 2.13). A telescope with an
integrated channel may be more convenient for a
dedicated purpose and less susceptible to damage
than one with individual sheaths. The advantages of
these specialized designs must be weighed against
the loss of versatility inherent in such a design.
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 Chapter 2 Instrumentation

Selection
The dizzying array of rigid endoscope sizes available
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in the market place can be even more confusing than

flexible endoscopes. The most versatile endoscope
for small animal practice is the Multi-Purpose Rigid™
endoscope (Figure 2.15a). With a diameter of 2.7
mm, working length of 18 cm and a 30 degree
viewing angle, this endoscope is ideal for rhinoscopy,
cystoscopy, otoscopy (in anaesthetized patients) and
endoscopy of small exotic animals (coelioscopy and
(a)
oral cavity examinations). It is also commonly used
for arthroscopy in dogs, intubation in rabbits and
laparoscopy (Figure 2.15b) or thoracoscopy in small
mammals, kittens and puppies.

(b)

(c)
(a) Rod lens otoscope (5 mm diameter with an
2.13
integrated channel of 5 Fr). (b) Cystoscope/ (a)
rhinoscope (9.5 Fr diameter with an integrated channel of
3 Fr). (c) Operating laparoscope (10 mm diameter with a
5 mm integrated channel). (©Karl Storz GmbH & Co. KG)

The optical quality of rigid endoscopes varies

greatly and is dependent upon the optical design
and quality of lenses used in the manufacturing
process. They also vary in terms of durability,
immersibility, gas sterilizability and autoclavability.
Finally, it should be remembered that one manu-
facturer’s rigid telescope will not necessarily be
compatible with another manufacturer’s light cable,
video camera or sheath systems.
A subclass of rigid endoscopes at the lower end of
the size spectrum (i.e. <2 mm in diameter) is the (b)
semi-rigid endoscope (Figure 2.14). Rather than the Multi-Purpose Rigid™ endoscope.
rod lens optical system of larger diameter telescopes, 2.15
(a) Top down: Examination and protection
these fine-diameter semi-rigid endoscopes utilize a sheath, arthroscopy sheath, laparoscopy trocar and
fused silica bundle. These tiny semi-rigid endoscopes operating sheath. (b) Laparoscopic ovariectomy in a
are useful for the examination of anatomical areas puppy. (©Karl Storz GmbH & Co. KG)
otherwise inaccessible with rod lens telescopes or
fibrescopes, such as the trachea of small birds and When seeking the best size endoscope for a given
the urethra of male cats. medical or surgical procedure, the following concepts
should be borne in mind:

• Larger diameter endoscopes produce larger

images and transmit more light
• Smaller diameter endoscopes fit into smaller
places but transmit less light
• Longer endoscopes will reach farther but
excessive length increases the chance of
breakage
• Specific sheaths and cannulae are required for
most rigid endoscopic procedures and must fit
properly in order to perform the desired
Semi-rigid endoscope (1 mm diameter, 20 cm examination or surgery with ease, and without
2.14
long). (©Karl Storz GmbH & Co. KG) injury to the telescope or patient.

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Ch02 Endo.indd 18 30/04/2013 09:06

 Chapter 2 Instrumentation

The second most popular size of rigid endoscope

(Figure 2.16) for small animal use is a 5 mm diameter,
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0 degree laparoscope, with typically a 33 cm working

length. This telescope size is ideal for both laparo-
scopy and thoracoscopy in small animal patients. It is
also the standard laparoscope used in many human
surgical procedures, and therefore a wide variety of
ancillary instrumentation is available. Since most
laparoscopic hand instruments are also 5 mm in
diameter, this means that the telescope and instru-
ments can be passed through the same cannula, with-
out the need for reducers or different sized cannulae.
(a)

Laparoscope (5 mm diameter) (right) with a

2.16
standard trocar/cannula (middle) and EndoTIP®
cannula (left). (©Karl Storz GmbH & Co. KG) (b)

Many other sizes of rigid and semi-rigid endo-

scopes are available and useful for small animal
practice. For example, a short 1.9 mm or 2.4 mm
diameter telescope (Figure 2.17a) is commonly used
for arthroscopy in dogs. An extended length 3.5 mm
or 4 mm diameter cystoscope (Figure 2.17b) is
commonly used for uroendoscopy in larger bitches
as well as transcervical endoscopic insemination.
Long narrow rigid endoscopes (Figure 2.17c) are
used for obtaining biopsy samples and retrieving
foreign bodies from the trachea, oesophagus and
stomach. A 7 mm or 10 mm diameter telescope can
also be used for laparoscopy and thoracoscopy (see
specific chapters for recommendations of endoscope
size for each organ system).
In addition to the critical factor of size in the choice
of the appropriate rigid endoscope, the previously
mentioned recommendations for the selection of a
flexible endoscope also apply to rigid endoscopes. Of
particular importance with regard to rigid endoscopes
is the need for compatibility with appropriate sheath
systems, cannulae and connections to light sources
and video cameras.
When selecting a second-hand rigid endoscope,
particular attention should be paid to optical quality
and light transmission. A simple inspection of light
transmission can be performed by pointing the light
post towards a window or light, and examining the
distal tip of the endoscope for black or grey areas in
the light fibre transmission zone, which indicate
broken fibres. Better still, the endoscope can be
connected to the light source that will be used and the
tip placed inside a dark container of similar size to
that of the cavity to be examined. If a video camera is
to be used, it should be borne in mind that this may
require considerably more light than viewing directly
through the eyepiece.
(c)
(a) Canine arthroscope (1.9 mm diameter) in
2.17
sheath with sharp and blunt obturators.
(b) Extended length cystoscope (29 cm working length,
17 Fr outer diameter). (c) Rigid endoscope (2.9 mm
diameter, 36 cm long) with optical grasping forceps.
(©Karl Storz GmbH & Co. KG)
The shaft of the telescope, as well as its distal tip,
should be carefully inspected for any dents, cracks or
other external damage which would be likely to cause
damage to the optical system, and thus affect image
quality. An endoscope is only as good as the picture it
can produce.
Instrumentation
There is a variety of ancillary instrumentation
required to perform rigid endoscopic procedures. In
most cases, some sort of sheath or cannula is
required to gain access to the anatomical region
being examined.
• The term sheath usually refers to a tube that
locks on to the telescope, providing not only
anatomical access but also access for the
passage of instrumentation, fluids or gas as
needed for the given procedure.
• The term cannula usually refers to a tube through
which rigid endoscopes or instruments are
placed, and are freely movable within the cannula
rather than being locked in place.

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Ch02 Endo.indd 19 30/04/2013 09:06

 Chapter 2 Instrumentation

Sheaths 2.19
Operating sheaths serve a variety of functions:
PDFLibrary.Net

protection of the telescope, the ingress and egress of Multi-Purpose Rigid™

endoscope (2.7 mm
fluids via the side ports, and the passage of flexible diameter) in operating
instruments (Figure 2.18) through the channel which sheath (left) and
come into view as the forceps tip exits the sheath. arthroscope sheath (right).
This type of telescope and sheath system is commonly (©Karl Storz GmbH & Co.
used for cystoscopy, rhinoscopy and otoscopy. The KG)
same system is used without irrigation fluids for
coelioscopic examination of small birds and reptiles.

Biopsy forceps for use alongside a telescope.

2.20
(©Karl Storz GmbH & Co. KG)

operating instruments during arthroscopy require

(a) accessory instruments placed through additional
portals (for more information see Chapter 13).

Cannulae
A conventional laparoscopy trocar and cannula are
shown in Figure 2.21. The trocar has a pyramidal tip
with cutting edges, which facilitates piercing the
body wall to provide a portal for the laparoscope and
rigid instrumentation. The Luer lock valve is used for
the attachment of insufflation tubing to establish a
pneumoperitoneum during laparoscopy. The cannula
(b) contains an automatic valve which snaps shut when
(a) Multi-Purpose Rigid™ endoscope with an instrument or telescope is not in place, thus main-
2.18
operating sheath and biopsy forceps. (b) Tips taining insufflation. A rubber washer provides a tight
of a variety of 5 Fr flexible instruments. (©Karl Storz GmbH seal around the telescope or instrument when placed
& Co. KG) through the cannula (Figure 2.22).
Arthroscope sheaths (see Figures 2.15a and
2.17a) have no instrument channel but serve to
protect the telescope and provide ingress of fluid
around the telescope to distend the joint during
arthroscopy. Arthroscope sheaths are also often used
in rhinoscopy, cystoscopy and otoscopy, when the
total diameter of an operating sheath is too large for
the opening (Figure 2.19); for example, in a small
cat’s nose or urethra. hen a biopsy sample is
acquired via the arthroscope sheath, small rigid
forceps (Figure 2.20) are used alongside the
telescope. It should be noted that using a small-
diameter telescope without a sheath should be 2.21
Standard laparoscopy cannula and trocar.
avoided, since the sheath protects the telescope and (©Karl Storz GmbH & Co. KG)
provides a means for fluid ingress, which helps
maintain a clear field of view.
Since arthroscopy requires a small incision into
the joint cavity, an arthroscope sheath system has
optional sharp and blunt obturators (see Figure
2.17a), which are used for initial creation of the portal.
Once access to the joint is successfully achieved, the Telescope through cannula used for
obturator is removed from the sheath and replaced by 2.22
laparoscopy and thoracoscopy. (©Karl Storz
the arthroscope. Fluid egress and the insertion of GmbH & Co. KG)

20

Ch02 Endo.indd 20 30/04/2013 09:06


A newer style laparoscopy cannula called an
EndoTIP® (Figure 2.23) requires no trocar. Instead
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the cannula is surgically placed by making a small
stab incision through the body wall, placing the tip
of the cannula in the incision and inserting the
cannula with a twisting ‘corkscrew’-like motion. y
eliminating the need for a sharp trocar, these
cannulae minimize the risk of inadvertent laceration
of intra-abdominal organs.
EndoTIP® cannulae require no trocar for entry.
2.23
(©Karl Storz GmbH & Co. KG)
Other
Various styles of rigid instruments for laparoscopy
and thoracoscopy are available in varying lengths
and diameters (Figure 2.24a). The instruments most
commonly used in small animal laparoscopy and
thoracoscopy are palpation probes, grasping forceps
and biopsy forceps (Figure 2.24b).
(a)
(b)
(a) Rigid instruments used for laparoscopy and
2.24
thoracoscopy. (b) Laparoscopic palpation
probe, grasping forceps and biopsy forceps. (©Karl Storz
GmbH & Co. KG)
Ch02 Endo.indd 21
Chapter 2 Instrumentation
Many rigid and flexible instruments, as well as tro-
cars and cannulae, are available in both reusable and
disposable forms (Figure 2.25). Although disposable
instruments are designed and recommended for
single use only, and therefore not easily cleaned
and sterilized, many of these instruments can be
reused several times as long as sterility, lubrication
and sharpness can be maintained. Reusable instru-
mentation is designed for longevity and repeated
cleaning and sterilization, and therefore comes at a
higher price than disposables. It is important to deter-
mine which type of instrumentation is more conveni-
ent and cost-effective in the long term.
Laparoscopic surgery using a 5 mm
2.25
laparoscope and EndoTIP® cannula. Note the
use of disposable forceps for coagulation and cutting.
(©Karl Storz GmbH & Co. KG)
The endoscope system
In addition to the endoscope and instruments, a
complete endoscope system includes other devices
such as:
• A light source
• A video camera and monitor
• Other optional devices, e.g. printers, digital
capture systems, pumps for insufflation, irrigation
or suction, electrosurgical generators and/or an
arthroscopic shaver.
The most basic endoscope system must include a
light source and fibreoptic light-transmitting cable
(Figure 2.26) to deliver light through the endoscope
and illuminate the site of examination. Depending on
the particular endoscopic procedure and model of
endoscope being used, a video camera and monitor
may or may not be necessary. However, in most
cases a video camera system is highly desirable as
the image seen on a television monitor is much larger
than that which can be seen through the eyepiece of
an endoscope, and it is more comfortable for the
endoscopist to accomplish the procedure. Further-
more, video imaging allows other members of the
endoscopy team to view the procedure, and also
makes possible the storage of still images or
streaming video either digitally or on to hard copy
prints and/or VHS or digital tape.
21
30/04/2013 09:06
 Chapter 2 Instrumentation
PDFLibrary.Net
(a)
(b)
(a) Halogen light source with built-in air pump
2.26
for insufflation. (b) Fibreoptic light-transmitting
cable. (©Karl Storz GmbH & Co. KG)
The final image produced on a television monitor
originates at the endoscope tip and its quality is
dependent upon the optics of the endoscope, the
power and colour temperature of the light source, the
electronics and resolution of the endo-video camera,
and finally the quality of the terminal monitor. Each of
these devices comprises one aspect of the entire
video chain (Figure 2.27). In order for a video system
to function at its maximum potential, each item in the
chain must be functioning properly. The quality of the
final image viewed on the monitor can only be as
good as the weakest link in the chain.
Video cables
Light source Camera CCU
Light guide
cable
Monitor
Endoscope
Camera head
The video chain starts with a light source and
2.27
ends with a video monitor. (©Karl Storz GmbH &
Co. KG)
Light sources
Light sources are available in several technology
types, styles and wattages. The amount of light
required for a given procedure depends upon a
number of factors:
• The size of the cavity to be illuminated
• The type of endoscope being used
• The light sensitivity of the endo-video camera
• The condition and length of the light-transmitting
cable.
The most common light source technology types
are halogen and xenon. Halogen is the more
economical choice, whereas xenon produces a better
22
Ch02 Endo.indd 22
quality, more powerful light, for a higher price. When
comparing the output of light from sources of different
technology types, simply comparing wattages is not
sufficient. Light output is measured in lumens.
Electricity usage is measured in watts. Xenon light
sources produce more lumens per watt than halogen;
for example, a 100 watt xenon light source is much
brighter than a 150 watt halogen light source.
For many years halogen was the technology type
most commonly found in veterinary endoscope
systems. The light produced from a halogen source
may be adequate for many small animal procedures
requiring low to medium levels of illumination.
However, with the advent of video-endoscopy and
advanced procedures, such as laparoscopic surgery,
xenon light sources are becoming increasingly
popular in the veterinary endoscopy suite. The colour
temperature of xenon is 5700 Kelvin, making it a
whiter, brighter light than halogen, which burns at
approximately 3000 Kelvin. This translates into more
realistic colour rendition of tissues when viewing
endoscopic images illuminated with xenon light.
However, these colour variations can be overcome to
some extent by using a high-quality endo-video
camera with a white balance feature.
Most light sources are fitted with an intensity
adjustment control knob, and some include an integral
insufflation pump that may be used to drive the
insufflation and irrigation of a gastroscope. When
using higher quality endo-video cameras with an
auto-exposure feature, the manual adjustment of light
intensity is not critical, as the camera will automatically
illuminate the subject properly. The most versatile
light sources have the ability to adapt to a variety of
light-transmitting cables. The light connector of a
gastroscope is typically quite different from that of a
simple rigid endoscope light cable (Figure 2.28).
(a)
(b)
(a) Xenon light source (175 watt) with a
2.28
connector for a simple fibreoptic light cable.
(b) Xenon light source (100 watt) with a built-in air pump
and connection for a gastroscope. (©Karl Storz GmbH &
Co. KG)
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 Chapter 2 Instrumentation

Besides technology type and versatility, the

portability of a light source (Figure 2.29) might be
PDFLibrary.Net

important to practitioners for some situations, such as

examination room applications, mobile practice or
emergencies.

Carbon dioxide insufflator designed for

2.31
laparoscopy. (©Karl Storz GmbH & Co. KG)

gas is then delivered to the patient via sterile tubing,

which connects from the front of the insufflator to a
Veress needle or to the Luer lock connector on a
laparoscopy cannula.
The Veress needle (Figure 2.32) is used for initial
insufflation of the patient, prior to the placement of
Hand-held light source attached to a rod lens any trocars, telescope or instruments. The needle
2.29
otoscope. (©Karl Storz GmbH & Co. KG)
consists of a sharp outer cannula and a blunt hollow
inner stylet, through which the gas passes.
Pumps and insufflators
Various types of pumps and insufflators are available 2.32
to aid in endoscopic imaging or therapy. Regarding
insufflation, a very important distinction between the Veress needle.
(a) The blunt hollow
use of room air and carbon dioxide must be made. stylet protrudes
Insufflation of the upper or lower GI tract during endo- through the sharp
(a)
scopy is achieved using room air. The air pump may outer needle.
be integrated into the light source or contained within (b) The sharp
a stand-alone unit (Figure 2.30). Air distension of the outer needle with
viscus during GI endoscopy is controlled manually by the spring-loaded
stylet retracted.
depressing a valve on the gastroscope handpiece.
(©Karl Storz GmbH
(b) & Co. KG)

Pump systems for irrigation and suction are useful

for a variety of endoscopic procedures, including
otoscopy, laparoscopy and thoracoscopy. Lavage of
the external or middle ear, abdomen or thorax under
endoscopic guidance is a relatively new concept in
veterinary medicine. The therapeutic value of powerful
yet precise flushing and suctioning of contaminated or
inflamed cavities is considerable. A versatile pump
system (Figure 2.33) can be used for these procedures,
as well as for GI insufflation, irrigation and suction.
Air pump designed for insufflation during GI
2.30
endoscopy. (©Karl Storz GmbH & Co. KG)

However, the insufflation required during laparo-

scopy is typically carbon dioxide (see also Chapter
7). The choice of carbon dioxide rather than room air
eliminates the possibility of air embolism formation,
which could, in rare instances, be fatal to the patient.
An insufflator for laparoscopy (Figure 2.31) is also a
much more sophisticated and sensitive device than
the air pump used in gastroscopy. This is because it
must automatically regulate gas flow and pressure in
order to maintain appropriate pneumoperitoneum,
whilst not exceeding values that could compromise
venous return or respiration of the patient. A
pressurized tank of carbon dioxide provides the
source of gas, which is regulated by the insufflator VETPUMP®2 suitable for insufflation, irrigation
2.33
and connected to it by a high pressure hose. The and suction. (©Karl Storz GmbH & Co. KG)

23

Ch02 Endo.indd 23 30/04/2013 09:06

 Chapter 2 Instrumentation

Fluid pumps dedicated to arthroscopy (Figure

2.34) are also available and represent an advanced
PDFLibrary.Net

method of joint distension, whereby flow rates and

pressures can be accurately and quickly adjusted.
Joint distension can also be achieved by the
gravitational flow of fluids hung above the level of
the patient, or by inserting a fluid bag into a
pressurized cuff.

(a)

(b)

An arthropump accurately regulates the flow

2.34
rate and pressure of sterile fluids needed to
distend the joint space during arthroscopy. (©Karl Storz
GmbH & Co. KG)

Video imaging systems

Although endoscopic images can be viewed directly
through the eyepiece of a fibrescope or rigid telescope,
most endoscopy systems nowadays include a video
camera or processor capable of transmitting the
image to a television monitor. Not only does this
capability make performing endoscopic procedures
much more comfortable for the surgeon, but it also
enables all members of the team to view the
procedure, and allows for documentation of the
findings with video or still images.
A basic endoscopic video system consists of a
camera head with integral cable, a camera control
unit (CCU; or processor) and a video monitor (Figure
2.35a). The camera head contains a coupler which
attaches to the eyepiece of a flexible or rigid
endoscope (Figure 2.35bc). The camera head itself
contains an objective lens, a prism assembly and
either one or three sensors. The sensor is called a
CCD (charged coupled device) which is a
semiconductor or chip responsible for sensing the
image and converting it to an electronic signal. In
three-chip cameras each of the three primary colours
(red, green and blue) is transmitted separately,
resulting in a more accurate colour reproduction and
resolution than with single-chip cameras. However,
single-chip cameras are significantly less expensive
and, therefore, more common in veterinary practice. A
modern high-quality single-chip camera can produce
perfectly acceptable results for veterinary endoscopic
diagnosis and surgery. Camera heads should be
lightweight, small and easy to clean and sterilize.
Some are soakable, gas-sterilizable and even
autoclavable. If the camera head is needed for
surgery but cannot be sterilized in a timely manner, a
disposable sterile camera sleeve may be used.
(c)
(a) Basic endoscopic video system. Clockwise
2.35
(bottom left): camera head, camera control unit,
xenon light source with fibreoptic cable and video monitor.
(b) Endo-video camera attached to a rigid endoscope.
(c) Endo-video camera attached to a fibrescope. (©Karl
Storz GmbH & Co. KG)
The endoscopic image is transmitted from the
sensor in the camera head, along a series of wires in
the cable, to a CCU or processor. Here the video
signal is processed for display on the monitor as well
as for transfer to recording and printing devices.
Some newer CCUs are capable of connecting to
video-endoscopes as well as endoscopic camera
heads. These models eliminate the need for two
different CCUs.
Modern endoscopic video cameras may contain a
wide variety of features, controllable via buttons either
on the camera head or on the CCU. Some of the most
useful are white balance, freeze frame, zoom, gain,
contrast enhancement and control of peripheral
recording devices. More recently, high-definition (HD)
endoscopic video cameras have become available.
This new generation of cameras is based on a three-
chip design and represents a further step in terms of
resolution, depth perception and colour contrast. In
addition, the HD format offers a 16:9 aspect ratio,
giving the surgeon a wider lateral view than the
standard definition 4:3 aspect ratio.

24

Ch02 Endo.indd 24 30/04/2013 09:06


The video monitor provides the final display for
viewing the endoscopic image and is connected via a
PDFLibrary.Net
cable, either directly from the camera processor or
from any number of various recording devices that
may be placed in between the camera processor and
the monitor. The video chain should always terminate
with the monitor. Video cables (Figure 2.36) come in
a variety of types, including composite (BNC), S-video
(Y/C) and RGB (limited to three-chip cameras).
S-video cables transmit the highest quality signal for
single-chip video cameras. The monitor resolution
must be properly matched to the camera head
acquisition resolution, in order to take full advantage
of the image quality capabilities of an endoscopic
video camera. For example, attaching a low-resolution
consumer grade monitor to a high-quality endoscopic
video camera will not yield the best results. High-
quality single-chip cameras typically offer about 450
lines of horizontal resolution, three-chip cameras
offer 750 lines of horizontal resolution, and high-
definition cameras >1000 lines of horizontal resolution.
Composite Y/C (S-video)
Composite Y/C (S-video)
Composite Y/C (S-video)
Composite Y/C (S-video)
Y/C (S-video) RGB
2.36 Video cables. (©Karl Storz GmbH & Co. KG)
Ch02 Endo.indd 25
Chapter 2 Instrumentation
Documentation
Until recently, endoscopic documentation was limited
to video prints and video tapes. However, in the digital
age video printers and VHS recorders are rapidly
being replaced by digital capture devices, which
facilitate capturing, storing and archiving both still and
video images on to any of a variety of digital media,
including CDs, DVDs, flash drives and computer
databases. These images can then be printed
whenever a hard copy is needed, without concern for
deterioration of image quality over time. In addition,
an advanced image data archiving (AIDA®) system
(Figure 2.37a) with a touch screen is available, which
enables the endoscopist or an assistant to capture
digital still images and start or stop digital video
sequences during surgery by simply tapping an icon.
Other devices, such as the TELE PACK® (Figure
2.37b), combine a light source, air pump, camera
processor, monitor, character generator and still
image capture system into one compact unit. The
images are captured on to a PCMCIA card, which can
then be inserted into any computer for downloading.
RGB
(a) RGB
RGB
RGB
(b)
(a) The AIDA® DVD system is a digital image
2.37
capture device. (b) The TELE PACK® compact,
portable endoscopy system includes a camera, light
source, keyboard, digital capture system and integrated flat
screen monitor in one unit. (©Karl Storz GmbH & Co. KG)
25
30/04/2013 09:06
 Chapter 2 Instrumentation
Digital capture and storage of images has
numerous advantages compared with hard copy
PDFLibrary.Net
prints and video tape:
• Space-saving
• No degradation in photo quality
• Easy transmission by email to colleagues
• Easy, cost-effective duplication for colleagues,
medical records or clients.
Traditional video printing and video taping are still
available and widely used for endoscopic documen-
tation. Virtually any recording device that accepts the
proper video signal cable from the back of the camera
processor can be used to record endoscopic images.
These devices should be chosen with resolution and
colour reproduction parameters capable of reproduc-
ing high-quality images of diagnostic value.
Energy sources
As veterinary surgeons move beyond diagnostic
endoscopy into minimally invasive surgical proce-
dures, there is an increasing need for energy sources
that attach to hand instruments (both rigid and flexible)
to effect haemostasis, cutting and other desired
results, such as lithotripsy in cystoscopy and tissue
debridement or capsular shrinkage in arthroscopy.
Electrosurgery units continue to be the standard in
veterinary practice, although lasers and ultrasonic cut-
ting and coagulation devices are gaining popularity.
Electrosurgical units (Figure 2.38) operate in
either a monopolar or bipolar mode. Insulated instru-
ments are available, designed for either monopolar or
bipolar use. Monopolar settings generate a current
that runs from the instrument tip to the target tissue,
and through the body of the patient to a grounding
plate. Care must be taken to avoid lateral thermal
damage to the tissues. Bipolar settings provide a
more discrete intraoperative haemorrhage control,
use significantly less electrical voltage and current,
and do not require a grounding plate since the current
is passed between the two electrodes located at the
tip of the bipolar instrument.
An electrosurgical generator can be used for
2.38
both endoscopic and open surgery. (©Karl
Storz GmbH & Co. KG)
Care must be taken to apply the appropriate
amount of electrical energy to provide adequate
haemorrhage control, whilst preventing tissue dam-
age secondary to carbonization. A recently developed
device that addresses these concerns, and is capable
of reliably sealing vessels up to 7 mm in diameter, is
26
Ch02 Endo.indd 26
the LigaSure® vessel sealing device from Tyco (Figure
2.39). With this device, the magnitude of electrical
energy and duration of application is achieved by the
virtue of ‘smart technology’ within the generator,
which produces an audible signal when appropriate
vessel sealing has been achieved.
LigaSure® vessel sealing device (manufactured
2.39
by Tyco). (©Karl Storz GmbH & Co. KG)
Electrosurgery is particularly advantageous as
more abdominal and thoracic surgeries are being
performed via laparoscopy and thoracoscopy. By
reducing the need to exchange instruments or
introduce suture material, a single instrument capable
of both coagulation and cutting, such as the LigaSure®
or Hotblade® (Figure 2.40), can significantly reduce
surgical time.
2.40
Hotblade® disposable bipolar cutting and
coagulation instrument (manufactured by Patton
Surgical). (©Karl Storz GmbH & Co. KG)
When choosing a laser or unit for electrosurgery,
attention should be paid to whether the instrumen-
tation will be used in a fluid or gas medium, because
certain devices and instrument tips are designed to
be effective in different media. In most cases, a single
unit may be useful for both endoscopic and open
surgery.
Power shavers
Power shavers are used in arthroscopy for the rapid
debridement of tissues within the elbow, shoulder and
stifle joints. The system consists of an electronic
control box, a handpiece and a variety of tips,
including blades and burrs (Figure 2.41). Handpieces
are typically available in standard and small-joint
sizes. The latter is most appropriate for canine
arthroscopy, although a standard handpiece may be
used in the stifle joint. The handpiece connects to the
control box and also has a connector for suction
tubing, through which debrided material is removed
along with irrigation fluids, which are continually
replaced through the arthroscope cannula ingress.
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PDFLibrary.Net
Motorized arthroscopic shaver system with
2.41
handpieces and blades. (©Karl Storz GmbH &
Co. KG)
One of the primary indications for a shaver in
canine arthroscopy is debridement of the fat pad to
improve visibility in the stifle joint. For this an
aggressive cutting blade is most useful. Burrs are
used for debridement of bone. Blades and burrs come
in a variety of sizes and styles, in both reusable and
disposable designs. Each consists of two parts: a
rotating inner cutting blade or burr, and a hollow outer
cannula. The most useful sizes for canine arthroscopy
are in the range of 2.0–4.0 mm.
(a) (b)
Ch02 Endo.indd 27
Chapter 2 Instrumentation
The endoscopy team and theatre
set up
The successful establishment of an efficient and cost-
effective endoscopy service requires a dedicated
team that is thoroughly familiar with equipment set
up, procedures and trouble-shooting. Since a sub-
stantial financial investment is required, it is recom-
mended that only a limited number of well trained
staff are authorized to use and handle the instru-
mentation. One of the best sources of information
regarding equipment care and set up is a knowledge-
able vendor who is experienced in all aspects of
endoscopy instrumentation care and use.
During each endoscopic procedure it is advisable
to have a veterinary nurse or surgeon dedicated to
anaesthesia, so that the primary endoscopist is free
to focus on the endoscopy. Although many diagnostic
procedures and some simple surgeries can be
performed by a single person, there are times when
an additional pair of hands will make the procedure
much easier to perform and more time-efficient. For
example, it may be helpful to have a camera operator
during laparoscopic surgery, or an assistant to
operate the biopsy forceps and prepare the samples
for submission to the laboratory during GI endoscopy
or bronchoscopy.
It is most convenient if the endoscopy system is
stored on a ready-to-use cart or in a dedicated room,
where procedures can be initiated with a minimum of
set up time. Figure 2.42 shows two examples of
complete endoscopy systems on mobile carts, which
are easily moved to the most convenient location of a
practice as needed. Only in this way are practitioners
inclined to use the system often, and for applications
that might otherwise be overlooked or considered too
cumbersome. It is recommended that spares of
(a) Mobile cart with
2.42
monitor, digital capture
device, camera and light source.
(b) Mobile cart with flat screen
monitor, camera, light source, digital
capture device, carbon dioxide
insufflator, arthropump and
VETPUMP®2. (©Karl Storz GmbH &
Co. KG)
27
30/04/2013 09:06
 Chapter 2 Instrumentation

certain critical items be kept on hand, such as light

bulbs and flexible biopsy forceps. This prevents the
PDFLibrary.Net

need to abort a procedure once the patient is under

anaesthesia if one of these items fails.
An efficient, ergonomic set up of the cart or
Anaesthetist
operating theatre is also vital in making endoscopy ca
rt
o
attractive and minimizing fatigue. At all times the Vi
de

monitor height should be adjusted to the eye level of

the surgeon, and positioned in such a way as to
minimize neck strain. The ideal positioning of the
video monitor is directly across from the endoscopist
Anaesthesia
(Figure 2.43ab). In cases where an assistant is machine

needed, the monitor should be placed so that it is Surgeon

easily viewed by both parties (Figure 2.43c). Relatively
inexpensive flat-screen monitors can be mounted on
the walls of the endoscopy suite to aid the surgeons (a)
and/or assistant, even if they are not of the same
quality as the primary viewing monitor stored
permanently on the endoscopy tower. Video cart
Prior to the procedure, all electronic devices and
non-sterile instrumentation should be tested either by Anaesthetist

the assistant or primary endoscopist, in order to

minimize procedure time once the patient has been
anaesthetized. Prior to placing the endoscope into

Anaesthesia
Sterile table

machine
the patient, a clear, focused, white balanced image
should be obtained on the monitor. Care should
always be taken prior to, during, and after the
procedure to protect the endoscope and the camera
head, two items which represent a substantial portion Surgeon
of the cost of an endoscope system.
(b)

Care, cleaning, storage and

maintenance
Anaesthesia
Video cart
machine
Proper care, cleaning and sterilization of endoscopes Anaesthetist

and instruments will prolong the life of the equipment

and prevent iatrogenic infection of the patient. All indi-
viduals using the equipment should be trained in its
wall monitor

wall monitor
Optional

Optional
proper care and handling to prevent unnecessary
damage and costly repairs. The following recommen-
dations are general guidelines only. The manufact-
urer’s specific recommendations for care, cleaning Surgeon Assistant
and sterilization of the instrumentation purchased
should always be consulted.

• Endoscopic instrumentation should be cleaned

immediately following use. This prevents
proteinaceous matter and bodily fluids from drying Sterile table

and adhering to the surface of instruments, which (c)

makes them more difficult to clean.
• Hand instruments and trocars should be
disassembled before cleaning, disinfecting and
sterilizing, so that all surfaces and crevices are
adequately contacted with cleaning and
disinfecting agents.
• A neutral pH enzymatic cleaning solution should
be used for the initial cleaning of endoscopes
and instrumentation.
• Only distilled or demineralized water should be
used for diluting cleaning solutions and rinsing, to
avoid mineral deposits that may damage
instruments, clog channels and prevent smooth
operation of moving parts.
(a) Room set up for gastroscopy. (b) Room set
2.43
up for laparoscopy in left lateral recumbency.
(c) Room set up for laparoscopy in dorsal recumbency.
This is the ideal set up for multiple surgeons or
procedures where the surgeon must move from one side
of the patient to the other. Note the additional monitors.
(©Karl Storz GmbH & Co. KG)
• Items containing optics, such as the endoscope,
camera head and light cable, should be handled
with particular care to prevent damage to the
glass lenses or fibres. It should also be noted
whether the particular items are completely
immersible in fluids, gas-sterilizable or
autoclavable before proceeding.

28

Ch02 Endo.indd 28 30/04/2013 09:06


Cleaning
Various brushes (Figure 2.44) are available to aid in
PDFLibrary.Net
cleaning endoscopic equipment. Brushes for instru-
ment channels or the lumens of sheaths and cannu-
lae should be of the appropriate diameter and length
for the intended equipment, to avoid damage to the
instrument channel and to ensure thorough cleaning.
The length of a flexible endoscope channel cleaning
brush is important because the back-and-forth motion
of the bristles inside the channel can actually cause
micropunctures, which lead to leakage of fluids into
the inner workings of the endoscope. A flexible endo-
scope channel cleaning brush should be long enough
to pass all the way through the channel until it exits
the other end, and should be smoothly withdrawn to
prevent ‘scrubbing’ the inside of the channel.
Cleaning brushes for endoscopes and
2.44
instruments. (©Karl Storz GmbH & Co. KG)
Ultrasonic cleaners are an excellent alternative
to manual cleaning of both rigid and flexible hand
instruments. Ultrasonic cleaning is helpful in
cleaning hard to reach areas of instruments, such
as hinges and locking mechanisms, but should not
be used for any equipment that has lenses or
fibreoptic bundles.
Enzymatic cleaning solution should be disposed
of once cleaning is completed and all equipment
should be rinsed thoroughly. A clean, lint-free, soft
cloth should be used to dry the equipment com-
pletely. Alternatively, compressed air can be used
for drying; this is particularly beneficial for instru-
ment channels, lumens and hinged areas. To main-
tain the working parts of the instruments, all joints,
hinges, locks and stopcocks should be lubricated
using the manufacturer’s recommended lubricants
or instrument milk. Opening and closing joints,
hinges, locks and stopcocks repeatedly will work the
lubricant into the intended area. Any excess lubri-
cant should be removed.
Once cleaning is complete, the equipment can be
disinfected or sterilized according to the manufac-
turer’s recommendations. or soakable instrumenta-
tion, high-level disinfection can be achieved using a
manufacturer-approved disinfectant solution, such as
glutaraldehyde or MedDis™ (Medichem International
Ltd). Gluteraldehyde containing sterilization solutions
are still used quite commonly in the USA and other
countries. However, as gluteraldehyde is a known
carcinogen, its use in the UK and other EU countries
has been superseded by safer alternatives, such as
Ch02 Endo.indd 29
Chapter 2 Instrumentation
MedDis™. It is imperative to consult with appropriate
authorities to determine the safe and legal use of glu-
teraldehyde in veterinary facilities. Proper staff train-
ing, protection and ventilation are important to ensure
that these products are used in a safe and efficacious
manner. These solutions usually have a shelf-life of
14 or 28 days from the time they are activated. It is
important to follow the instructions on the label as
soaking times, solution reuse and solution disposal
may vary. It is recommended not to soak instruments
containing optics (endoscopes, light cables and cam-
era heads) in any solution for longer than 45 minutes.
Sterile water should be used to rinse equipment thor-
oughly, as disinfectant residues that come in contact
with the patient can cause irritation. Instruments
should be dried completely with sterile soft cloths or
sterile (filtered) compressed air. Lenses, light posts
and the glass surfaces of light cables can be cleaned
with alcohol wipes to thoroughly dry them and remove
any remaining residue. Disinfected instruments
should either be used immediately or stored in a man-
ner to avoid recontamination.
Sterilization
There are several methods of sterilization for endo-
scopic equipment. It is important to check with the
equipment manufacturer to determine which methods
are authorized for the instrumentation in question,
before proceeding. Equipment that is to be sterilized
will need to be packaged properly, depending on the
method of sterilization. There are a variety of storage/
sterilization trays available that are designed for spe-
cific instrumentation (Figure 2.45). The proper tray
should be chosen, based on the type of instrumenta-
tion and method of sterilization. A common method for
sterilizing rigid endoscopes, flexible endoscopes and
instruments is ethylene oxide (ETO) gas sterilization.
A pressure compensation cap must be attached to
flexible endoscopes during gas sterilization. Steam
sterilization or autoclaving is another common sterili-
zation method for some instruments and rigid endo-
scopes. Telescopes and camera heads that are
autoclavable may be authorized only for specific
cycles and temperatures. Flexible endoscopes are
usually not steam-sterilizable due to the high temper-
atures involved in this process.
Sterilization and storage tray for rigid
2.45
endoscopes and instruments. (©Karl Storz
GmbH & Co. KG)
29
30/04/2013 09:06
 Chapter 2 Instrumentation

Two additional sterilization methods, STERRAD® 2.46

and Steris, are relatively uncommon in veterinary
PDFLibrary.Net

practice due to cost. STERRAD® is a type of hydrogen Mobile cart

with
peroxide gas plasma sterilization. Steris uses video-
paracetic acid for the sterilization process. endoscope
stored in a
Storage hanging
Endoscopes and instruments should be stored in a position to
convenient and safe place, so that damage is maximize
drainage
prevented yet the equipment is readily available for and reduce
use without undue set up time. Flexible endoscopes stress on
are best stored in a hanging position (Figure 2.46) glass fibres.
to allow any residual fluid to drain and to minimize (©Karl Storz
stress on fibres, which would otherwise occur when GmbH &
left coiled for extended periods of time in the Co. KG)
transportation case.

References and further reading

Beale BS, Hulse DA, Schulz KS and Whitney WO (2003) Arthroscopic
instrumentation. In: Small Animal Arthroscopy, pp. 5–21. Elsevier
Science, Pennsylvania
Chamness, CJ (1999) Endoscopic instrumentation. In: Small Animal
Endoscopy, 2nd edn, ed. TR Tams, pp. 1–16. Mosby, Missouri
Chamness, CJ (2005) Introduction to veterinary endoscopy and
endoscopic instrumentation. In: Veterinary Endoscopy for the Small
Animal Practitioner, ed. T McCarthy, pp. 1–20. Elsevier Saunders,
Missouri
Freeman, LJ (1999) Operating room setup, equipment and instrumen-
tation. In: Veterinary Endosurgery, ed. LJ Freeman, pp. 3–23.
Mosby, Missouri
Stasi K and Melendez L (2001) Care and cleaning of the endoscope.
Veterinary Clinics of North America: Small Animal Practice –
Endoscopy, 31 (4), 589–603
Tams TR (1999) Small Animal Endoscopy, 2nd edn, Mosby, Missouri

30

Ch02 Endo.indd 30 30/04/2013 09:06


PDFLibrary.Net
Flexible endoscopy:
basic technique
Introduction
With skill and the right flexible endoscopic equipment,
most parts of the gastrointestinal (GI) tract, major air-
ways and lower urinary tract are now accessible, and
many patients have benefited from such endoscopic
investigations. However, in some cases endoscopy
may be unhelpful, and both indications and contra-
indications can be found in specific chapters.
Regrettably, endoscopy can result in serious compli-
cations, such as hypoxia during respiratory endo-
scopy and GI perforation during GI endoscopy. Thus,
‘the goal must be to maximise the benefits whilst mini-
mising the risks. The endoscopist needs to be profi-
cient, undertaking procedures for good indications on
patients who are fully prepared and protected, with
skilled assistants, and using optimum equipment. The
basic principles are similar for all areas of flexible
endoscopy, recognising specific circumstances where
the risks are greater’ (Cotton and Williams, 2003).
Minimum standards are applied to endoscopic profi-
ciency in human medicine, and the veterinary profes-
sion should aspire to the same level.
Learning the techniques needed to perform
endoscopy can, for the most part, only be obtained by
undertaking procedures on live patients. There is
some, but limited, expertise to be gained using models
or cadavers. For example, the ability to manipulate
the tip so that the endoscopic view remains centred in
the lumen of the viscus as the endoscope is advanced,
can be acquired by passing the endoscope within a
model or a fresh cadaver, although the colour,
movement and feel is not realistic. Training on healthy
animals in wet labs is not permitted within the UK
except under the Animal (Scientific Procedures) Act
1986, although such classes may be available abroad.
Therefore, in the UK, veterinary surgeons trying to
become proficient in endoscopy should ideally train
under a proficient endoscopist. Such opportunities
are limited and therefore CE courses, extensive
reading, use of models and viewing recorded
endoscopy procedures should be undertaken before
contemplating performing endoscopy.
Safe use of the endoscope
Before explaining the generic skills needed to use an
endoscope, it is important to emphasize the need for
safe practice to protect the endoscopist, the patient
and the equipment.
Ch03 Endo.indd 31
Chapter 3 Flexible endoscopy: basic technique
3
Edward J. Hall
Protecting the endoscopist
Methods for cleaning and disinfecting endoscopes
are explained in Chapter 2. Rigorous compliance is
critical in order to minimize the risk of transmitting
infection, not only from patient to patient, but also
from patient to operator. Fully immersible endoscopes
should be used, as only they can be completely
disinfected. Although the risk of a veterinary
endoscopist contracting an infection from their
patients is small compared with their medical
counterparts, contact with potentially zoonotic material
(e.g. GI contents, faeces, respiratory secretions) by
direct contact, by splashing or via aerosolization is
still possible. Appropriate precautions should always
be adopted, making the assumption that all patients
are potentially infectious, even if there is no objective
evidence of infection.
Protective clothing should always be worn, and
gowns, gloves and eye protection are all recommended.
Measures to reduce infection recommended in human
endoscopy (Cotton and Williams, 2003) include:
• earin lo es owns and eye protection
(glasses or visor)
• re ent hand-washin
• Co erin all s in brea s with waterproof
dressings
• se of paper towels when handlin soiled
accessories
• Putting soiled items directly into a sink and not
on to clean surfaces
• Appropriate disposal of ha ardo s waste
needles and syringes
• ood eneral hy ienic practice in the
endoscopy room.
Protecting the patient
Endoscopy should only be performed when indicated,
and not because the equipment is available. Thorough
investigation by blood tests, radiographs and ultra-
sound examination should generally precede endo-
scopy. The place of endoscopy in the investigation of
different organ systems is put in context in the
following chapters, but it must be remembered that
endoscopy is not without risk and may not be the best
approach in some cases. The risks and benefits to
the patient must be considered: how likely is
endoscopy to give a diagnosis versus the risk of the
anaesthetic and procedure?
31
4/3/08 09:39:31
 Chapter 3 Flexible endoscopy: basic technique

Attainment of a certain level of proficiency (see

above) is necessary before any endoscopy should be
PDFLibrary.Net

attempted, and an understanding of the role of

endoscopy in the whole diagnostic effort as well as its
indications, relative merits and dangers must be
appreciated. Inappropriate use (e.g. mishandling,
overly aggressive or forceful use) can result in
significant injury to the patient. Therefore, adequate (a)
equipment, and not necessarily the cheapest, is
needed for maximum benefit. Factors influencing the
choice of equipment are discussed in Chapter 2 and
in the specific organ chapters.
Except perhaps for proctoscopy, veterinary
patients must be anaesthetized to permit endoscopy
without compromising the safety of patient, endo-
scopist or equipment. The requirement for general
anaesthesia necessitates the presence of an assistant
to monitor the patient, as the endoscopist may be too (b)
engrossed in the procedure to recognize significant Damage to a flexible endoscope can make it
changes in vital signs before it is too late. Indeed the 3.1
unusable. (a) Compression damage to the
‘assistant’ must be in control and be able to intervene bending section of a gastroscope caused by a trolley
if the endoscopist is endangering the patient, perhaps being wheeled over the tip as it trailed on the floor.
by over-inflating the stomach. Endoscopy should (b) Breakage of the biopsy forceps due to over-vigorous
never be done single-handed. closure of the cups; excessive pressure does not improve
the biopsy quality, but stretches and ultimately breaks the
operating wire.
Protecting the endoscope
A flexible endoscope is a very effective tool if used
properly. However, inappropriate use can result not ends of the fibres and ultimately leads to fibre
only in injury to the patient but also expensive damage breakage. Thus, leakage testing should be performed
to the endoscope. As endoscope technology has after every procedure to avoid the need for expensive
advanced, instrument durability has improved, but repairs. Heat sterilization irreversibly damages the
endoscopes are expensive investments and must still whole endoscope and must never be used. Information
be handled carefully and well maintained. An on how to test for leakage, and clean and disinfect
understanding of the strengths and limitations of flexible endoscopes is detailed in Chapter 2.
endoscopic equipment and its care is essential for its For the reasons given above, it is imperative that
longevity. With care, the working life of a flexible the endoscopist takes care to ensure secure handling
endoscope should exceed 10 years, and some 20- of the endoscope. When the endoscope is being held
year old endoscopes are still in service today. outside the patient, all parts of the endoscope should
As detailed in Chapter 2, both fibreoptic and be secure, with no part being allowed to dangle or
flexible endoscopes contain light/illumination ‘guides’, swing freely and knock against a solid surface. The
i.e. bundles of glass fibreoptic fibres that transmit light endoscope can be held securely in one or both hands
to illuminate the patient. Fibreoptic endoscopes also (Figure 3.2).
contain an image bundle of similar diameter, coherent,
glass fibres. Both of these glass fibre bundles are
flexible (hence the endoscope is flexible) but very
fragile; they are susceptible to compression and
sudden shocks. Biting of the insertion tube, or trapping
it in a door or suitcase hinge, is very likely to result in
damage (Figure 3.1). However, merely tapping the
end of the endoscope on the edge of a table once
may be sufficient to shatter fibres or dislodge the
objective lens.
Illumination by the light guide will gradually
diminish as more fibres in it are broken and so minor
damage may not be instantly apparent, but the
breakage of a single fibre amongst the coherent fibres
of the image bundle immediately results in a black
spot in the viewed image. The presence of too many
broken fibres impairs viewing (see Chapter 2), and
ultimately can make the endoscope unusable. Repair
is then by replacement of the whole bundle, and can (a) (b)
cost thousands of pounds. Similarly, perforation of the Endoscopes should be carried securely in (a)
3.2
insertion tube or biopsy channel causes leakage and one or (b) both hands to avoid accidental
ingress of water, which loosens the glue securing the damage.

32

Ch03 Endo.indd 32 4/3/08 09:39:32


When the umbilical cord is attached to the light
source and the insertion tube is within the patient,
PDFLibrary.Net
only the handpiece needs to be held; however, care
should be taken when withdrawing the insertion tube
from the patient as the end may unexpectedly exit the
patient, pulled by the weight of the unsupported inser-
tion tube, and drop, potentially striking the examina-
tion table or floor and possibly causing damage.
Demonstrating the flexibility of an endoscope by
tightly coiling it should be avoided, and the bending
section should not be manipulated by the fingers; only
the control knobs should be used to check the range
of bending. The umbilical cord should be connected
and disconnected from the light source by pushing/
pulling in one line, with twisting/rocking motions
avoided. After use, especially if endoscope cleaning
is likely to be delayed, the channels should be flushed
and clean water aspirated to remove gross debris and
prevent the development of a blockage when the
channels dry out.
When the endoscope is not in use it must be
stored securely and not left unattended on a work sur-
face. It may be transported safely within its suitcase,
but should not be stored there long-term as it will ulti-
mately take on a permanent curve. Furthermore, stor-
age in the suitcase is likely to encourage microbial
growth, especially if the endoscope channels are not
dried thoroughly. Storage on a secure wall hanger
that allows the insertion tube to hang vertically and
allows free air circulation is ideal.
Preparation for endoscopy
Preparation of the patient for endoscopy varies
depending on the procedure being performed, and is
detailed in the relevant chapters. Every time before
an endoscope is used, the equipment should be
checked to ensure it works. An image should be
visible and the following components checked before
the patient is anaesthetized:
• Air p mp
• Suction
• Air water al e
• ction al e
• Disposable cap on biopsy accessory channel
• ip deflection
The light source should be switched on just before
the induction of anaesthesia. All necessary ancillary
equipment, as required for the specific procedure,
should be made available and includes some or all of
the following:
• rotecti e clothin
• o th a if performin pper or respiratory
endoscopy
• iopsy forceps
• ormalin pots
• ash t be and sterile saline
• Cytology brush and slides
• raspin forceps bas ets forceps and other
retrieval devices
Ch03 Endo.indd 33
Chapter 3 Flexible endoscopy: basic technique
• n ection aspiration needles
• ecordin e ipment (camera C and capt re
software, video or DVD recorder, etc.).
Handling the flexible endoscope
There are certain endoscopic techniques and ‘tricks’
that are applicable in specific circumstances, and
these are detailed in the relevant chapters. However,
the way to hold and use flexible endoscopes is generic
and this information follows. With practice, manoeuv-
ring becomes second nature, and the length of the
procedure becomes shorter, permitting the skilled
endoscopist to examine more carefully and consider
the findings in relation to the clinical problem and
previous experience. However, endoscopy is not a
race, and adequate time should be taken to minimize
trauma and maximize the value of any investigation.
General handling rules
The endoscope should be used gently, and excessive
force should be avoided when:
• assin the insertion t be in to the patient
• otatin the endoscope on its lon a is (applyin
torque), especially when looped within a viscus
• rnin the steerin wheels to deflect the tip
Biopsy forceps should never be inserted when the
bending section is fully retroflexed.
Holding the handpiece
When performing flexible endoscopy, the umbilical
cord is plugged into the air/water pump and light
source, and the endoscopist and patient arranged
(see Chapter 2) to permit efficient technique. The
operator holds the handpiece in their left hand, whilst
guiding the insertion tube into the patient with their
right hand (Figure 3.3).
3.3
Holding the
handpiece
correctly in the
left hand whilst
guiding the
insertion tube
with the right.
33
4/3/08 09:39:33
 Chapter 3 Flexible endoscopy: basic technique

All flexible endoscopes are currently designed for

the handpiece to be held in the left hand, and are
PDFLibrary.Net

grasped most securely by placing the control head in

the palm of the hand with the umbilical cord running
between thumb and forefinger down the back of the
hand (Figure 3.4). This positioning allows easy
placement of fingers on the valves and steering
controls and, with fibreoptic endoscopes, is necessary
to keep the endoscope in the right orientation to the
eye (see Figure 3.3).

3.4
Holding the
handpiece. The
handpiece is
held in the palm
of the left hand
with the
umbilical cord (a) (b)
running between
the thumb and
forefinger down
the back of the
hand, allowing
the fingers to
reach the
buttons and
control wheels.

(c)

When the handpiece is held in the palm, with the
umbilical cord running between the base of the thumb
and index finger, the index and middle fingers can
each be used to operate the valves, whilst the fourth
and fifth fingers give stability through a ‘two finger’
grip (Figure 3.5a). Alternatively, the third, fourth and
fifth fingers can be used to stabilize the handpiece
(Figure 3.5b). This ‘three finger’ grip requires the left
index finger to operate both valves, but does offer
greater control of steering by the left thumb. The
choice between using the two or three fingered grip is
based on the comfort of the grip, which is partly
dependent on the distance between the control
wheels and the accessory/biopsy channel opening,
and on personal preference.
Rotation of the handpiece
The handpiece can be rotated on its long axis in order
to help steer (see below). Such movement is limited if
a fibreoptic endoscope is being held to the eye, as it
generally makes the operator alter their head and/or
body position. However, if a fibreoptic endoscope with
a camera attachment or a video-endoscope is being
used, some endoscopists during gastroscopy prefer
to rotate the handpiece through 90 degrees in their
hand when almost full insertion has been achieved.
The left thumb can then work the valves, whilst the
right hand operates the steering controls (Figure 3.5c).
This reduces the strain on the endoscopist who can
remain standing upright. However, this variation is not
possible with a fibreoptic endoscope held to the eye.
3.5 Gripping the endoscope handpiece. (a) Using
the fourth and fifth fingers to stabilize the
endoscope handpiece, the left index and middle fingers
are free to operate the air/water and suction buttons,
respectively. (b) Using a three finger grip to stabilize the
handpiece, the left index finger is used to operate the
valves, whilst the thumb controls the up/down steering
wheel. (c) Rotation of the handpiece of a video-
endoscope once almost full insertion has been achieved
allows the left thumb to work the valves, and the right
thumb and fingers to manipulate the steering wheels.
Using the controls
The buttons and valves
The top of the gastroscope handpiece houses two
valves: suction and air/water. The rear button (normally
colour-coded red) controls suction and is operated by
full depression. To enable suction, the tip of the endo-
scope should be deflected into any pools of fluid and
submerged. It is not uncommon for GI mucosa even-
tually to be sucked into the channel. When released
a small red dot on the mucosa, a suction artefact,
may be seen (Figure 3.6). This is not a serious prob-
lem, but must not be mistaken for a lesion.
The forward button (normally colour-coded blue)
controls air/water instillation. Air from the air pump
passes continuously along the umbilical cord and out
through a hole in the centre of the button; coverage of
the hole by light pressure from a finger deflects the

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Ch03 Endo.indd 34 4/3/08 09:39:35

 Chapter 3 Flexible endoscopy: basic technique

3.7
PDFLibrary.Net

Holding the handpiece

of a bronchoscope; the
lever for 2-way tip
deflection is operated
by the left thumb, and
the suction button by a
finger. There is no air/
water channel in
bronchoscopes.
➚

The conventional orientation when holding the

3.6 The red dot in the mucosa (arrowed) is a gastroscope handpiece in the left hand (see Figure
suction artefact caused by tissue being sucked 3.4) permits manipulation of both steering wheels by
up accidentally, and must not be mistaken for a lesion. the left thumb and fingers. The left thumb can be used
(Courtesy of S Warman)
to move either wheel, with the free fingers being used
to lock the position of the wheel by acting as a ratchet
as the thumb is repositioned (see Figure 3.5b). Thus,
single-handed control of steering is possible with
airflow along the insertion tube and into the patient to
practice and is necessary when the right hand is
enable insufflation of the viscus. Further depression
manipulating the biopsy forceps.
of the button allows the flow of water in order to flush
In actual fact, a major part of steering can be
mucus, blood or debris from the objective lens at the
achieved simply through deflecting the tip up/down by
tip when the view is obscured.
the left thumb manipulating the inner wheel, and then
Dedicated bronchoscopes do not have an air/
flexing/extending the left wrist so that the endoscope
water button as there is no need to insufflate the
rotates on its long axis. This has the effect of making
respiratory tract to gain a view. Some, but not all,
the tip ‘look’ to the left and right (Figure 3.8) without
bronchoscopes have a suction channel, which, if the
the need to deflect the left/right wheel at all. Only
bronchoscope has been disinfected properly, can be
used to aspirate lavage fluid into a trap container put
in the suction line.

The steering wheels

Gastroscopes have two wheels on the handpiece to
control the deflection of the tip. The smaller ‘outer’
wheel (i.e. the wheel further from the body of the
handpiece) deflects the tip left/right whilst the larger
‘inner’ wheel rotates it up/down. The ability to retroflex
the bending section at least 180 degrees in at least (a)
one plane is essential for gastroscopy, and 210–90
degrees up/down is the norm for gastroscopes (see
Chapter 2). Paediatric and veterinary gastroscopes
that have a tight radius of curvature of the bending
section, to enable manoeuvring in the stomach, are
preferred.
Deflection 90–90 degrees left/right is achieved by
turning the outer wheel anticlockwise/clockwise (for-
ward/backward). Steering 210–90 degrees up/down
is achieved by turning the inner wheel anticlockwise/
clockwise (forward/backward). Dedicated broncho- (b)
scopes only need to deflect in 90–90 degrees left/ (a) Upward deflection of the endoscope tip and
right, i.e. in one plane. Such deflection is often con- 3.8
(b) longitudinal rotation effectively allow the
trolled by a simple lever, which is operated by the left endoscopist to look left or right, without having to
thumb (Figure 3.7). manipulate the left/right steering wheel.

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Ch03 Endo.indd 35 4/3/08 09:39:37

 Chapter 3 Flexible endoscopy: basic technique
when fine control is needed (e.g. traversing the
pylorus) is it necessary to use the right hand to operate
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a steering wheel, although inexperienced endoscopists
do usually find it easier to use both right and left hands
to steer. At nearly full insertion of a video-gastroscope,
when trying to intubate the pylorus, rotation of the
handpiece in the palm of the hand (see Figure 3.5c)
allows fine control of both wheels by the right hand.
Friction brakes
Friction brakes (Figure 3.9) are operated by levers or
knobs labelled ‘F’ or ‘B’. They permit the position of
any tip deflection to be maintained without holding the
steering wheel in position manually, although it is still
possible to move the steering wheels by applying
increased pressure. Devised to help maintain deflec-
tion during certain phases of human colonoscopy, the
ability to fix the endoscope tip does help the novice
endoscopist maintain the tip position at times when
the right hand is undertaking other functions such as
inserting the biopsy forceps. The experienced endo-
scopist may not need to use these brakes.
(a) (b)
3.9 Application of the deflection brakes permit the
endoscope tip to be held in a deflected position
without the need to control the steering wheels.
(a) Friction brakes ‘off’. (b) Friction brakes ‘on’.
Video-endoscope controls
Most video-endoscopes and video camera attach-
ments for fibreoptic endoscopes have up to four
buttons on the handpiece, which toggle on/off, and
can be programmed to control a number of functions
related to the image:
• ree e-frame often a small li e ima e will rotation of the handpiece whilst the tip is fixed will
appear in the corner of the screen whilst the main
image is frozen
• pen close iris to alter the ill mination le el
• Zoom in/out – to magnify the image
• ma e recorder on off pa se to control
recording to video tape or DVD
• Video print to control printin of ima es as • on it dinal rotation (tor
hard copy.
36
Ch03 Endo.indd 36
Using the endoscope in a patient
Body position
The endoscopist should either try to stand upright (to
avoid back strain) or be seated. The length of insertion
tube outside the patient should be kept in as straight
a line as possible. Leaning over the patient and
looping of the insertion tube outside the patient is
considered poor technique, leading to operator strain,
tension on the endoscope and difficulty in steering
because as soon as the tip is deflected, looping the
endoscope results in movement of the image.
Looping also makes advancement of the
endoscope more difficult: the loop grows longer as
the endoscope is inserted further and the tip does not
advance, and in the stomach the pylorus may actually
appear to move away (so-called paradoxical motion).
This problem is countered by withdrawing the
endoscope until the loop is flattened so that the
endoscope can be inserted further in a straight line.
Controlling the insertion tube
To insert the endoscope into the patient, it is necessary
to support and guide the insertion tube with the right
hand. Support is not necessary when the endoscope is
at nearly full insertion during gastroscopy or colono-
scopy; insertion and withdrawal is simply accomplished
by pushing the handpiece in and out, because the
insertion tube is being held in a straight line within the
oesophagus or large intestine and cannot loop.
Some endoscopists use an assistant to stabilize
the insertion tube and to advance or withdraw it. This
may be helpful during colonoscopy; the endoscopist’s
right hand remains clean as it does not have to touch
faecal contamination of the insertion tube. The
assistant can also manually close the anus to stop air
escaping, making insufflation more efficient. However,
having to instruct an assistant to move the insertion
tube forwards and backwards adds a layer of
complexity to the process and is not generally
recommended.
Rotating the insertion tube on its long axis
(sometimes referred to as ‘torquing’) is facilitated by
the right hand on the insertion tube whilst turning the
handpiece. This function of the right hand used to be
essential when the construction of the insertion tube
was inadequate to prevent twisting and possible
damage of the fibreoptics during rotation. In modern
endoscopes, the more robust construction means
that this role for the right hand is not essential, and
the insertion tube can be rotated simply by rotating
the handpiece. Nevertheless, longitudinal rotation
should not be performed if the endoscope is looped
within a viscus, as the distal tip may be constrained
within a length of bowel and be unable to rotate;
simply strain the fibreoptics.
Steering the endoscope
Steering is accomplished by a combination of:
• nsertion retraction
in )
• p down tip deflection
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 Chapter 3 Flexible endoscopy: basic technique

• Left/right tip deflection stomach and can be stopped by an assistant gently

• assi e mo ement as the endoscope follows the constricting the oesophagus in the neck. Similarly, an
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wall of a viscus. assistant can squeeze the anus shut during

colonoscopy to aid insufflation. Finally, neoplastic
The novice endoscopist often struggles to steer infiltration may make the GI tract wall rigid, so an
the endoscope, not only because they are not profi- inability to insufflate can be a sign of pathology,
cient in the use of the steering wheels and rotating the assuming that the other causes of failure to insufflate
endoscope (torquing), but because they dwell on (detailed above) have been ruled out.
which way to turn the endoscope tip. It is true that the
direction of tip deflection is usually written on the Red-out
steering wheels but that is of little help when trying to Although the focal length of the objective lens in
see where to go, when which way is which is not obvi- endoscopes is very short, usually being able to focus
ous. Indeed unless there are distinct visible land- at distances as near as 2–3 mm, if the lens is too
marks, such as the angularis incisura in the stomach close or even in contact with tissue, it is impossible to
(see Chapter 4), it may be impossible to determine see more than an out of focus red blur. This is called
which way is up/down–left/right except by observing ‘red-out’ (Figure 3.10).
pooling of liquid in the most dependent part. The ori-
entation within a tube (such as the oesophagus or
intestine) is not particularly relevant, as the true orien-
tation of the image depends on the relative rotational
position of the patient and the endoscope.
The experienced endoscopist does not think in
terms of turning left/right–up/down, but intuitively
knows which way to turn by observing the direction
the image moves as they start to move a steering
wheel. Unfortunately this is something that can only
be acquired through practice, although prior
proficiency on video games may impart some
advantage. The thought process involved is similar to
that of reversing a car around a corner; initially one
has to think which way to turn the wheel to direct the
car in the correct direction, but with practice it becomes
second nature. However, just as there are good and
bad drivers, some operators find endoscopy easier
than others. Nevertheless, with adequate practice,
most should be able to perform a satisfactory
endoscopic examination.
3.10 Red-out. Loss of a clear image occurs when the
Insufflation endoscope lens is too close to the GI mucosa.
The ability to instil air into the GI tract is essential to It is corrected by withdrawing the endoscope, deflecting
be able to obtain a clear view. The rate of air insuffla- the tip slightly and insufflating. (Reproduced from the
tion should be varied, depending on the size of the BSAVA Manual of Canine and Feline Gastroenterology,
patient, the ability of the viscus to expand, and the 2nd edition)
rate air escapes. The rate can be controlled by adjust-
ing the setting of the air pump and by adjusting the Novice endoscopists often feel they have done
length of time the air hole is covered. The novice something wrong when red-out occurs. However, it
endoscopist often forgets that their finger is covering happens to all endoscopists; it is just that the more
the air hole and inadvertent continuous insufflation experienced ones know how to correct the image so
leads to over-inflation of the viscus. Over-inflation of that it is not a problem. To get rid of red-out, some or
the stomach is poor technique because, as well as all of the following manoeuvres are undertaken:
making pyloric intubation difficult (see Chapter 4),
the gastric dilation impairs venous return to the heart • li ht withdrawal of the endoscope this mo es
and splints the diaphragm, threatening the anaesthe- the tip back from the mucosa
tized patient’s life. The anaesthetic assistant should • ns fflation with air inflation of the isc s mo es
always be aware of the possibility of over-inflation the mucosa away from the lens
and inform the endoscopist whenever they feel air • Deflection of the tip sli ht deflection combined
should be withdrawn. with the above techniques will allow the
If a viscus will not inflate, the first thing to check is endoscopist to obtain a view of the lumen.
that the air pump is working. If the failure of the viscus
to expand is actually because of excessive air Clearing the lens
escaping during insufflation, the rubber seal on the It is not uncommon during GI endoscopy for the lens
accessory/biopsy channel should be checked for to be obscured by blood, mucus or GI contents. This
leaks, and replaced if worn. Air escaping up the can be cleared by depressing the air/water button and
oesophagus may also prevent insufflation of the flushing with water. After flushing, a drop of clear

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Ch03 Endo.indd 37 4/3/08 09:39:39

 Chapter 3 Flexible endoscopy: basic technique

water on the tip may interfere with the view, and

should be removed by repetitively sucking and blowing
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air. Failure to flush properly may be due to:

• ac of water in the water bottle

• Blocked channel
• oss of rin aro nd water bottle endoscope
connection.

Whenever pools of liquid are found during

endoscopy, it is important to suck out the fluid as it
may obscure a lesion. If there is solid matter present,
simple washing may be enough to clear it. Where
there is more food or faecal material, larger volumes
of warm water can be flushed down the biopsy
channel from a syringe, and then aspirated. If this is
unsuccessful, repeat endoscopy after adequate
preparation of the patient may be necessary.
Occasionally during gastroscopy and duo-
denoscopy, insufflation causes bilious fluid to foam
and vision becomes obscured. In minor cases,
flushing with water and sucking out the fluid is effective
in clearing the view. In more severe cases, it is
possible to instil a dilute solution of simethicone.

Advancing through sphincters

It is generally recommended that the endoscope
should only be advanced under direct vision in order
to avoid iatrogenic damage. Within the GI tract, if the
way forward cannot be seen, the endoscope should
be withdrawn and more air insufflated until the lumen
is visible. However, that general principle may have to
be modified to traverse sphincters, such as the
oesophageal sphincters, pylorus and ileocolic valve.
Occasionally, the sphincter is open and the lumen
can be visualized as the endoscope is advanced
through, but in many cases the sphincter remains
closed. In such situations, red-out will occur until the
tip reaches the far side. In order to pass closed
sphincters, gentle pressure is applied whilst constantly
readjusting the tip to engage in the opening of the
sphincter. As red-out occurs, there is usually the
impression of aiming for the darkest area of red-out,
which represents the lumen.

Advancing around flexures

A similar problem of red-out may occur as the
endoscope advances around a flexure (e.g. proximal
duodenal flexure, colonic flexures) and the tip
impinges on the outer radius of the intestinal bend. If
the red-out is seen to be moving, it is generally safe to
keep advancing the endoscope until it enters the next
straight length of gut and the lumen can be seen
(Figure 3.11). With this ‘slide-by’ technique, it is
important to realize that the manoeuvre may have
caused some mucosal damage, and any linear
streaks of hyperaemia or haemorrhage on the mucosa
seen as the endoscope is withdrawn back around the
flexure should be recognized as artefacts. One
method that may help avoid such artefacts is to pre- Slide-by technique for advancing the
deflect the tip before the flexure is reached so that the 3.11
endoscope around flexures. Red-out occurs as
next length of intestine can be entered atraumatically the endoscope tip passes along the wall until the next
(Figure 3.12). straight length of intestine is reached.

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Ch03 Endo.indd 38 4/3/08 09:39:39


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(a)
(b)
3.12 (a) Linear haemorrhages at a small intestinal
flexture are artefactual and caused by the
endoscope tip scraping the mucosa of the outer curvature
of the flexture. (b) Pre-deflection of the tip before reaching
a flexure allows visualization along the next length of
intestine and avoids slide-by induced artefacts.
Biopsy techniques, handling and
preparation
Originally, endoscopes were devised merely to view
the inside of various organ systems. Advances in
technology now mean it is also possible to collect
Ch03 Endo.indd 39
Chapter 3 Flexible endoscopy: basic technique
fluid, cytology samples and biopsy specimens.
Therapeutic procedures are increasingly possible and
are discussed in the relevant chapters.
Brush cytology and other samples
Brush cytology
Sheathed cytology brushes are inserted via the
biopsy channel of the endoscope, opened within the
organ and rubbed against the mucosa. They are
then withdrawn into the sheath before removal from
the endoscope, and smears are made and stained.
They may be useful in the detection of Helicobacter
infection and for differentiation of neoplastic masses,
as well as for the identification of inflammatory air-
way disease.
Fluid collection
Sterile polyethylene tubing passed through the biopsy
channel can be used to collect fluid samples, e.g.
duodenal aspirates for culture. All these samples
should be collected before biopsy specimens are
taken to avoid blood contamination. Bronchoalveolar
lavage can also be performed using this tube or
through the biopsy channel if it has been sterilized
(see Chapter 6 for more further information).
Fine-needle aspiration
Fine-needle aspirates are occasionally taken with
sheathed injector needles to obtain cytological
samples from mucosal masses, but pinch biopsy
specimens for histological and other laboratory
examinations are more valuable.
Biopsy
When to perform a biopsy?
Specimens should always be obtained during
endoscopy, even if the mucosa appears grossly
normal. The exceptions to this rule are that biopsy
samples are only taken from the lower respiratory
tract and the oesophagus if there are visible lesions.
The risk of bleeding within the airway means that the
risk/benefit of biopsy is only justified if a mass or
unusual lesion is seen; brush cytology and broncho-
alveolar lavage are usually performed instead. Biopsy
of grossly normal oesophageal mucosa is not usually
undertaken as the mucosa is very tough and
inadequate tissue samples are typically obtained;
oesophagitis is usually recognizable grossly, and so
oesophageal biopsy is mostly reserved for rare cases
of oesophageal neoplasia.
Collecting biopsy specimens
Before beginning endoscopy, biopsy forceps should
be made ready and checked that the cups open. If
they are stuck, immersion in warm water or mineral oil
may release them, sometimes with gentle separation
of the cups by a fine needle or fingernail pressure.
It is difficult to operate the endoscope and the
forceps, and usually the forceps are operated by an
assistant. They should be familiar with the opening/
closing mechanism before commencing the
procedure. The thumb is inserted through the ring
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4/3/08 09:39:40
 Chapter 3 Flexible endoscopy: basic technique
and the fingers work the mechanism (Figure 3.13);
opening the hand opens the cups and vice versa. If
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the endoscope has passed around a number of
flexures, opening the cups may be difficult as the wire
is bent, and straightening the endoscope as much as
possible helps opening. The operator should not
squeeze too hard when the cups are closed, as this
does not improve the grip on the tissue, but merely
stretches the wire so that it breaks prematurely. Re-
usable forceps should be well maintained and
lubricated. Disposable biopsy forceps need no
maintenance, but are not as cost-effective as well
maintained re-usable forceps.
(a)
(b)
Correct (a) opening and (b) closing of biopsy
3.13
forceps. The thumb is inserted in the handle
and the fingers clasp the slider. As the palm of the hand is
clenched, the cups close.
When the endoscopist is taking a biopsy sample,
the forceps are inserted through the cap on the biopsy
channel, which maintains a seal preventing insufflated
air from escaping. The forceps are inserted in repeated
short lengths to avoid kinking. Similarly, forceps are
removed in short lengths after biopsy, as rapid removal
can damage the biopsy channel due to the heat
generated through friction. A cardinal rule to maintain
the health of the endoscope is that biopsy forceps
should not be inserted whilst the endoscope tip is
retroflexed. If the forceps are forced with the tip in the
retroflexed position, there is a real danger of
perforating the biopsy channel. This is as disastrous
as a hole in the outer sleeve, as it allows ingress of
water inside the endoscope, and importantly may not
be detected unless a leakage test is performed.
When the endoscopist is ready to take a biopsy
sample, they should instruct the assistant to ‘open’
and ‘close’. The tissue is grasped by the forceps cup,
but unless it is very friable it is not actually cut off;
tissue has to be avulsed by pulling the forceps sharply.
In GI tissue, a tug can often be felt as the biopsy is
avulsed, indicative that a good deep specimen has
40
Ch03 Endo.indd 40
been obtained. If the tissue pulls away easily, either it
is too superficial or it is severely diseased.
Which biopsy forceps?
There is a vast array of types of biopsy forceps
available (see Chapter 2) and it is not always clear
when a particular type is preferred. Ellipsoid cups
tend to collect more tissue than round cups, and the
presence of a fenestration in the cup potentially
reduces crush artefact by allowing the tissue to bulge
through the holes. The choice of smooth or serrated
edges to the cups depends on the toughness of the
tissue being sampled. If the tissue is very tough and
the forceps tend to slip off, forceps containing a spike
can help, although they may reduce the volume of
tissue that can be sampled. Rotatable forceps, where
turning the handle turns the cups, can be helpful if
trying to biopsy on the edge of a fold and the cups
open in the wrong plane. These forceps are more
robust but more expensive.
In reality, the two major factors influencing the size
and quality of the biopsy specimen are the size of the
biopsy forceps (as dictated by the diameter of the
biopsy channel) and the pressure exerted by the
operator. There is always a compromise between the
diameter of the biopsy channel (and hence the size of
the biopsy specimen) and the external diameter of the
endoscope (and hence the size of the patient) (see
Chapter 2).
The harder the forceps are pushed, the bigger the
tissue sample obtained (Danesh et al., 1985), and it is
here that experience pays dividends. The most
pressure can be exerted if the biopsy cups are
perpendicular to the tissue, and the experienced
endoscopist knows how to achieve this position, and
how hard to push safely. When taking biopsy speci-
mens along a tube (e.g. the descending duodenum),
‘swing-jaw’ forceps help turn the cups into the tissue
to get a bigger bite (Figure 3.14). However, whether
the increased expense of these forceps is worthwhile
is debatable. Techniques for taking biopsy specimens
from specific areas are detailed in the relevant
chapters, but in general deflation of a viscus before
biopsy can increase the size of the sample, by
reducing stretching of the mucosa.
(a)
(b)
(a) As ‘swing-jaw’ biopsy forceps are opened
3.14
(b) the cups tilt towards the tissue. This aids
taking biopsy samples when the forceps are not
perpendicular to the tissue surface.
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 Chapter 3 Flexible endoscopy: basic technique

Processing biopsy specimens

There are two ways of dealing with the biopsy
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specimen when the forceps have been withdrawn

from the endoscope. The cups can simply be
immersed in 10% formalin and opened, releasing the
tissue into the pot, or the specimen can be carefully
removed from the cups with a fine needle and oriented
before fixation. The tissue can be laid on card or even
slices of cucumber, but tissue cassettes with a foam
insert (Figure 3.15) are easiest to use.

3.15 (a) 1.0 mm

Tissue cassette with
foam insert for collecting
biopsy specimens
before fixation in
formalin and processing.

(b) 1.0 mm

The needle and cassette method has the advan-

tage that histological processing is more efficient;
samples are not lost and tissue is not sectioned in the
wrong plane. However, the method is tedious and the
sample can become macerated as it is manipulated
by the needle. Proponents of the immersion method
argue that it is much quicker and that many more
specimens can be collected in the same time, so that
it does not matter if some are lost or wasted in
processing. Of course the forceps cups must be
rinsed before being reinserted into the endoscope.
It is rare to take more than two or three specimens (c) 1.0 mm
from the respiratory tract, but at least six and preferably
nearer twelve samples should be collected from each 3.16 Sections of endoscopic biopsy samples
demonstrating common artefacts. (a) Crush
region of the GI tract examined (with the exception of artefact with loss of discernible tissue and cellular
the oesophagus, see above). This number is neces- structure. (b) Cross-section of isolated villi when tissue is
sary because some specimens may be too small, not oriented in a perpendicular fashion. (c) Fragmentation
some may fragment or be lost in processing, and some of a small tissue biopsy sample. H&E stained sections.
may be sectioned in the wrong plane (Figure 3.16). (Reproduced from the BSAVA Manual of Canine and
Biopsy specimens are usually processed for Feline Gastroenterology, 2nd edition)
routine histology, but samples can also be used for
electron microscopy, immunohistochemistry and bio- any lesions found during endoscopy, in addition to
chemical analysis. Cytological examination of squash taking biopsy specimens. It is also sometimes
preparations may be worthwhile if trying to reach an suggested that either the whole procedure or at least
early presumptive diagnosis of lymphoma, but they images of all landmarks are recorded to be able to
are difficult to interpret. prove that a full examination was performed in case
of future litigation.

Image recording
All endoscopic investigations should be accompanied
by a written report, and standardized proformas are
being produced (see Chapter 4). Alternatively, there
are software packages that produce a written report
incorporating recorded images.
There are a variety of ways of recording the
endoscopic image, as detailed in Chapter 2. For
good medical records it is advisable to try and record
References and further reading
Cotton PB and Williams CB (2003) Practical Gastrointestinal Endoscopy:
the fundamentals, 5th edn. Blackwell Publishing Ltd., Oxford
Danesh BJZ, Burke M, Newman J et al. (1985) Comparison of weight,
depth, and diagnostic adequacy of specimens obtained with 16
different biopsy forceps designed for upper gastrointestinal endoscopy.
Gut 26, 227–231
Simpson JW (2005) Gastrointestinal endoscopy. In: BSAVA Manual of
Canine and Feline Gastroenterology, 2nd edn, ed. EJ Hall, JW Simpson
and DA Williams pp. 34–49. BSAVA Publications, Gloucester.
Tams TR (1999) Small Animal Endoscopy, 2nd edn. Mosby, St. Louis

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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract
4
PDFLibrary.Net
Flexible endoscopy: upper
gastrointestinal tract
Edward J. Hall
Introduction
Upper gastrointestinal (GI) endoscopy is one of the
most common endoscopic procedures performed in
companion animal practice, and encompasses exami-
nation of the oesophagus, stomach and proximal
small intestine. It is possible to examine the oesopha-
gus with a rigid endoscope (which may also be useful
for foreign body removal) but a flexible endoscope is
preferred for diagnostic investigation of the oesopha-
gus, and is essential to be able to examine the stom-
ach completely and to intubate the small intestine. And
whilst early flexible endoscopes were only able to per-
mit observation of the GI tract, modern gastroscopes
can now also be used for sampling tissues and liquids
and even for some therapeutic procedures.
This endoscopic procedure is minimally invasive
and atraumatic, with low morbidity and very low
mortality. Hence its popularity as a way of investigating
GI disease is increasing almost exponentially.
However, it should only be used in cases where a
diagnosis has not been achieved by conventional
non-invasive investigations. Furthermore, to perform
this procedure effectively and safely takes much
practice and it is sensible to use the endoscope
initially only to carry out simple procedures, such as
oesophagoscopy, to avoid the disappointment of
failure whilst developing skill and confidence.
Passage through the pylorus into the duodenum
should not be expected at the first attempt; even the
most experienced endoscopist finds this process
difficult sometimes and occasionally impossible.
Role of endoscopy in investigating
GI disease
Complete information on the investigation of GI
disease is available in the BSAVA Manual of Canine
and Feline Gastroenterology, but it should be
emphasized here that endoscopy and GI biopsy are
only part of the investigative process. Before
endoscopy, routine investigations should be
performed to confirm that the procedure is indicated.
A complete history and full physical examination is
mandatory, and a faecal examination is important if
there is diarrhoea. Routine laboratory tests will
determine firstly whether systemic disease is causing
the GI signs, and secondly whether it is safe to
anaesthetize the patient.
42
Ch04 Endo.indd 42
Plain thoracic and abdominal radiographs and
an abdominal ultrasound examination should also
always be performed before endoscopy to ensure
there are no unexpected foreign bodies present or
masses/lesions beyond the reach of the endoscope.
However, the place of contrast radiography has
changed since endoscopy has become available;
although, it should be considered a complementary
procedure and not necessarily redundant. Contrast
procedures do not require anaesthesia and provide a
better estimation of oesophageal diameter and
function, and gastric motility and emptying. Radio-
graphs and ultrasonography also detect extramural
diseases. However, endoscopy is more sensitive for
the detection of mucosal disease and has the clear
advantage of a potential, definitive diagnosis through
biopsy. Yet the limitations of endoscopy should be
recognized (Figure 4.1).
Endoscopy cannot assess:
• Functional diseases
• Motility disorders
• Hypersecretory disorders (e.g. enterotoxigenic bacteria)
rush border enzyme deficiencies
• The whole GI tract
• Submucosal lesions
• Intraperitoneal lesions
Limitations of endoscopy in investigating upper
4.1
GI disease.
Indications
Endoscopy is often indicated in the investigation of
suspected oesophageal, gastric and small intestinal
disease if the lesion can reasonably be expected to
be accessible from the GI tract lumen. Exploratory
surgery is realistically the only other alternative for
reaching a definitive diagnosis, but there is clearly an
increased risk with surgery (Shales et al., 2005) and
an inevitable convalescence period whilst wounds
heal. In addition, patients with protein-losing entero-
pathies often have impaired healing and endoscopy
provides the safest method of obtaining a definitive
diagnosis in most cases. Thus, the clinical advantages
of endoscopy to patients are:
30/04/2013 09:13
 Chapter 4 Flexible endoscopy: upper gastrointestinal tract

• Can be discharged on the same day as the It should again be stressed that upper GI
procedure endoscopy is only part of the investigation of
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• No convalescence or wound healing suspected GI disease, and that it is inappropriate to

• Can be immediately treated with steroids if
indicated.
The recommended best practice for intestinal
biopsy (Figure 4.2) is to perform endoscopy first and
reserve surgery for focal diseases or where endoscopy
fails to provide an answer (Elwood, 2005).
Yet it is important to emphasize that with some
diseases (e.g. lymphangiectasia, alimentary lymph-
oma) endoscopic biopsy samples may not be diag-
nostic and full-thickness biopsy material from
laparoscopy or exploratory laparotomy may be
required. Exploratory surgery has a higher diagnostic
sensitivity as the whole GI tract can be examined,
full-thickness biopsy specimens can be obtained from
all levels of the GI tract, and intraperitoneal disease
can be investigated. Even if ileoscopy (via colon-
oscopy; see Chapter 5) is performed in addition to
upper GI endoscopy, there is a significant length of
intestine that cannot be examined by standard flexi-
ble endoscopes, and views of the pancreas, liver and
other abdominal organs are, hopefully, never seen.
Endoscopic intestinal biopsy:
• Is preferred
• Is adequate for diagnosis in most cases
Carries a significantly lower risk than surgery
Effective endoscopic intestinal biopsy requires:
• A competent endoscopist using adequate technique
• The endoscopist to have clinical responsibility and to work with an
experienced pathologist
Surgical biopsy should be reserved for those cases:
• Where diseased tissue is known to be beyond the reach of an
experienced endoscopist
• When endoscopic biopsy has failed to produce a diagnosis
• Where non-mucosal disease is suspected or full-thickness biopsy
is required
Best practice in intestinal biopsy (Elwood,
4.2
2005).
perform the procedure before less invasive and less
risky investigations have been performed. The value
of routine laboratory tests to rule out non-GI disease,
and diagnostic imaging (plain radiographs and
ultrasonography) to localize disease and identify
surgical conditions, must never be forgotten and they
should precede endoscopy routinely.
Full upper GI endoscopy
In patients where clinical signs or other investigations
do not localize the disease, a full endoscopic
examination (i.e. oesophago-gastro-duodenoscopy)
should always be performed. However, if oesophageal
disease is suspected from the clinical signs and/or
radiographs, there is usually no need to advance
beyond any significant lesion that is found. In contrast,
when performing gastroscopy, it is likely (and
therefore standard practice) that it will be necessary
to examine the small intestine as well as the stomach.
For example, an animal presenting with vomiting due
to gastric ulcers may also be suffering from intestinal
disease, which can cause vomiting as well, and
duodenal biopsy samples are necessary to rule this in
or out. Thus, endoscopists need to be able to intubate
the duodenum if they are to perform an adequate
examination, and inexperienced endoscopists should
not be investigating such cases until proficient.
It is impossible to be proscriptive about how an
individual actually performs endoscopy, and the
method described below is the author’s personal
preference. Yet as long as the endoscopist examines
all areas, the endoscopic examination will be
adequate. The examination needs to be documented
to demonstrate that the procedure was performed
adequately. This can be achieved using either
recording equipment or a reporting form that requires
a complete endoscopic examination to have been
performed in order for it to be filled in. The WSAVA GI
Standardization Group has produced a proforma that
endoscopists are welcome to use for their own
practice (Figure 4.3).

ENDOSCOPIC EXAMINATION REPORT – UPPER GI ENDOSCOPY

Date of procedure: ………………………… Case Number: …………………………

Patient: Name …………………………………………… Client: Mr/Ms/Mrs/Dr ………………………………………………………

Dog � / Cat � Other � Address ………………………………………………………………………
Age: …………… years old ………………………………………………………………………
Sex: M � F � / neutered � ………………………………………………………………………
Breed: ………………………………………… Phone ………………………………………………………………………

PROCEDURE(S): __________________________________________________________________________________
Indication(s) for procedure: __________________________________________________________________________________
Endoscope(s) used: __________________________________________________________________________________
Forceps/retrieval device(s) used: __________________________________________________________________________________

Upper GI endoscopy reporting proforma. This standard form was developed by the WSAVA Gastrointestinal
4.3
Standardization Group (Drs Washabau, Willard, Hall, Jergens, Day, Mansell, Wilcox, Minami, Guilford and
Blizer) with sponsorship from Hill’s Pet Nutrition). (continues)

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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract

PROBLEMS/COMPLICATIONS:
Perforation � Excessive bleeding � Anaesthetic complications � Excessively long � Other �
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Comments: ______________________________________________________________________________________________________________
� Unable to complete full examination: why? ______________________________________________________________________________
� Unable to obtain adequate biopsies: why? ______________________________________________________________________________
� Unable to retrieve foreign object: why? ______________________________________________________________________________
� Visualization obscured why? ______________________________________________________________________________

SAMPLING: Biopsy � Brush cytology � Washing � Aspiration � Foreign body retrieved �

DOCUMENTATION: Video � Photographs �

Oesophagus Normal � Dilated � F. body � Mass � Stricture � Hiatal hernia �

Lesion Code Comments (include location)

Hyperaemia/vascularity
Discoloration
Friability
Haemorrhage
Erosion/ulcer
Contents (mucus/bile/food)
GOS open/other lesions
Code: Normal = 0 Slight = 1 Moderate = 2 Severe = 3
Stomach Normal � Polyp(s) � F. body � Mass � Parasite(s) �
Site(s) of lesions: Fundus � Body � Incisura � Antrum � Pylorus �
Site(s) of biopsies: Fundus � Body � Incisura � Antrum � Pylorus �

Lesion Code Comments (include location)

Can’t inflate lumen
Hyperaemia/vascularity
Oedema
Discoloration
Friability
Haemorrhage
Erosion/ulcer
Contents (mucus/bile/food)
Passing endoscope through pylorus

Duodenum/Jejunum Normal � Polyp � F. body � Mass � Parasite(s) �

How far was the tip of the endoscope advanced? ___________________________________________________________
Was papilla seen? Yes � No �

Lesion Code Comments (include location)

Can’t inflate lumen
Hyperaemia/vascularity
Oedema
Discoloration
Friability
Texture
Haemorrhage
Erosion/ulcer
Lacteal dilatation
Contents (mucus/bile/food)
Code: Normal = 0 Slight = 1 Moderate = 2 Severe = 3

(continued) Upper GI endoscopy reporting proforma. This standard form was developed by the WSAVA
4.3
Gastrointestinal Standardization Group (Drs Washabau, Willard, Hall, Jergens, Day, Mansell, Wilcox, Minami,
Guilford and Blizer) with sponsorship from Hill’s Pet Nutrition). (continues)

44

Ch04 Endo.indd 44 30/04/2013 09:13

 Chapter 4 Flexible endoscopy: upper gastrointestinal tract

Comments and Recommendations: ___________________________________________________________________________________________

PDFLibrary.Net

________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Endoscopist signature __________________________________

(continued) Upper GI endoscopy reporting proforma. This standard form was developed by the WSAVA
4.3
Gastrointestinal Standardization Group(Drs Washabau, Willard, Hall, Jergens, Day, Mansell, Wilcox, Minami,
Guilford and Blizer) with sponsorship from Hill’s Pet Nutrition).

Oesophagoscopy • Confirm the presence of a gastric foreign body

Oesophagoscopy is indicated in the investigation of following diagnostic imaging
patients with signs of oesophageal disease or for spe- • Remove selected foreign bodies
cific treatment of oesophageal problems (Figure 4.4). • Investigate significant haematemesis not
responding to symptomatic treatment.

Diagnostic endoscopy In chronically vomiting patients, routine investi-

gations should be performed before considering
Investigation of clinical signs of oesophageal disease: endoscopy, as non-gastric diseases frequently cause
Regurgitation vomiting. Plain radiographs and an ultrasound exami-
Dysphagia
Painful swallowing
nation are performed first to guide the endoscopist as
Excessive salivation/inability to swallow to what to look for, and to find unexpected chronic
gastric foreign bodies. Gastroscopy can be used to
Investigation of diagnostic imaging abnormalities: confirm the likely presence of a tumour by visualizing
Plain radiographs: the tissues and collecting biopsy specimens. Gastritis
• Radiodense foreign body is a common cause of chronic vomiting but changes
• Megaoesophagus (NB Caution – potential risk of inhalation)
are rarely observed on laboratory tests or radio-
• Hiatal hernia
• Gastro-oesophageal intussusception graphs. Endoscopic examination and biopsy collec-
• Neoplasia tion are therefore essential in reaching a diagnosis.

Contrast radiographs:
• Stricture
• Radiolucent foreign body
• Vascular ring anomaly (endoscopy rarely necessary unless foreign Diagnostic endoscopy
material impacted)
Oesophageal reflux Investigation of clinical signs of gastric disease:
• Neoplasia Nausea and salivation
Chronic vomiting
Therapeutic endoscopy Haematemesis and/or melaena
Unexplained anorexia
Selected foreign body removal
Stricture dilation Investigation of diagnostic imaging abnormalities:
Plain radiographs:
• Radiodense foreign body
4.4 Indications for oesophagoscopy. • Neoplasia

Contrast radiographs:
• Radiolucent foreign body
Clinical signs of oesophageal disease, supported • Ulcer
by plain and contrast radiography, may sometimes • Suspected neoplasia
provide a definitive diagnosis (e.g. foreign body,
vascular ring anomaly, stricture formation or extra- Ultrasonography:
oesophageal mass). However, with the exception of • Foreign body
extra-oesophageal disease, oesophagoscopy is • Ulcer
• Suspected neoplasia (loss of layering, mass, thickened gastric
important in their evaluation and treatment. Oeso- wall, ulcer)
phagoscopy is the most reliable way of detecting
reflux oesophagitis, as this often cannot be detected Therapeutic endoscopy
radiographically, even by fluoroscopy.
Selected foreign body removal
Percutaneous endoscopic gastrostomy (PEG) tube placement
Gastroscopy (± removal)
Gastroscopy is indicated in patients presenting with Polypectomy
vomiting and for specific therapeutic purposes (Figure
4.5). Gastroscopy is rarely indicated in acute vomiting
4.5 Indications for gastroscopy.
unless it is required to:

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Ch04 Endo.indd 45 30/04/2013 09:13

 Chapter 4 Flexible endoscopy: upper gastrointestinal tract
Duodenoscopy
Intubation of the small intestine (duodenoscopy ±
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jejunoscopy) is indicated in patients presenting with
vomiting or other GI signs, and for specific therapeutic
purposes (Figure 4.6). Except in the smallest patients,
only duodenoscopy is possible because of the limited
length of the endoscope.
Diagnostic endoscopy
Investigation of clinical signs of intestinal disease:
Chronic vomiting
Chronic diarrhoea
Melaena (and haematemesis if no gastric lesions present)
Change in appetite
Unexplained weight loss
Abdominal pain (although investigation by laparotomy more useful)
Investigation of diagnostic imaging abnormalities:
Radiographs:
• No radiographic abnormalities despite clinical signs
Ultrasonography:
• Diffusely thickened intestinal wall
• Loss of intestinal wall layering in proximal intestine
Therapeutic endoscopy
Endoscopic jejunostomy tube placement
4.6 Indications for duodenoscopy.
Duodenoscopy is indicated in cases of chronic
diarrhoea and/or vomiting, especially when the patient
exhibits haematemesis, melaena or panhypoprotein-
aemia. The results of preliminary investigations
(including abnormalities of serum folate and
cobalamin concentrations) are used to provide
evidence to suggest small intestinal disease and the
need to collect biopsy samples. Cats with small
intestinal disease often present with chronic vomiting
rather than chronic diarrhoea, and some cats with
recurring hairballs have inflammatory bowel disease,
indicating the need for intestinal biopsy samples in
cases of chronic vomiting. Thus, in all cases where
the stomach is being examined, it is usual to examine
the duodenum at the same time.
Jejunoscopy
Although it may be possible to reach the proximal
jejunum in smaller patients, one of the significant
limitations of gastroscopy is that the intestinal tract is
much longer than a standard gastroscope, and thus
large sections cannot be examined. Jejunoscopy
(also known as enteroscopy), in addition to
duodenoscopy, may be indicated for the investigation
of specific small intestinal problems (Figure 4.7).
Focal causes of haemorrhage
Focal neoplasia
Patchy disease (if duodenoscopy is not diagnostic):
Inflammatory bowel disease
• Lymphangiectasia
• Alimentary lymphoma
4.7 Indications for enteroscopy.
46
Ch04 Endo.indd 46
However, the availability of enteroscopes is very
limited in veterinary medicine and exploratory laparo-
tomy is usually performed if the whole small intestine
requires examination.
Ileoscopy
Visualization and biopsy of the ileum can be achieved
quite often during flexible colonoscopy (see Chapter
5), and is a useful adjunct when upper small intestine
endoscopy is indicated.
Contraindications
Endoscopy may be an inappropriate way to reach a
diagnosis in patients with a suspected GI disease,
e.g. gastroduodenoscopy cannot diagnose pancrea-
titis as a cause of vomiting and diarrhoea. Endoscopy
also requires general anaesthesia and in some
instances this may be too dangerous to perform; if a
patient is too sick to be anaesthetized for surgery it is
also too sick for endoscopy. Specific contraindications
to endoscopy are given in Figure 4.8.
Poor anaesthetic risk
Relative:
• Poor cardiopulmonary reserve
• Uraemia
Absolute:
• Uncorrected bleeding disorder
• Non-reversible hypoxaemia
• Unstable cardiac arrhythmia
• Cardiac failure
Poorly prepared patient
Food not withheld (i.e. stomach full)
Known coprophagia not prevented by muzzling
Inadequate investigations prior to endoscopy
4.8 Contraindications to endoscopy.
Instrumentation
The skill needed to intubate the duodenum through
the pylorus can only be acquired by practice, although
an understanding of what one is trying to achieve and
how to manipulate the endoscope helps (see Chapter
3). It is the technological advances in endoscope
design and construction that have made gastroscopes
narrow enough to pass the pylorus and yet be steer-
able. The components of a flexible endoscopy system
are discussed in detail in Chapter 2, but the features
specifically needed for an endoscope capable of per-
forming upper GI endoscopy are listed in Figure 4.9.
• Insertion tube with at least 1 m working length
• Tip diameter < 9.5 mm
• Minimum 2.2 mm accessory/biopsy channel
4-way tip deflection:
– ability to retroflex tip (turn 8 degrees) in one plane
– small radius of curvature to bending section
bility to insufflate with air
• Ability to wash lens remotely
Features of a flexible endoscope suitable for
4.9
gastroscopy.
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 Chapter 4
The features of endoscopes are discussed in
Chapter 3 but, for upper GI endoscopy specifically,
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the greater the tip deflection and the smaller the
radius of the bending section, the greater the
manoeuvrability of the endoscope. It is the capability
to be retroflexed that is essential to permit complete
examination of the stomach.
The distance along the GI tract that can actually
be reached depends on the size of the patient and the
length of the endoscope. Paediatric gastroscopes
typically have a working length of 1 m and, with skill,
the duodenum of dogs up to 40 kg can be routinely
intubated, whilst in smaller animals it may be possible
to reach the jejunum. However, pyloric intubation in
an adult Great Dane, for example, would be impossible
as the insertion tube would not reach. Thus, for most
patients a 1 m insertion tube is of adequate length but
will be too short in giant-breed dogs. Dedicated
veterinary gastroscopes tend to have a longer working
length (up to 1.5 m) and are therefore useful for larger
dogs. However, they are more difficult to manoeuvre,
especially in smaller animals, as a large part of the
insertion tube remains outside the patient and tends
to loop. Enteroscopes several metres long are
available for inspection of the jejunum, but are rarely
used; they are very expensive, very difficult to
manipulate and often have no biopsy channel.
The diameter of the tip of the insertion tube is also
crucial in dictating the size of patient that can be
examined. A tip diameter >9.5 mm cannot easily be
inserted into puppies and cats, and is likely to pre-
clude pyloric intubation in cats, and in dogs <20 kg.
Thus, the diameter of the endoscope used is a com-
promise; a narrower endoscope will allow passage
through the pylorus in smaller patients, but the wider
the endoscope the bigger the accessory channel and
the bigger/better any biopsy specimen harvested.
Both 2.2 mm and 2.8 mm channels will permit the col-
lection of adequate biopsy samples, but those from
the 2.8 mm channel will inevitably be bigger. Biopsy
channels any smaller than 2.2 mm are inadequate as
the samples collected are so small that they are likely
to fragment (see Chapter 3); being so superficial they
do not contain the connective tissue necessary to
hold the sample together. For most patients, a gastro-
scope with a tip diameter between 7 mm and 9 mm is
appropriate. In any gastroscope with a tip diameter
< 9.5 mm, the largest biopsy channel available is
2.8 mm, but even the narrowest gastroscope cur-
rently available, with a tip diameter of 5.2 mm, can still
accommodate 2.2 mm biopsy forceps by combining
the biopsy channel with the air/water channel.
Only forward-viewing scopes are used routinely for
veterinary endoscopy. Side-viewing endoscopes (duo-
denoscopes) are used in human gastroenterology for
endoscopic retrograde cholangiopancreatography (i.e.
catheterization of the bile and pancreatic ducts) but
this procedure is not routine in veterinary endoscopy. A
wide field of view (90 to 120 degrees) facilitates orien-
tation and a panoramic examination, thereby decreas-
ing the likelihood of missing a lesion or foreign body in
the stomach. A depth of focus of 3–100 mm is usually
adequate; a minimum visible distance of >5 mm pre-
vents detailed examination of the mucosa.
Ch04 Endo.indd 47
Flexible endoscopy: upper gastrointestinal tract
Insufflation is essential as the oesophagus,
stomach and small intestine must be inflated to
enable visualization. A xenon light source is preferred
because the greater illumination permits a panoramic
view across the distended stomach. Suction is
necessary to remove GI secretions and air (see
Chapter 2 for more details about equipment).
Finally, a range of endoscopic accessories may
be required for therapeutic purposes (see below).
However, it is essential that biopsy forceps are
available for diagnostic purposes. Biopsy samples
from the stomach and intestine should always be
taken, even if the tissue appears grossly normal. Only
in the oesophagus, where the mucosa is so tough
that taking biopsy samples is usually fruitless, is this
not done.
Patient preparation
Preparation of the patient for upper GI endoscopy
requires nothing more than withdrawal of food for at
least 12 hours before the procedure so that the
stomach is empty. Water does not need to be withheld
before the procedure. Endoscopy too soon after a
meal should be avoided because:
• Visualization is difficult; lesions and foreign
bodies may be missed
• Pyloric intubation is difficult or impossible
• The endoscope may get clogged
• There is a danger of aspiration during recovery.
Day-case endoscopy is more likely to result in
gastric contents being found because, even if the cli-
ent does withhold food, they do not realise that their
pet can scavenge or eat grass (Figure 4.10). It is
preferable to hospitalize the patient overnight before
endoscopy; this allows time for preliminary investi-
gations and ensures the patient does not eat before
the procedure.
Mass of
4.10
grass in
the stomach of a
poorly prepared
patient obscures
examination of the
stomach.
Normally the stomach will be empty within 12
hours of withholding food. So, assuming that the
animal has not accidentally eaten, finding food in the
stomach can give useful information about an
anatomical outflow obstruction or a functional delay in
gastric emptying. If a barium contrast radiographic
study has been performed, endoscopy should
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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract
preferably be delayed for 24 hours. Aspiration of
barium into the endoscope could cause a serious
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blockage. Any residual barium found should only be
aspirated through a tube and not directly via the
suction channel.
Premedication and anaesthesia
Premedication
Premedication should be used to smooth induction
and recovery. If a patient is very agitated before
induction it is common to find foamy saliva in the
oesophagus, and this can interfere with the view.
Acepromazine maleate (ACP) plus pethidine or
buprenorphine are suitable combinations for seda-
tion of dogs. In cats, buprenorphine and ACP is
efficacious. Atropine is not necessary, and some
believe that by drying secretions, it makes the pro-
cedure more difficult. Others claim it actually makes
pyloric intubation easier, whilst narcotics stimulate
pyloric tone. An intravenous catheter should be
placed, and ECG and pulse oximetry monitoring
are recommended.
Anaesthesia
General anaesthesia is essential for upper GI endo-
scopy, and intubation with a cuffed endotracheal (ET)
tube mandatory because of the risk of reflux. Some
endoscopists have a preference for tying the tube to
the mandible but this is not essential. Tying around
the mandible or maxilla is most secure; passing the
tie around the back of the head is least secure as the
repeated movements of the endoscope tend to dis-
lodge the ET tube, but is a necessity in cats and
brachycephalic dogs.
The safest anaesthetic regime is the one the
operator is most familiar with, e.g. induction with
thiopental or propofol and maintenance with halothane
or isoflurane with oxygen are suitable. In some
countries medetomidine is the preferred agent for
canine endoscopy. The anaesthetic circuit used (from
T-piece to circle) depends on the size of patient.
Nitrous oxide is not used because insufflation of
the stomach will permit diffusion of nitrous oxide
(‘third space effect’) and cause over-distension of the
stomach. Yet as the analgesic properties of nitrous
oxide are not present, some patients show signs of
discomfort (e.g. tachypnoea) even when apparently
fully anaesthetized, especially when the pylorus is
intubated or the GI tract is inflamed. This temporary
problem can be overcome by tactical use of
intermittent intravenous diazepam.
Air insufflation is essential during upper GI
endoscopy to open the lumen and move the wall
away from the tip of the endoscope so that an image
can be obtained. However, the assistant monitoring
the anaesthetic should be aware of over-inflation of
the stomach as it may cause cardiorespiratory
compromise through compression of the diaphragm
and caudal vena cava.
A mouth gag (speculum) must always be inserted
to prevent damage to the endoscope.
48
Ch04 Endo.indd 48
Patient positioning
After induction and intubation, the patient is put in left
lateral recumbency for routine upper GI endoscopy
(Figure 4.11). This position places the gastric antrum
uppermost (i.e. right side up) so that air will fill it and
make the pylorus more visible. However, retroflexion
to examine the cardia and fundus is essential,
especially as foreign bodies tend to fall into the fundus
and would otherwise be missed. For gastrostomy
tube placement right lateral recumbency is used, as
the tube is placed through the left flank (see below).
The patient is placed in left lateral recumbency
4.11
for routine upper GI endoscopy. Note the ET
tube is securely fastened and a gag and pulse oximeter
are being used.
Procedure
The patient should be prepared as described above.
Contrast studies should not be performed immediately
before endoscopy.
The endoscopy equipment should be checked
before the patient is anaesthetized (see Chapter 3).
When the patient has been induced and the ET tube
placed and secured, the patient is positioned in left
lateral recumbency for the procedure. As soon as the
swallowing reflex has been abolished, the procedure
can begin. Lubrication of the endoscope tip with KY
jelly can help insertion, as long as it is kept off the
lens. A mouth gag must always be inserted. The
procedure should then be carried out as quickly as
possible, without rushing, and so it is important that
all ancillary equipment (e.g. biopsy forceps, formalin
pots, etc.) are made ready before the procedure.
It is usual to perform a full examination, but
with only a quick inspection of the oesophagus and
stomach on the way to the duodenum. Delay in
intubating the pylorus is believed to make it more
difficult, and therefore the stomach and oesophagus
are re-examined fully and the required biopsy sam-
ples are collected at leisure on the way out.
Nevertheless, it is important to have a brief inspec-
tion of these organs to ensure that, when viewed
after duodenoscopy, apparent lesions are not arte-
facts induced by the endoscope. However, the fol-
lowing notes describe the procedure in order of
anatomical location (see below).
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 Chapter 4
Oesophagoscopy
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Insertion
After extending the head and neck, the endoscope is
passed along the midline of the hard palate into the
pharynx, reaching the upper oesophageal (crico-
pharyngeal) sphincter either blindly or preferably
under direct visualization. When viewed, the sphincter
appears as a star-shaped opening dorsal to the lateral
folds of the larynx, and towards which the endoscope
is steered. If entry into the oesophagus is performed
blindly, ET intubation for anaesthesia usually forces
the endoscope to pass into the oesophagus; however,
the pyriform recesses either side of the larynx can
trap the tip, the endoscope should not be forced if it is
being inserted blindly. Gentle pressure is applied to
pass the sphincter, and air is continually insufflated to
enhance the view. However, red-out frequently occurs
as the sphincter is passed.
Oesophageal body
After passing the sphincter, indicated by a reduction in
the force needed to advance the endoscope, forward
motion is halted and, after re-adjustment of the tip, the
lumen is centred in the view. The endoscope is then
advanced in short segments down the oesophagus
whilst trying to keep the entire mucosal circumference
in view. Re-alignment is required as it rounds the curve
at the thoracic inlet and more minor adjustments may
be needed as the endoscope progresses onwards.
There may be redundant tissue at the thoracic
inlet, which gives the impression of a diverticulum, but
it can be obliterated by extending the neck. The
indentation by the trachea may be seen in the neck
and cranial thorax, and the great vessels and heart
will be seen pulsating through the oesophageal wall.
The distal feline oesophagus has circular folds.
By inspecting all the mucosa as the endoscope is
advanced, pathological lesions will not then be
confused with iatrogenic damage when the endoscope
is withdrawn.
Exiting the oesophagus
In the distal oesophagus the lower oesophageal
sphincter will be seen, usually as a star- or slit-like
opening and occasionally bulging slightly cranially.
Anatomically it is not a true sphincter, but endo-
scopically it usually acts as one. However, depend-
ing on the depth of anaesthesia, it may be open and
not closed.
If the lower oesophageal sphincter is closed, slight
angulation (30 degrees) of the tip with continued
insufflation is needed to pass into the stomach. Red-
out may occur until the gastric lumen is reached, as
indicated by a sudden loss of resistance to forward
motion. If resistance is not overcome when trying to
enter the stomach, it is usually because the endoscope
tip has missed the lower oesophageal sphincter and
is impacted lateral to it. Excessive force should not be
applied; the endoscope should be withdrawn slightly
and redirected prior to trying intubation again.
Oesophageal inspection and biopsy
The endoscopist should try to examine all the
oesophageal mucosa as the endoscope is inserted,
Ch04 Endo.indd 49
Flexible endoscopy: upper gastrointestinal tract
but a fuller examination may be performed as the
endoscope is withdrawn. Biopsy specimens are not
routinely taken because the mucosa is too tough.
Oesophagitis is usually recognized by its gross
appearance and biopsy specimens are usually only
taken if there is any doubt as to the nature of a lesion,
or if it has already been treated symptomatically and
has not responded. Any masses should be biopsied,
but they are rare. Biopsy forceps with a spike can aid
procurement of tissue (see Chapter 3) and cytology
may be helpful when lesions are present.
Gastroscopy
Initial examination
A full examination of the stomach with biopsy is
ultimately performed, but it is easier to try to intubate
the pylorus as soon as possible. Too much inflation of
the stomach introduces a bulge in the greater
curvature that makes advancement into the antrum
and through the pylorus more difficult.
Once in the stomach it is necessary to orientate so
that this quick inspection can identify lesions to be
examined more closely later, and the antrum and
pylorus can be found. The initial examination of the
stomach will detect foreign bodies, food, fluid, bile
and blood. Such findings can be important indicators
of the underlying pathology but may hinder further
endoscopic examination of the stomach as it impairs
visualization and makes passage of the endoscope
into the duodenum difficult.
Orientation
The initial view on entering the stomach is of the
junction of the fundus and body on the greater
curvature, assuming the endoscope tip is not adjacent
to the mucosa (Figure 4.12). Slight tip deviation then
4.12
The view on
entering the
stomach is of the
junction of the
fundus and body.
Note the parallel
rugal folds on the
greater curvature
running towards
the antrum beneath
the angle of the
lesser curvature.
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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract

gives a panoramic view of the body towards the

Rugal folds on greater curvature are roughly parallel and run towards antrum. However, if the tip is against the mucosa, red-
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the antrum out will occur. Slight withdrawal of the tip and more
The antrum has fewer rugal folds insufflation will enable a view of the lumen.
Any waves of peristalsis roll along the antrum towards the pylorus
In order to reach the pylorus there are a number of
On retroflexion and inflation, the endoscope entering through the
cardia is visible landmarks that can be used (Figure 4.13). Of these
The lesser curvature divides the fundus and body from the antrum techniques, retroflexion and further insertion of the
The pylorus may be visible at the end of the antrum, or its position is tube with insufflation is probably the best to perform if
marked by: one is ‘hopelessly lost’. Once the cardia has been
• A group of rugal folds identified, by observing the point where the insertion
• Waves of peristalsis encircling it enters the stomach, relaxation of the tip deflection
ile and foam being refluxed through it
(i.e. reducing retroflexion) brings the lesser curvature
Landmarks used to provide orientation in the
into view, and below it will be the antrum (Figure
4.13
stomach. 4.14). The angle of the lesser curvature (angularis
incisura) is the most important landmark, with the
cardia and antrum above and below, respectively.
Fundus/cardia
Examination of the antrum
Once orientation has been achieved, the endoscope
Angularis
incisura can be advanced along the rugal folds of the greater
curvature into the antrum. The antrum has fewer rugal
folds, and a ring of contraction passing towards the
Antrum with pylorus may be present (Figure 4.15). In cats, the
bile bubbling angle at the lesser curvature is quite acute and a
through from slide-by technique (see Chapter 3) may be needed to
pylorus pass into the antrum. Alternatively, the tip can be pre-
deflected within the body and the endoscope then
(a) advanced into the antrum.

Angularis Cardia 4.15

incisura
Ring of peristalsis
migrating down the
antrum towards the
pylorus.

Antrum
Fundus

(b)

Cardia
Angularis
incisura
Antrum
(c)
Orientation in the stomach. In order to reach the
4.14
pylorus there are a number of landmarks that
can be used: (a) the angularis incisura divides the antrum
(below) from the fundus and cardia (above), through
which the insertion tube can be seen entering the
stomach. (b) Approximate position of the endoscope in
the stomach. (c) Passage of the tip of the insertion tube
around the angularis incisura to enter the antrum.
In larger dogs, as the endoscope approaches the
antrum, either there is a tendency for the tip to get
stuck in the greater curvature or, as the insertion tube
is advanced, the tip may even appear to move
backwards, i.e. away from the pylorus. This so-called
paradoxical movement happens particularly when the
stomach is over-inflated. It occurs because the
insertion tube is moving along the greater curvature
of the stomach and when pressure is applied to try to
advance the tip, it actually presses on the greater
curvature, which expands to accommodate it. With
continual pressure, the tip often swings past the
angularis incisura and back into the fundus towards
the cardia as over-inflation has made the greater
curvature so rounded the tip cannot enter the antrum
(Figure 4.16).
This problem can be prevented by deflating the
stomach as much as possible whilst maintaining a
view, or by turning the tip slightly into the greater
curvature so that it advances into the antrum, or by

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Ch04 Endo.indd 50 30/04/2013 09:13

 Chapter 4
Distension of the fundus allows the insertion
4.16
tube to form a loop, which tends to direct the tip
up towards the cardia. Advancement of the insertion tube
further distends the gastric wall and compounds the
problem.
rotating the endoscope slightly as it is advanced.
Finally, if all else fails, external compression to the
lower right body wall flattens the flexure and may
assist entry into the antrum.
The pylorus is found at the end of the antrum and
duodenal intubation is attempted (see below). The
pylorus has a wide variety of appearances but should
not be obscured by excessive folds (Figure 4.17). It
may demonstrate rhythmical opening and closing.
Occasionally, bile or foam will reflux from the
duodenum (see Figure 4.14).
Examination of the body
After pyloric intubation and duodenoscopy, a more
complete examination of the whole stomach is made.
Fluid may pool in the stomach, particularly in the
fundus, and should be sucked out to ensure no
submerged lesions are missed. Rugal folds on the
greater curvature will be seen to flatten and reappear
as the stomach is inflated and deflated, respectively.
Ch04 Endo.indd 51
Flexible endoscopy: upper gastrointestinal tract
4.17
The normal pylorus
of a cat.
Examination of the cardia and fundus
By complete upward movement of the inner wheel
and full retroflexion of the tip (the so-called ‘J manoeu-
vre’) it is possible to view the lesser curvature. bove
it are the cardia and fundus, and below it the antrum.
The degree of narrowing of the lesser curvature is an
indication of the degree of inflation; a sharp ‘edge’ to
the angularis incisura and complete flattening of rugal
folds is an indication of over-inflation and air should
be sucked out of the stomach.
Partial withdrawal of the endoscope whilst retro-
flexed will bring the view of either the cardia or pylorus
closer, depending which way the tip is pointing,
although the pylorus cannot be intubated by this
method. When viewing the fundus and cardia, by with-
drawing the endoscope the tip is drawn towards the
cardia for a closer view, and by rotating the retroflexed
insertion tube on the long axis (torquing) it is possible
to view the whole cardiac region (Figure 4.18).
(a)
(b)
(a) Retroflexion allows visualization of the cardia
4.18
and fundus. (b) Withdrawal of the retroflexed
endoscope allows closer vision of the cardia, and rotation
on its long axis allows visualization of the whole area.
51
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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract
Gastric biopsy
Before taking biopsy samples, brush cytology is a
simple, sensitive technique for identifying spiral
bacteria. A small amount of gastric mucus is retrieved
on a sleeved cytology brush; stained with Diff-Quik,
spiral bacteria are readily seen (Figure 4.19).
Approx
10µm
Brush cytology showing gastric spiral
4.19
organisms. (Reproduced from BSAVA Manual of
Canine and Feline Gastroenterology, 2nd edition)
The general technique for taking and handling
biopsy specimens is described in Chapter 3. Where
gross lesions are detected during gastroscopy, multi-
ple biopsy samples should be collected from the
‘lesion’ and the surrounding ‘normal’ tissue. If no mac-
roscopic lesions are observed chronic inflammatory
disease may still exist and samples should always be
collected from all regions of the stomach. Samples
from different areas may be placed in different forma-
lin pots, although if grossly normal there is an inclina-
tion to pool them. However, if a specific lesion is seen
and biopsied, the tissue should be fixed separately.
Samples are usually taken from all areas of the stom-
ach (cardia, fundus, greater and lesser curvature, and
antrum). At least two biopsy samples should be col-
lected from the fundus, four from the body (lesser and
greater curvature) and two from the antral canal.
Alternatively, a mixture of 8–10 samples from different
areas can be pooled.
The forceps naturally tend to turn to the lesser
curvature, which will be easier to biopsy if the stomach
is deflated. Over-inflation of the stomach stretches
the mucosa and smaller biopsy samples are obtained.
If insufflation is needed to see where the biopsy is
being taken from, it is worth deflating the stomach
after positioning the open cups so that when the cups
are closed more tissue is grasped. Taking samples
from the edge of a rugal fold increases the yield
(Figure 4.20).
Biopsy specimens from the fundus and cardia
should be collected by inserting the forceps with the
endoscope in a neutral position and then retroflexing
to avoid damaging the biopsy channel within the
bending section. Care must also be taken to avoid
taking biopsy samples of the insertion tube as it
enters at the cardia, and so a clear view should be
obtained. The antral mucosa is tougher than other
52
Ch04 Endo.indd 52
4.20
Gastric biopsy.
(a) A rugal fold is
grasped by the
biopsy forceps and
avulsed. (b) Site of
a gastric biopsy.
(Reproduced from
BSAVA Manual of
Canine and Feline
Gastroenterology,
2nd edition)
(a)
(b)
areas and biopsy specimens are consequently small;
taking two biopsy samples during the same pass of
the forceps gives an increased yield.
Biopsy samples should be collected from the
periphery of any ulcer and not the centre of the lesion.
This is because sampling the centre of the ulcer may
result in perforation and is usually not diagnostic,
collecting only fibrous or necrotic tissue and
inflammatory cells. When malignancy is suspected,
repeated sampling from the same site may reveal
neoplastic cells deeper in the lesion, while superficial
layers contain only non-specific necrotic tissue.
Once all the gastric biopsy specimens have been
harvested, all air should be removed from the stomach
before the endoscope is withdrawn into the
oesophagus to reduce respiratory embarrassment
and the risk of reflux.
Duodenoscopy
Entering the duodenum through the pylorus is the
hardest part of upper GI endoscopy, and has been
likened to trying to push a 3-foot piece of stiff rope
through a small hole in a strong wind! Pharmaco-
logical intervention with metoclopramide has not
been shown to help experienced endoscopists, and
its augmentation of peristalsis may even make the
procedure harder. Glucagon (0.05 mg/kg i.v.) can be
given to relax the pylorus, but is not needed by expe-
rienced endoscopists.
Engaging the pylorus
Over-inflation is the biggest mistake made when
trying to intubate the pylorus (see Figure 4.16). The
inflation and pressure on the greater curvature closes
off the antral canal. The stomach assumes a round
shape with the antral opening flattened, the pylorus is
30/04/2013 09:13
 Chapter 4
moved out of view and antral contractions are
stimulated. It then becomes difficult to enter the
antrum and virtually impossible to find the pylorus, let
alone intubate the duodenum. In addition, as the
endoscope is advanced along the greater curvature
towards the pylorus it stretches the greater curvature
so that the endoscope tip actually moves away from
the pylorus. This paradoxical motion gets worse the
more the stomach is over-inflated.
When this occurs, air must be sucked out and the
endoscope tip moved back before repeating the
manoeuvre. When repeated it is important to ensure
that the stomach is not continually being insufflated
as novice endoscopists tend to forget their finger is
covering the air hole. The endoscope tip should be
kept lying along the greater curvature, so that the tip
is more likely to move into the antral canal successfully.
Particularly in cats, slight rotation of the insertion tube
on its long axis may assist the process. However, the
inexperienced endoscopist may have to try this
manoeuvre several times before the endoscope
passes to the pylorus and can easily get frustrated.
Pyloric intubation
The pylorus is visualized at the end of the antrum,
and by advancing the endoscope along the greater
curvature of the stomach the tip engages with the
pyloric canal and passes through into the duodenum.
This manoeuvre may fail, especially if the stomach is
over-inflated, with the tip moving up towards the car-
dia. The tip needs continual re-alignment because as
the endoscope is advanced it distorts the greater cur-
vature and moves the relative position of the pylorus.
Once the tip is engaged with the pylorus and the
lumen centred, the aim is to move the endoscope tip
forward whilst continually readjusting the centring.
With video-endoscopes it may be easier to rotate the
endoscope through 90 degrees so that the handpiece
lies flat in the palm (see Chapter 3). As red-out often
occurs as the pylorus is passed, one may simply aim
at the blackest area; there is often an impression of
the mucosa sliding by. Intermittent puffs of air may
assist the passage of the tip, but continual insufflation
will cause over-inflation. It also seems logical to push
the endoscope forward to pass the pylorus but,
because of paradoxical movement, it actually can
help to withdraw the endoscope slightly to straighten
it before proceeding forward. It may also help to suck
air out of the stomach; the deflation of the stomach
then forces the endoscope tip forward as the stomach
collapses over it, and if it has been steered to the right
position the tip may exit the pyloric canal automatically.
If the tip keeps slipping out of the pylorus or cannot
even reach the pylorus, the endoscope should be
withdrawn, the stomach deflated and the process
started again.
The keys to success in pyloric intubation are:
• The stomach should not be over-distended
• The endoscope tip position should be constantly
readjusted by steering manoeuvres to keep the
pylorus in the centre of the field of view
• It should be performed as soon as possible, but
patience is required.
Ch04 Endo.indd 53
Flexible endoscopy: upper gastrointestinal tract
Entering the duodenum
As the pyloric canal is passed the mucosal colour
changes to red or it may be bile-stained. However,
red-out may continue as the cranial duodenal flexure
is negotiated. If the endoscope is freely moving there
will be an impression of the mucosa sliding by as
forward pressure is exerted. Turning both control
wheels clockwise assists slide-by. After 5–10 cm,
intermittent tip deflection and insufflation will usually
achieve a luminal view of the duodenum.
Consolidating small intestine intubation
Once the proximal duodenal flexure has been passed
and the lumen visualized, it is relatively easy to push
the endoscope along the intestine. In most dogs, intu-
bation of the descending duodenum to the distal duo-
denal flexure should be possible. In small dogs and
cats, it may even be possible to reach the proximal
jejunum with a 1 m insertion tube. However, once
past the pylorus of larger dogs, if using a fibreoptic
endoscope, the handpiece is often in the patient’s
mouth, and the endoscopist’s face ad acent.
Paradoxically, further movement along the duodenum
can often be achieved by slightly withdrawing the
endoscope or by external compression of the stom-
ach, thereby reducing looping of the insertion tube in
the stomach. A slide-by technique may help round fur-
ther flexures, but torquing the instrument becomes
more difficult. The duodenum should not be over-
inflated as air may reflux into the stomach, causing
over-distension.
Failure to intubate
As discussed previously, duodenal intubation is one
of the most difficult endoscopic procedures to carry
out, especially when the pylorus is closed. Even
experienced endoscopists can find it impossible to
achieve in some individuals. It is therefore important
not to persist too long as injury or perforation of the
pylorus can occur. Undue force to try and enter the
duodenum should not be used as it increases the risk
of perforation.
Occasionally in these patients, rotating the patient
to dorsal or right lateral recumbency may facilitate
success. Another trick is to blindly pass the biopsy
forceps through the pylorus and then pass the
endoscope along this temporary guidewire, as in a
Seldinger catheterization technique. However, this is
often not successful as the proximal duodenal flexure
prevents minimal entry of the forceps. A few biopsy
specimens may be obtained blindly, but it is unsafe to
take repeated samples from the same site without
being able to view it.
Duodenal biopsy
Before harvesting biopsy specimens, duodenal juice
can be collected to look for Giardia and for culture.
A sterile polyethylene tube is passed and any pooled
liquid collected. However, fluid is sparse and it may
be more productive to insert the tube as far as
possible, deflate the duodenum and then slowly
withdraw the tube whilst applying gentle suction to
retrieve the fluid that has pooled between the
mucosal folds.
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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract
It is important to note that many forms of small
intestinal disease are not apparent macroscopically
and can only be detected after histological examination
of biopsy samples. Therefore, in all cases, multiple
mucosal biopsy samples should be collected from
different regions of the small intestine.
If the biopsy forceps are used parallel to the
mucosa only villus tips will be sampled, so to obtain
the best intestinal biopsy specimens it is useful to
position the biopsy forceps perpendicular to the
intestinal mucosa. Increased pressure will increase
the size of biopsy, and perforation is unlikely if the
forceps are opened before pushing. Optimum biopsy
specimens can be collected by a number of techniques
(Figure 4.21).
(i) (ii) (iii)
(a)
(b)
(c) (d)
Techniques to enhance the size and quality of
4.21
duodenal biopsy specimens. (a) Samples
should be taken: (i) from the distal duodenal flexure,
(ii) from the ‘back’ of a peristaltic wave and (iii) after
deflation of the duodenum so that folds develop. (b) The
forceps should be placed on the wall of the descending
duodenum and the endoscope tip deflected into the wall,
whilst pushing the mucosa away with the forceps to allow
the biopsy site to be viewed. (c) The open cups should
be pushed along the wall to scoop up a larger piece of
mucosa. (d) ‘Swing-jaw’ forceps should be used (see also
Chapter 3).
If the jejunum is reached, more flexures are
passed and it not only becomes harder to rotate and
steer the endoscope but it is also more difficult to
collect biopsy specimens. Indeed, old forceps that
have not been lubricated may be so ‘sticky’ that the
cups will not open because of the excessive twisting,
even though they opened when operated before
insertion. The failure to open is frustrating, but
occasionally the cups will eventually open if the
54
Ch04 Endo.indd 54
forceps can be advanced out of the endoscope
sufficiently far to be relatively straight. Alternatively,
brand new forceps may be robust enough to open.
After examination and biopsy of the duodenum,
the endoscope is withdrawn into the stomach for a
more careful examination (see above). However, it is
important to observe the proximal duodenal flexure
during withdrawal as lesions missed as the endoscope
entered may be seen. Duodenal ulcers are rare but
are typically seen just distal to the pyloric canal.
Jejunoscopy
So-called push enteroscopy uses an endoscope up
to 3 m in length. This is usually narrow and may not
have an accessory channel, so is merely used for
viewing without biopsy. Typically it is difficult to steer,
and may be guided through the stomach by passage
through an oversleeve or by being ‘piggy-backed’ on
a standard gastroscope.
Complete examination of the whole small intestine
can only be guaranteed by using a double balloon
enteroscope. This specialized instrument has an
oversleeve with an inflatable balloon in addition to an
inflatable balloon behind its tip. By repeated cycles of
inflating and deflating each balloon alternately, whilst
advancing the insertion tube and then the oversleeve,
the intestine can be shortened like a concertina so
that the whole length is eventually seen. This process
is complex and slow and is not currently performed in
veterinary medicine in the UK.
Ending the examination
After a full duodenal examination, gastric examination
and biopsy, the air is withdrawn from the stomach. If
gastric contents are found in the oesophagus on with-
drawal of the endoscope, they should be sucked out
and, if necessary, the oesophagus lavaged. Leaving
gastric acid, bile and digestive enzymes in the oesoph-
agus of a patient recovering from anaesthesia (and
therefore having depressed swallowing) can predis-
pose to inhalation pneumonia, oesophagitis and even
stricture formation. The oesophagus is inspected
again for lesions before the procedure is ended.
Rigid oesophagoscopy
Flexible endoscopy is essential for examination of
most of the upper GI tract due to its tortuous anatomy.
However, just as rigid endoscopes can be used for
colonoscopy, these instruments can be used to exam-
ine the oesophagus but are potentially most useful for
the removal of oesophageal foreign bodies.
A colonoscope (Figure 4.22) is basically a rigid
hollow tube with a light source and an obturator to aid
insertion. Once the patient’s head and neck have
been extended, insertion into the oesophagus in a
straight line is feasible. Then, after removal of the
obturator, it is possible to inspect the oesophageal
mucosa. However, the view is poor as the field of view
is limited by the length of the endoscope relative to
the diameter of its distal aperture. Insufflation whilst
looking through a magnifying window attached at the
other end improves the view, but insertion of instru-
ments is then not possible. Thus, examination by a
flexible endoscope is always preferred if available.
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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract

Rigid colonoscope suitable for aiding the
4.22
removal of oesophageal foreign bodies. Note the
obturator to facilitate atraumatic insertion, and rubber bulb
for insufflation once the viewing window has been sealed.
However, a rigid colonoscope can be useful when
removing sharp oesophageal foreign bodies. The
endoscope acts as a sleeve through which either rigid
grasping forceps or a flexible endoscope with forceps
is inserted. Once the object has been freed from the
site of obstruction, it can be pulled into the lumen of
the rigid endoscope and removed within it so that the
proximal oesophageal mucosa is not traumatized.
This arrangement is also helpful if removing multiple
or sharp gastric foreign bodies with a flexible
endoscope, as it reduces the risk of trauma to the
oesophagus.
Normal findings
Oesophagus
The oesophageal mucosa (Figure 4.23) is generally
pale grey/pink and always paler than the gastric
mucosa. In breeds with pigmented tongues (e.g.
Chow Chow, Shar pei) patches of the oesophageal
mucosa may also be pigmented. The surface is
smooth, and the oesophagus usually appears flac-
cid. Occasionally, when anaesthesia is too light, a
wave of contraction flashes down the oesophagus.
The lumen may appear quite large because of anaes-
thesia and megaoesophagus must not be misdiag-
nosed. The lumen may contain a small amount of
clear fluid and sometimes bile, but the presence of
food is abnormal.
As the oesophagus is inflated, longitudinal folds in
the proximal body of dogs are obliterated and a
smooth tube is seen. Indentation by the trachea is
seen where the cervical and cranial thoracic
oesophagus drapes over it, and the outline of tracheal
rings may even be visible. Pulsations of the wall mark
the position of adjacent great vessels and heart.
Submucosal vessels are not visible in normal dogs,
but are sometimes seen in puppies and cats. In cats
the distal oesophagus has numerous annular folds of
mucosa.
The normal oesophagus is hard to biopsy because
the mucosa is tough and the forceps tend to slide off.
A biopsy is usually only performed if there is significant
oesophagitis or there is a mass (see Chapter 3).

(a) (b) (c)

Endoscopic appearance of the normal oesophagus. (a) Indentation of
4.23
the trachea into the oesophagus in the cranial thorax. (b) In cats the
distal oesophagus has numerous annular folds of mucosa. Submucosal vessels
are not visible in normal dogs, but are sometimes seen in puppies and cats.
(c) Normal lower oesophageal sphincter. (d) ‘Z-line’ demarcation between the
paler oesophageal mucosa and the redder gastric mucosa at the open lower
oesophageal sphincter.

(d)

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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract
The lower oesophageal sphincter is usually closed
and the significance of an open lower oesophageal
sphincter is uncertain, unless there is adjacent reflux
oesophagitis (see below) when a hiatal hernia may be
suspected. A sharp demarcation between the grey/
pink oesophageal and redder gastric mucosa (known
as ‘ -line’ in humans) may be seen and should not be
confused with oesophagitis.
Stomach
The gastric mucosa (Figure 4.24) should be pink and
glistening. Patches of hyperaemia are sometimes
seen and are thought to be due to local differences in
blood flow. They often disappear as the procedure
proceeds and are not considered pathological.
Submucosal vessels are seen in the cardia and
fundus only when the stomach is fully inflated. There
may be a few mucus strands crossing the lumen as
opposing mucosae are separated by insufflation. In
some dogs dark spots within the mucosa are seen.
They seem to correspond with the lymphoid follicles
induced by Helicobacter infection, but it is not clear
whether these are actually abnormal.
4.24
Endoscopic
appearance of
normal stomach.
(a) Parallel rugal
folds running
towards antrum.
(b) Lymphoid
follicles are
darker spots on
the rugal folds.
(a)
(b)
Rugal folds are generally smooth and tend to run
in straight lines along the long axis of the stomach.
They flatten on insufflation and reform as the stomach
is deflated. The antrum has fewer folds except around
the pylorus, where a few folds are expected. The
normal pylorus may be open or closed but should not
be obscured by mucosal folds. Waves of peristalsis
56
Ch04 Endo.indd 56
may be seen migrating concentrically towards the
pylorus (see Figure 4.15). These are more common
in dogs than cats, occurring three to four times per
minute, and seem to be stimulated by over-distension
of the stomach. They also increase in incidence the
longer the procedure takes.
Duodenum
The duodenal mucosa (Figure 4.25) is pink and has
the appearance of crushed velvet or good quality
terry towelling, although the granularity depends to a
certain extent on the degree of distension and spe-
cies; the texture is slightly grainier and the mucosa
slightly pinker in dogs compared with cats. Biopsy
samples should always be taken, even if the gross
appearance is completely normal, as there may
be significant microscopic inflammation present.
Submucosal vessels are not visible.
4.25
Endoscopic
appearance of
a normal
descending
duodenum in
(a) a cat and
(b) a dog. Note
the paler
duodenal
mucosa in cats.
(a)
(b)
One landmark in the canine duodenum is the
major duodenal papilla, where the common bile duct
and major pancreatic duct enter; it is often not
detected in cats. In some dogs (but not in cats) there
is also a minor duodenal papilla for a second
pancreatic duct. These appear as small white flattish
protuberances and may be overlooked until the
endoscope is being withdrawn. The minor papilla (if
present) is slightly clockwise of the position of the
ma or papilla. lso only in dogs, Peyer’s patches
(lymphoid aggregates) are usually visible as 1–3 cm
pale oval depressions along the antimesenteric
border of the descending duodenum (Figure 4.26).
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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract

(a) (b) (c)

Landmarks in normal canine duodenum. (a) The major duodenal papilla in the duodenum of the dog is the site
4.26
of entry of the common bile duct and major pancreatic duct. (b) Peyer’s patches (lymphoid aggregates) in the
duodenum appear as pale round depressions along the antimesenteric border of the descending duodenum. (c) The
minor duodenal papilla (m) is seen in some but not all dogs distal to the major duodenal papilla (M) and approximately
100 degrees clockwise from it.

Pathological conditions The more common pathological conditions that

The aetiopathogenesis, diagnosis and treatment of
various GI conditions are discussed in the BSAVA
Manual of Canine and Feline Gastroenterology, 2nd
edition. The endoscopic appearance of the more
common diseases is described here.
Oesophagus
Reddening, ulceration or masses within the oesopha-
gus are abnormal and are readily detected by endo-
scopy, as are obstructions due to strictures or foreign
bodies. However, megaoesophagus and extraluminal
obstructions are difficult to recognize, although the
accumulation of fluid and/or food is definitely abnormal.
can be recognized endoscopically in the oesophagus
are listed in Figure 4.27, with examples given in
Figure 4.28.
Megaoesophagus
A large cavernous lumen extending the length of the
oesophagus is very suggestive of megaoesophagus
(see Figure 4.28a) but under anaesthesia a normal
oesophagus can appear flaccid and distended.
However, accumulation of liquid and food is abnor-
mal. Dilatation secondary to a vascular ring anomaly
only extends to the heart base, and pulsating vessels
may be seen impinging on the oesophageal wall in
unusual positions.

Condition Appearance

Megaoesophagus • Fluid and fermenting food retained in voluminous folds

(Figure 4.28a) • Thin mucosa – submucosal vessels visible
• Sometimes areas of reddening/oesophagitis
Often difficult to pass lower oesophageal sphincter as endoscope is diverted into fold

Oesophagitis • Erythema, irregularity, erosions

(Figure 4.28bc) Just proximal to lower oesophageal sphincter if reflux oesophagitis
• Distinguish from junction with gastric mucosa

Stricture • Circumferential narrowing of mucosa so that endoscope cannot be passed

(Figure 4.28d) • ± Oesophagitis
Smooth mucosa if fibrous scarring
• Irregular if due to neoplasia

Neoplasia (rare) and granuloma • Carcinomas and sarcomas are rare and appear as friable, often ulcerating masses
(Figure 4.28ef) • Submucosal leiomyomas often appear at the gastro-oesophageal junction as smooth swellings covered by
normal mucosa, and sometimes cause bulging of the gastric mucosa
• Granulomas due to Spirocerca infection (not in UK)

Extramural compression • Cranial dilatation with narrowing of the oesophagus at some point
ulging inflamed mucosa
• Examples: anterior mediastinal lymphoma, persistent right aortic arch

4.27 Endoscopic appearance of oesophageal lesions. (continues)

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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract

Condition Appearance

Hiatal hernia • Sometimes ballooning of oesophageal wall into oesophageal lumen

(Figure 4.28g) • ± Distal oesophagitis

Gastro-oesophageal intussusception • Ballooning of gastric rugal folds through lower oesophageal sphincter into lumen making it hard to pass
endoscope
• Necrosis in severe cases

Diverticulum • Variable size opening into diverticulum

(Figure 4.28h) • Pocket usually full of liquid and/or food
Often difficult to understand orientation

4.27 (continued) Endoscopic appearance of oesophageal lesions.

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

Examples of oesophageal lesions. (a) Megaoesophagus. (b) Severe oesophagitis following reflux under
4.28
anaesthesia for ovariohysterectomy. (c) Spontaneous reflux oesophagitis. (d) Oesophageal stricture.
(e) Submucosal leiomyoma in a dog. (Courtesy of EJ O’Neill) (f) Squamous cell carcinoma in an old cat. (Courtesy of SMA
Caney) (g) Hiatal hernia with bulging of the oesophageal wall into the oesophageal lumen. (h) Oesophageal diverticulum
filled with fluid. (i) Fish hook lodged at the gastro-oesophageal junction.

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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract

Stricture is uncertain. Fresh or changed blood (appearance

Occurring anywhere in the oesophagus, a stricture
(see Figure 4.28d) appears as a distinct circumferen-
tial narrowing of the lumen. It may be pale due to
fibrosis but there is often oesophagitis proximally.
The lumen may narrow so severely that only closed
forceps can pass.
Neoplasia
Tumours of the oesophagus (see Figure 4.28ef) are
very rare except in certain parts of the world (e.g.
South Africa) where infection with Spirocerca lupi is
common. Cats most frequently suffer from squamous
cell carcinomas, whilst in dogs adenocarcinomas and
submucosal leiomyomas are sometimes seen.
Foreign body
Oesophageal foreign bodies (see Figure 4.28i) are
readily detected and can sometimes be removed
endoscopically (see below).
Stomach
The presence of irregularity, friability, ulceration and
overt masses in the gastric mucosa are all abnormal.
Patches of hyperaemia are not necessarily considered
pathological and the significance of lymphoid follicles
like coffee grounds) is abnormal and a bleeding ulcer
or tumour should be sought. The presence of food is
abnormal if the patient has truly had food withheld for
12 hours and may reflect an outflow obstruction or
abnormal motility, which is most frequently associated
with inflammatory bowel disease.
The more common pathological conditions that
can be recognized endoscopically in the stomach are
listed in Figure 4.29, with examples given in Figure
4.30.
Gastritis
Gastritis (see Figure 4.30a) is indicated by irregularity
and friability of the mucosa. There may be small areas
of haemorrhage associated with erosions (i.e. very
superficial ulcers) in gastritis (Figure 4.30b). Biopsy
specimens should always be collected as there may
be no macroscopic evidence of gastritis.
Ulcers
Benign ulcers (e.g. non-steroidal anti-inflammatory
drug (NSAID)-induced; see Figure 4.30c) tend to
have smooth edges and form a depression in the
mucosa, whereas neoplastic ulcers are often
proliferative, raised and feel rigid on biopsy.

Condition Appearance
Gastritis • May appear grossly normal
(Figure 4.30a) • Increased mucus
• Increased number of lymphoid follicles
• Mucosal thickening, granularity and friability
• Erosions ± ulcers
• Sub-epithelial and frank haemorrhage
• Reduced size and number of rugal folds and prominent submucosal vessels in atrophic gastritis
Erosion • Erosions are shallow areas of mucosal disruption
(Figure 4.30b) • Red/brown discoloration
Causes: inflammatory disease; non-steroidal anti-inflammatory drugs ( S I s); ‘stress’ or severe illness
Ulcer • Mucosal disruptions penetrating the submucosa
(Figure 4.30c) • Raised, thickened border
• Dark brown ulcer bed due to bleeding
• Yellow/white necrotic tissue
Changed blood in gastric fluid in fundus
Causes: inflammatory disease; S I s; neoplasia
Pyloric stenosis • Enlarged, protuberant pylorus
• Small pyloric canal
• ± Retained food
• ± Erythema/erosions around pylorus
Benign mucosal antral polyp • Commonly seen in old dogs
Of no clinical significance unless bleeding
Hypertrophic pylorogastropathy Thickened rugae not completely flattened by insufflation
(Figure 4.30d) Prominent light reflectivity suggestive of oedema
• May be focal or extend to antrum/pylorus
Neoplasia • Gastric haemorrhage
(Figure 4.30e) • Ulcerated tissue
• Thickening/stiffening of mucosa; rigid when biopsied
• Carcinomas often on lesser curvature extending to cardia or antrum
• Ulcers on greater curvature either non-malignant or lymphoma
Parasite • Physaloptera worm in lumen (not in UK)
• Ollulanus in cats is a microscopic cause of gastritis

4.29 Endoscopic appearance of gastric lesions.

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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract
(a) (b)
(d) (e)
Hypertrophic pylorogastropathy
Excessive folds around the pylorus are typical of
hypertrophy (see Figure 4.30d).
Gastric neoplasia
Gastric adenocarcinoma (see Figure 4.30e) is most
commonly seen on the lesser curvature and may be
suspected if more than three of the following six
observations are made (Simpson, 2005).
• Mucosal colour change to a mottled purple
instead of pink
• Deep pigmentation of the mucosa
• An obvious mucosal mass
• Ulceration
• Loss of normal gastric landmarks
• Rigidity of the gastric mucosa.
Gastric lymphoma can affect some or all of the
stomach and the mucosa is often lumpy and friable.
However, in all cases the observation must be
confirmed by histopathological examination. Deep
biopsy specimens may be required to make the
diagnosis, as superficial tissue is often necrotic.
Gastric parasites
Physaloptera spp. worms in the stomach are not seen
in the UK, and Ollulanus tricuspis is too small to be
recognized grossly by endoscopy.
Duodenum
Deep duodenal ulceration is rare in the dog and cat
and is most commonly associated with malignancy,
but inflammation and erosions are common leading
60
Ch04 Endo.indd 60
(c)
Examples of gastric lesions.
4.30
(a) Gastritis showing
submucosal haemorrhage. (b) Multiple
minor gastric ulcers (erosions)
associated with chronic gastritis.
(c) Ulcer on the lesser curvature
following non-steroidal anti-inflammatory
drug administration. Hair and debris are
stuck in the ulcer; the fresh blood seen
is from an adjacent biopsy site.
(d) Hypertrophic pylorogastropathy.
Note the multiple thickened mucosal
folds around the pylorus, which is not
visible. (e) Gastric carcinoma. A large
ulcerated mass is visible.
to friability of the mucosa, increased granularity and
sometimes bleeding. However, there is a well recog-
nized disparity between the gross and histological
appearance, and intestinal biopsy specimens should
always be taken.
The more common pathological conditions that
can be recognized endoscopically in the duodenum
are listed in Figure 4.31, with examples given in
Figure 4.32.
Condition Appearance
Inflammatory • Increased granularity
disease • Increased friability
(Figure 4.32abc) • Erosions
• Haemorrhage
• Linear haemorrhage: artefact from trauma;
eosinophilic inflammatory disease
Lymphangiectasia • Multiple white spots indicating dilated
(Figure 4.32df) lipid-filled lymphatics
• Similar appearance seen in postprandial
state
Neoplasia • Thickening and irregularity if
(Figure 4.32e) lymphosarcoma
• Mass or annular obstruction with
adenocarcinoma
• Adenomatous polyps occasionally seen in
cats
Parasite • Toxocara – motile, photophobic
(Figure 4.32gh) • Uncinaria – small (1–2 cm), white
• Taenia – recognizable by segmentation
4.31 Endoscopic appearance of duodenal lesions.
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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract

(a) (b) (c)

(d) (e) (f)

(g) (h)
Examples of duodenal lesions. (a) Inflammatory bowel disease: lymphoplasmacytic enteritis. Note the increased
4.32
granularity. (b) Inflammatory bowel disease: eosinophilic enteritis. Note the increased irregularity and ulcerated
areas. (c) Inflammatory bowel disease: bleeding associated with eosinophilic enteritis. (d) Alimentary lymphosarcoma.
Biopsy is required to confirm the cause of this ulcerated proliferative tissue. (e) Adenocarcinoma: an annular ulcerated
mass is visible (arrowed). (f) Lymphangiectasia. Note the multiple dilated lacteals containing white lymph. (g) Isolated
Toxocara worm in duodenum of a cat. Swallowed hair is also visible. (h) Segmented tapeworm in the duodenum of a dog.

Inflammatory bowel disease
The mucosa is often irregular and may be ulcerated
and even bleeding (Figure 4.32abc). The tissue is
usually friable: bleeding often occurs when the
mucosa is traumatized by the endoscope merely
touching it, and large pieces may be avulsed when
biopsy is performed.
Alimentary lymphosarcoma
There is no pathognomonic gross appearance for
alimentary lymphosarcoma (Figure 4.32d), and a
biopsy should always be performed. However,
mucosal biopsy may be inadequate in some cases,
with a full-thickness biopsy being required for a
definitive diagnosis. The mucosal surface may appear
very smooth because of infiltration and loss of villi, or
very irregular and friable, and there may be patchy,
lumpy infiltration.
Intestinal adenocarcinoma
Carcinomas are more common in the colon (see
Chapter 5) and stomach (see Figure 4.30e), although
gastric carcinomas can extend to involve the duo-
denum. Primary intestinal adenocarcinomas (Figure
4.32e) are seen most commonly in the ileum of
older cats, and are occasionally found endoscop-
ically in the canine duodenum, where they typically
are ulcerated.

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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract
Lymphangiectasia
Lymphangiectasia (Figure 4.32f) can be patchy and
full-thickness biopsy of other parts of the small
intestine may be needed. Sometimes the lymphatics
are markedly dilated with fat and appear as multiple
white globules in the mucosa, but a similar less
severe appearance can occur postprandially, and so
biopsy confirmation is essential.
Intestinal parasites
Occasionally, roundworms (Figure 4.32g) and tape-
worms (Figure 4.32h) are seen endoscopically. They
are rarely of clinical significance. Single roundworms
can be retrieved endoscopically for identification,
although they are photophobic and migrate away
from the endoscope light if they are not caught quite
quickly. Uncinaria hookworms (small white worms)
are occasionally found in the duodenum. Trichuris is
typically found in the caecum (see Chapter 5).
Foreign body removal
Foreign bodies in the GI tract are quite a common
problem in dogs and range from soft objects (e.g.
socks) to bones, stones and fish hooks and even
bizarre objects such as toys (Figure 4.33). Cats
being more fastidious most typically only swallow
needles and thread, and baby teats. Foreign bodies
can be managed:
• Conservatively (natural passage)
• By surgical removal
• By endoscopic removal.
(a) (b)
(d) (e)
62
Ch04 Endo.indd 62
The method chosen for removal will depend on
the:
• Clinical state of the patient
• Anatomical location of the foreign body
• Size of the foreign body
• Type of foreign body:
– sharp or smooth
– containing lead, caustics or zinc (e.g.
batteries).
• Radiological evidence of:
– obstruction
– perforation.
Instrumentation
A number of instruments that fit down a 2.8 mm
accessory channel are available for grasping foreign
bodies (see Chapter 2). There are fewer instruments
small enough to pass a 2.2. mm channel. However,
it must be remembered that even an instrument
able to be inserted down a 2.8 mm accessory
channel never opens wider than approximately
2 cm, and so large round objects may never be
retrievable endoscopically. A quick exploratory
laparotomy is preferable to spending hours ‘fishing’
in the stomach and failing.
The instruments available include:
• Basket forceps
• Rat-tooth or alligator jaw grasping forceps
• Multi-prong forceps (2-, 3-, 4- and 5-prong,
W-shaped)
• Snares
• Magnets.
(c)
Gastric foreign bodies.
4.33
(a) Rubber ball in stomach.
Despite being swallowed, the ball was
too large to be retrieved endoscopically
and a gastrotomy was performed.
(b) Coin. Note that it has fallen down to
the cardia. (c) Sock. (d) Peach stone.
(e) Stone.
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 Chapter 4
Of these, large grasping forceps and basket
forceps are the most versatile and useful. Basket
forceps and snares when opened spring to a
‘memorized’ shape and can be manipulated by
steering the endoscope over the foreign body before
being closed tight.
Oesophageal foreign bodies
These should be removed as soon as possible as
they cause pain and dysphagia, and can easily
perforate, especially as the most common foreign
bodies are ribs and vertebrae with multiple sharp
protuberances. Surgical removal is not ideal in light of
the possible complications, but endoscopic removal
is not always easy because it is hard to lift the mucosa
away from any protuberances, and trauma may be
caused as the object is pulled up the oesophagus or
pushed into the stomach. It can also be hard to
achieve a good grip. Immediate referral for removal
under fluoroscopic guidance is a sensible approach
(Figure 4.34).
If endoscopic retrieval is to be performed,
protection of the mucosa as the foreign body is
withdrawn can be attempted by:
• Inserting the endoscope through a rigid tube into
which the foreign body, e.g. fish hooks, open
safety pins, is withdrawn
• Having a thick plastic sleeve attached around the
end of the endoscope by an elastic band. The
sleeve is flapped back as the endoscope is
inserted but unfolds and covers the foreign body
as it is withdrawn, e.g. bones that are too large to
be pulled into a rigid endoscope.
4.34
A bone stuck
in the
oesophagus
has caused
severe
oesophagitis.
If a fish hook is caught in the oesophagus it may
have to be pushed through the mucosa back into the
lumen before it can be retrieved. Alternatively, by
grasping and forcing the hook down the oesophagus
it may be pulled through the mucosa with just a small
linear tear. If it appears to go deeply or is lodged near
a great vessel, surgical removal is safer. If the case is
being referred for endoscopic removal, it is helpful not
to cut an attached line exiting the mouth as this helps
find the hook.
Ch04 Endo.indd 63
Flexible endoscopy: upper gastrointestinal tract
Gastric foreign bodies
It is remarkable the size of foreign body that animals
can swallow and pass naturally. The presence of a
stone or bone in the stomach should not immediately
be assumed to be the cause of any vomiting; bones
will dissolve in gastric acid, and stones are frequently
passed. When deciding whether a foreign body can
be removed endoscopically, the size and nature of
the foreign body must be considered and whether
adequate grasping instruments are available. Rubber
balls are often impossible to retrieve even though the
patient managed to swallow them. Sharp points
should be grasped (ideally with rubber-tipped forceps)
so that they do not cause trauma on withdrawal, or
the object should be held so that the sharp point is
trailing as the object is pulled up the oesophagus,
e.g. grasping fish hooks in the middle of the curve
means the tip is pointing backwards as it is removed.
When attempting to grasp objects they frequently
fall into the fundus. Manipulating them back into the
antrum either with the endoscope or by turning the
patient on to their right side can help. Once the foreign
body is securely grasped, the endoscope, graspers
and foreign body are removed as a whole until they
are outside the mouth when the foreign body can be
released. The biggest difficulty is getting past the
lower oesophageal sphincter. Holding the cervical
oesophagus closed and insufflating to the maximum
whilst deflecting the tip obliquely may help.
Soft items can be grabbed by almost any instru-
ment (i.e. grasping or pronged forceps, basket for-
ceps) but biopsy forceps should not be used as they
will be blunted. If multiple foreign bodies are to be
removed endoscopically, an oversleeve can be
placed into the oesophagus to reduce the trauma of
repeated intubation and extubation.
Ring-shaped foreign bodies can sometimes be
removed by entrapment with suture material when
grasping forceps are not available. Biopsy forceps
are pre-placed through the endoscope and grasp one
end of a long, strong suture before the endoscope is
passed. Once in the stomach, the suture material is
passed through a hole in the foreign body and let go.
It is then picked up on the far side and withdrawn
through the mouth. The foreign body can then be
withdrawn on the loop produced by pulling both ends
of the suture material.
Duodenal foreign bodies
Duodenal foreign bodies that can be grabbed with an
endoscope are rare, and surgical intervention is
indicated if there is evidence of obstruction.
Contraindications
Endoscopic retrieval is the safest and preferred
method, but a number of objects cannot be removed
this way because:
• They are stuck
• They have caused perforation
• They have moved beyond the reach of the
endoscope
• They are too large to grasp
• They are too large to pass the gastro-
oesophageal junction.
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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract
Complications
Following removal of an oesophageal foreign body
there may be severe oesophagitis, which should be
treated to try to prevent stricture formation. If perfora-
tion has already occurred, or is caused by attempts at
endoscopic removal, exploratory surgery should be
performed as soon as possible. Sharp gastric foreign
bodies may cause gastric ulceration, which can be
treated symptomatically with sucralfate and acid
blockers once the foreign body has been removed.
Oesophageal stricture
Causes
Oesophageal strictures develop following severe
ulceration of the oesophagus down to the level of the
submucosa, often combined with chemical/enzymatic
inflammation caused by reflux of gastric acid, bile and
pancreatic peptidases. They are most commonly
caused following:
• Gastro-oesophageal reflux during anaesthesia
• Foreign body removal
• Ingestion of caustic substances
• Ingestion of potentially ulcerogenic tablets (e.g.
doxycycline, clindamycin) that get stuck.
Signs of dysphagia, regurgitation and swallowing
pain develop 1–2 weeks after the initiating event as
the stricture gradually forms.
Stricture dilation
Surgical resection of strictures is not usually attempted
because of the risks of dehiscence or further stricture
formation. Endoscopic-guided dilation is the preferred
treatment. The stricture can be dilated by bougienage
or balloon dilation under endoscopic guidance.
Bougienage
Conical rubber probes of gradually increasing dia-
meter are introduced to dilate the stricture gradually.
The method is considered more likely to cause
trauma as there is a shear force applied to the stric-
ture, and passage of the probe into very narrow stric-
tures is tricky, even when visualized endoscopically.
(a) (b)
(a) An oesophageal stricture. The open biopsy forceps are used as an internal measure; the cups span 4–5 mm,
4.35
indicating how narrow strictures can be. (b) Balloon dilation of the stricture. (c) Dilation of the stricture seen in
Figure 4.28d has led to a mucosal tear and only partial dilation of the remainder of the stricture. The induced oesophagitis
is likely to cause healing by further stricture formation.
64
Ch04 Endo.indd 64
Balloon dilation
This method is preferred because it is more controllable
and radial stretching is less traumatic (Figure 4.35).
Dedicated oesophageal balloon catheters are
available but are expensive; second-hand out-of-date
cardiac balloon catheters are suitable. The balloon
catheter is usually inserted alongside the endoscope
and through the stricture and inflated to stretch the
stricture. However, if the stricture is very narrow it can
be difficult to insert the balloon into the stricture.
Through-the-scope balloon catheters can be used as
they are inserted via the accessory channel and can
be manoeuvred by steering the endoscope tip.
However, they cost several hundred pounds and are
almost single use, because after inflation they are very
difficult to deflate and retrieve through the accessory
channel without tearing.
The balloon should be long enough to dilate the
whole length of the stricture, and typically is 6–10 cm
long. A range of balloon diameters is available and a
graduated dilation can be performed. However, it is
common practice just to use a 2 cm diameter balloon
as that degree of dilation provides satisfactory
resolution of signs, and unnecessary expense for
extra catheters is spared.
Following identification of the stricture by
oesophagoscopy, dilation is attempted, noting the
distance from the mouth as indicated on the insertion
tube markings. This allows the exact site to be found
the next time for comparison. The balloon is positioned
within the stricture and inflated with water rather than
air as this gives an increased hydraulic effect (see
Figure 4.35).
A syringe or pump is connected to a pressure
gauge and the maximum pressure permitted for the
balloon is used. Dilation is held for 1–2 minutes. If
dilation is successful the oesophageal lumen
becomes wider and some bleeding is seen. If there is
no bleeding, dilation has probably not worked (the
balloon may have slipped) and should be repeated.
Postoperative care
After dilation the patient is treated for severe oesopha-
gitis to try to prevent re-stricture formation with:
(c)
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 Chapter 4
• Sucralfate
• Metoclopramide
• Acid blocker (cimetidine, ranitidine, omeprazole)
• Soft/liquidized food.
Resting the oesophagus by gastrostomy tube
feeding may also help and is useful if the animal
is severely debilitated, although the lack of stimula-
tion of peristalsis may make stricture re-formation
more likely.
There is no evidence that steroids are helpful in
preventing stricture re-formation. Indeed they may
delay healing, but prednisolone is advocated by
some at 1 mg/kg/day for 7–10 days. The use of the
antifibrotic colchicine is even more controversial.
Recently, endoscopic intralesional injections of triam-
cinolone into the stricture just before it is dilated
have been recommended, but success rates have
not been published.
Historically, repeat dilation was only performed
when regurgitation recurred. However, recent
evidence suggests that frequent repeated dilation
(i.e. twice weekly) until there is no clinically significant
stricture present gives better results; between one
and twenty plus dilations may be needed. If dilation
fails, or the client cannot afford repeated dilations,
there are four options:
1. Feed a liquidized diet permanently: rarely
satisfactory as signs will probably persist.
2. Place a permanent gastrostomy feeding tube.
3. Try to place an expandable stent endoscopically:
expensive; stents are made for humans and are
usually too large for dogs and cats.
4. Euthanasia.
Complications
Some trauma (and haemorrhage) is necessary for the
dilation to have any effect, but the tissue is friable and
the risk of perforation or rupture of major vessels is
real. Occasionally, an acute tension pneumothorax is
caused, and the anaesthetic monitoring needs to be
good to detect respiratory compromise as soon as
4.36 The principle of placing a PEG tube.
Ch04 Endo.indd 65
Flexible endoscopy: upper gastrointestinal tract
possible. Minor oesophageal tears should be left to
heal spontaneously with percutaneous endoscopic
gastrostomy (PEG) tube feeding in the interim. Major
tears may require surgical repair, although that
increases the risk of further stricture formation.
Percutaneous endoscopic
gastrostomy tube placement
Gastrostomy tubes are very useful for maintaining
nutrition in chronically ill animals or patients where
naso-oesophageal or oesophagostomy tube feeding
is not possible ( oran, 2 5). astrostomy tubes can
be placed:
• Surgically:
– logical if patient is undergoing a laparotomy,
e.g. post-gastric dilatation and volvulus
– too invasive in a potentially debilitated patient
if other surgery is not required.
• Blindly (e.g. ELD device):
– risk of splenic laceration.
• Endoscopically:
– safer and quicker
– more convenient.
Principle
The principle of endoscopic placement of a
gastrostomy feeding tube is that an endoscope is
used to catch a line inserted through the body wall
into the stomach and to pull it out through the mouth.
The line is then fixed to the end of the tube and pulled
back out through the body wall with the feeding tube
attached until only the mushroom tip remains in the
stomach. After fixation on the outside of the body,
food can be placed directly into the stomach through
the PEG tube (Figure 4.36).
The early descriptions of this technique (Armstrong,
1992; Bright, 1993) described quite complex methods
of passing the tube into the stomach and securing its
position. Today, the process is much simpler with the
advent of PEG tube kits which contain all the
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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract
equipment needed and a PEG tube with an integral
dilator and wire loop attachment. Both the original
method and the kit method are described here, as
some readers may not have access to the kits.
However, kits (Figure 4.37) are becoming more widely
available and their ease of use makes this method
achievable by anyone with an endoscope.
4.37 PEG tube kit (Mila International Inc.).
Indications
The principle of feeding assistance is to place the
feeding tube as high up the GI tract as anatomically
possible, and to use a tube that can be left in place as
long as is necessary ( oran, 2 5). aso-oesophageal
tubes are only suited to short-term liquid feeding.
Oesophagostomy tubes can be used if the disease is
confined to the oronasopharynx; PEG tubes do not
need to be used in these patients. However, if the
patient has suffered head trauma they tend to tolerate
a PEG tube better than an oesophagostomy tube.
PEG tubes can be used for:
• Severe, painful oropharyngeal disease (e.g.
facial fracture)
• Oesophageal disease:
– severe oesophagitis
– during serial dilations of a stricture
– incurable obstruction (e.g. recurrent/refractory
stricture, neoplasia)
– ? megaoesophagus.
• Prolonged anorexia (e.g. feline hepatic lipidosis).
The use of permanent gastrostomy tubes to treat
megaoesophagus is controversial; some patients do
well but others continue to inhale saliva and die of
pneumonia.
Contraindications
PEG tubes should not be placed if there is:
• Persistent vomiting
• Persistent inhalation of saliva in patients with
megaoesophagus
• Very temporary anorexia.
Instrumentation
The equipment needed for the original and revised
methods of placement is listed in Figure 4.38, with
examples given in Figures 4.39 and 4.40.
66
Ch04 Endo.indd 66
Original method
Mushroom tip catheter:
• Gastrostomy tubes for surgical placement can be used for
endoscopic placement, but the wide bore syringe adaptor end
needs to be cut off first
If the mushroom tip is small or too flexible to be self-retaining,
then ‘flanges’ can be cut from the opposite end, slit and then slid
on to the tube
Large bore needle or over-the-needle catheter
‘ ishing line’ nylon or wire long enough to reach from the mouth to
the flank
Disposable pipette tip as a dilator
Scalpel
Suture material
Syringe port adaptor
Revised method (pre-prepared kit)
Mushroom tip catheter:
• The tips are large and rigid enough to be self-retaining and do
not need ‘flanges’
• The other end is tapered to act as a dilator
• A swaged-on wire loop is used for attachment to the wire pulled
through endoscopically
Large bore needle or over-the-needle catheter
ire loop long enough to reach from the mouth to the flank
Scalpel
Suture material
Syringe port adaptor
NB. Some human PEG tube kits also contain drapes and disposable
basket forceps as standard
4.38
Equipment needed for placement of a PEG
tube.
(a)
(c)
(b)
Mushroom tip catheter. (a) PEG tube showing
4.39
mushroom tip and centimetre markers (Cooks
Medical Supplies). (b) PEG tube showing wide openings
for food (Cooks Medical Supplies). (c) PEG tube (Mila
International Inc). The foam in the mushroom tip becomes
rigid when the feeding adaptor is fitted as it forces air
down a small tube in the wall of the main feeding tube into
the mushroom. A large central hole for feeding is visible.
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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract

the stomach, so that when the line is threaded it is

instantly entrapped. Once the line has been grasped,
the needle is withdrawn from the stomach to prevent
accidental trauma and the line is pulled out through
the mouth with the endoscope (Figure 4.41). The line
exiting the mouth is then attached to the gastrostomy
tube, and it is here that the original method becomes
slightly confusing.

Revised (kit) PEG tube. A wire loop is swaged on

4.40
to the hard conical end of the tube, which acts
as its own dilator; the mushroom tip is at the other end.

A siliconized mushroom-tipped gastrostomy tube

is used. The mushroom tip is necessary to keep the
tube in place in the stomach. An 18–20 Fr tube for
cats, and 18–24 Fr tube for dogs are suitable. A large
bore needle or catheter and some strong nylon (e.g.
fishing line) or wire are needed to pull the tube into
position. The line is initially grasped by the endoscope (a)
with grasping forceps or a snare, and a dilator is
necessary to ease the passage of the tube back
through the stomach and body wall. Finally suture
material is needed to fix the tube in place.

Method
The patient is anaesthetized and placed in right lateral
recumbency as the tube will be inserted in the left
flank. A site on the left flank, from behind the costal
arch to just ventral to the end of the 13th rib, is clipped
and surgically prepared. The endoscope is inserted
into the stomach, which is inflated as much as
possible. This pushes the spleen away from the
space between the stomach and body wall so that it (b)
cannot be traumatized. It also allows identification of
the site into which the tube will be inserted.

• The light may be seen shining through the body

wall (transillumination); some light sources can
shine a burst of very bright light to aid
transillumination.
• A gloved finger pushed into the prepared site will
show an indentation in the stomach visible
endoscopically.

Ideally, the insertion site should be at the junction of

the body and the antrum; if it is too near the pylorus the
mushroom tip may cause an obstruction. To access
this optimum site can be difficult or even impossible in
deep-chested dog breeds. Once the optimum site has
been determined, the endoscope is withdrawn back to
the cardia for safety, and a large bore needle or over-
the-needle catheter is pushed through the body wall
into the lumen. The fishing line or wire is then threaded
through the needle into the stomach, and the line is
grasped using the endoscope. It should be remem-
bered that the distal end needs to be anchored to stop
it being pulled completely through by accident.
Biopsy forceps should not be used to grasp the
line as they will be blunted, but grasping or basket
forceps can be used. It is easiest to pre-place open
basket forceps over the needle as soon as it enters
(c)
Placing the line to insert a PEG tube. (a) A
4.41
needle is inserted through the flank into the
inflated stomach. (Courtesy of D Holden) (b) The needle
entering the stomach viewed endoscopically. The wire is
now inserted. (c) The wire loop inserted through the
needle is grasped by basket forceps and pulled out
through the mouth.
Original method
Firstly, a disposable pipette tip (Figure 4.42) is
threaded on to the line with the conical point towards
the mouth; ultimately, this will dilate the path through
the body wall. The line is then attached securely
to the non-mushroom end of the gastrostomy tube,
so that when it is pulled into the stomach and

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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract

(a)

(b)

(c)
Fitting the pipette tip on to a PEG tube. (a) The
4.42
end of the PEG tube and pipette tip. The flared
tip of the PEG tube is cut off and the pipette tip is
threaded on to the wire exiting the mouth. (b) The wire is
then fixed to the tube by a transfixion knot. A needle
pushed through the tube aids placement of the transfixing
wire. (c) After securely attaching the wire to the PEG tube,
the pipette tip is slid over the join to act as a dilator for
when the tube is pulled out through the body wall.

out through the body wall, the mushroom tip remains Pulling the PEG tube through the body wall.
4.43
in the stomach. To make a secure attachment, the (Courtesy of D Holden)
line is transfixed on the tube before tying the knot;
this is achieved by feeding it through a large bore
needle inserted temporarily through the tube as a
guide. The end of the tube is then tucked within the
pipette tip.
The line entering the flank is then pulled, bringing
the feeding tube into the stomach and up to the
body wall. Strong traction is then applied to force
the pipette tip and tube through the body wall (Figure
4.43). It is usually necessary to make a small skin
incision to ease its passage, but the minimum nec-
essary cut should be made or the wound irritates
the patient.

Revised method
The wire loop is inserted into the stomach and
retrieved endoscopically as above. The simplicity of
the method comes when attaching the line to the
tube, as the swaged-on loop can be attached without
knotting. The conical end then acts as the dilator
(Figure 4.44).
(a)
Wire loop for inserting PEG tube. (a) The
4.44
mushroom tip of the PEG tube is looped through
the swaged-on wire loop to join it to the wire loop passing
out of the mouth. (continues)

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Ch04 Endo.indd 68 30/04/2013 09:14

 Chapter 4
(b)
(c)
(continued) Wire loop for inserting PEG tube.
4.44
(b) The wire loops are interlocked. (c) Pulling
the wires tight produces a knotless connection.
Fixing the PEG tube
With either method, once the tube has exited the
body wall, it is pulled so that the mushroom tip lies
snug against the stomach wall. This should be
checked endoscopically (Figure 4.45); if there is
blanching of the mucosa, the tube has been pulled
too tight. The most secure way to fix the tube is with a
Chinese finger-trap suture. The position of the tube is
noted against centimetre markers on the tube in case
of future migration (see Figure 4.43). The end of the
tube is cut off (eliminating the pipette tip or swaged-on
wire loop) and a syringe adaptor port fitted so that the
tube can be capped (Figure 4.46).
Patients tolerate PEG tubes well unless the suture
is too tight, or the site is wrapped in occlusive
dressings. A stretch netting (e.g. Surgifix; Figure 4.46)
is sufficient protection and an Elizabethan collar is not
usually needed. The stoma site is cleaned daily and
antibiotic cream applied if necessary.
4.45
Endoscopic
appearance of a
fitted PEG tube.
(a) Cooks Medical
Supplies tube.
(b) Mila
International Inc.
tube.
(a)
(b)
Ch04 Endo.indd 69
Flexible endoscopy: upper gastrointestinal tract
(a)
(b)
Fixing the PEG tube. (a) A feeding adaptor is
4.46
placed on the end of the PEG tube, which is
attached to the body wall by a Chinese finger-trap suture.
(b) The PEG tube is covered lightly with a stretch netting
dressing. (Courtesy of A Harvey)
Use
The PEG tube is not used for the first 24 hours, and
then initially sterile water is inserted just in case the
tube has migrated. If there is any doubt as to its
position, an iodine-based contrast medium (e.g.
Conray) is instilled and the stomach radiographed.
Once water can be given without problems liquid
feeding is introduced, gradually increasing from 1/3 to
2/3 to 3/3 of the caloric requirement over three days.
The food is warmed before feeding. Usually 4 divided
meals a day are tolerated, but if that provokes
vomiting, more frequent smaller feeds or even trickle
feeding by syringe pump can be introduced. Before
every feed or after 6 hours of trickle feeding, the
residual volume should be checked by aspirating the
gastric contents through the tube. If the patient is not
clearing the food, the feeding rate should be reduced
and prokinetics (e.g. metoclopramide) considered.
Before each feed the tube is flushed with water to
ensure patency, and then again after feeding to try to
keep it patent, as well as to give the patient their daily
water requirement. If the tube becomes blocked it can
be cleared either with a probe or, preferably, by
instilling a cola drink and leaving the tube capped; the
acid and effervescence in the cola usually resolve the
obstruction. Blockages are most frequently caused by
failure to flush the tube adequately, or by including
medication in the feed. Liquid medications are
preferred and any tablets must be crushed finely.
The first PEG tube can be left in for at least 6
months without problems in many patients, and own-
ers are generally willing to manage them at home.
Tubes are removed either when there are complica-
tions (e.g. wound infection) or when they are no
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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract

longer needed as the patient is taking its full caloric

requirement orally, or when a permanent device is
going to be inserted.

Long-term use
PEG tubes can be left in situ for months. If or when
they need replacing, a low-profile device (button) can
be fitted (Figure 4.47).

Removal of a PEG tube. Basket forceps are

(a) 4.48
used to grasp the mushroom tip of the PEG
tube as it is cut off outside the patient.

• If a rubber Foley tube is used as it rapidly

disintegrates in gastric acid
• If the mushroom is too small/soft as the tube may
migrate out; applying a ‘flange’ resolves this
problem
• If the tube is too tight it may cause tissue
necrosis and the patient will chew the tube
• If the tube is not capped when not in use,
leakage of gastric acid can cause acid burns on
(b) the skin (Figure 4.49)
• If a patient also has a chest drain in place, the
Low-profile gastrostomy tube. (a) The different
4.47
sizes of stalk are to accommodate differences in
tubes must be labelled. Accidental feeding
the thickness of the body wall. The conical mushroom is through the chest tube into the pleural space has
lodged in the stomach, whilst the feeding port is flush to killed patients.
the skin. (b) Stretching the device with a stylet allows it to
be inserted through the stoma when the PEG tube is finally
removed, producing a permanent gastrostomy.

Removal
The PEG tube should not be removed for at least 7
days after insertion to allow adhesions to form and
prevent leakage. That is why this feeding method is
not appropriate if the patient needs assisted feeding
for only a few days.
There are several ways of removing the tube:

• The mushroom tip can be stretched with a stylet

and the tube pulled out
• The tube can be cut off against the body wall:
– it will pass naturally if the patient is >20 kg
– retrieve endoscopically: this allows inspection
of the stoma.
The process can be speeded up by pre-grasping
the mushroom endoscopically before it is cut off
(Figure 4.48).
Problems and failures
Although well tolerated, PEG tubes can cause
problems:
4.49 Acid burns caused by a leaking PEG tube.
Jejunostomy tube placement
These are more commonly inserted surgically, but
they can be inserted endoscopically if the patient
already has a PEG tube (Tams, 1999). The endoscope
is advanced into the stomach and grasping forceps
are then steered so that they exit via the PEG tube.
The forceps are then used to grasp the tip of the

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 Chapter 4
jejunostomy tube, pull it into the stomach through the
PEG tube, and then carry it through the pylorus as far
down the small intestine as possible. The tube must
be long enough that the other end remains protruding
from the PEG tube in order that a syringe can be
attached.
Polyp removal
Polyps in the upper GI tract are very rare compared
with the large intestine (see Chapter 5) and their
removal is not discussed here. Laser surgery can
be performed with a compatible endoscope (see
Chapter 14).
Complications of upper GI
endoscopy
Although endoscopy is minimally invasive, there is the
potential to do harm to the patient (this is fortunately
rare) or to damage the equipment (see Chapter 3).
Gastrointestinal perforation
Perforation of the GI tract can result from forceful
insertion of the endoscope without adequate visuali-
zation of the lumen, or from poor biopsy technique. It
is most likely to occur when trying to intubate the duo-
denum. However, most perforations actually occur
when the tissue is diseased and, sometimes, even
just vigorous insufflation is sufficient to rupture an
ulcerated area. The perforation (and even intraperito-
neal organs) may be visible but as the viscus is likely
to collapse seeing this cannot be relied upon. Air
escaping into the peritoneal cavity will cause abdomi-
nal distension that cannot be relieved, and can be
verified by abdominal radiography or abdominocen-
tesis. Although a rare complication, the endoscopist
should always be prepared to take a patient to emer-
gency laparotomy if perforation occurs.
Mucosal haemorrhage
Significant haemorrhage is fortunately a rare event
and intervention is rarely needed. It is usually
associated with malignancy. Haemorrhage following
collection of biopsy samples is rarely significant, and
it is not routine practice to prescribe acid blockers or
(a) (b)
Ch04 Endo.indd 71
Flexible endoscopy: upper gastrointestinal tract
sucralfate after biopsy. Where a significant bleed
does occur (Figure 4.50) application of ice cold water
through an endoscopic catheter will usually halt it. If
this fails a 1 in 10,000 adrenaline solution may be
applied in a similar manner.
Laceration of major vessels or adjacent
organs
Laceration of major vessels and adjacent organs is
rare but can occur during foreign body removal and
stricture dilation.
Gastric dilatation
Gastric dilatation can occur following administration
of lavage solutions or during recovery if air is not
adequately removed after gastroscopy. Theoretically,
a volvulus could follow and it is wise to deflate the
stomach before withdrawing the endoscope.
Decreased venous return from gastric
over-distension
Over-distension of the stomach during the proce-
dure is a much more common problem than volvu-
lus. As well as making pyloric intubation difficult or
impossible, it has significant haemodynamic and
cardiorespiratory effects similar to those seen in a
spontaneous volvulus:
• Compression of the caudal vena cava: rapid drop
in venous return and blood pressure
• Compression of the diaphragm and decreased
tidal volume: splinting of the diaphragm prevents
adequate respiratory function.
Acute bradycardia
A slowing heart rate is sometimes encountered,
especially when the small intestine is entered, and
occurs particularly in toy breed dogs and patients with
severe GI disease. This appears to be a vagovagal
reflex and can be abolished by atropine. However,
there may also be increased respiratory and skeletal
movements, and tactical intravenous diazepam can
be helpful.
Bacteraemia
Transient bacteraemia occurs in about 5% of humans
undergoing endoscopy. The incidence of bacteraemia
Endoscopic appearance of
4.50
massive GI bleeding. (a) A large
blood clot is seen in the gastric lumen,
following bleeding from biopsy of a gastric
ulcer. (b) A stream of blood is seen in the
duodenum after biopsy of a more distal
duodenal mass.
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 Chapter 4 Flexible endoscopy: upper gastrointestinal tract
in dogs and cats undergoing any form of GI endoscopy
is unknown and perioperative antibiotics are not
routinely used. However, it would be sensible to use
them in ‘at-risk’ patients, e.g. patients with I bleeding
or valvular heart disease, as one would when
performing dentistry.
Transmission of infection
Poorly disinfected endoscopes can transmit
enteropathogenic organisms, and even within the
same patient it is common sense to perform upper
before lower GI endoscopy. Adequate disinfection of
a gastroscope is an essential part of the process and
starts as soon as the procedure finishes, with the
endoscopist flushing the channels of gross material
before thorough cleaning (see Chapter 2).
72
Ch04 Endo.indd 72
References and further reading
Armstrong JP (1992) Enteral feeding of critically ill pets. Veterinary
Medicine 87, 900–907
Bright RM (1993) Percutaneous endoscopic gastrostomy. Veterinary
Clinics of North America 23, 531–545
Elwood C (2005) Best practice for small intestinal biopsy. Journal of Small
Animal Practice 46, 315–316
Hall EJ, Simpson JW and Williams DA (2005) BSAVA Manual of Canine
and Feline Gastroenterology, 2nd edn, ed. EJ Hall et al. BSAVA
Publications, Gloucester
Shales CJ, Warren J, Anderson DM et al. (2005) Complications following
full-thickness small intestinal biopsy in 66 dogs: a retrospective study.
Journal of Small Animal Practice 46, 317–321
Simpson JW (2005) Gastrointestinal endoscopy. In: BSAVA Manual of
Canine and Feline Gastroenterology, 2nd edn, ed. EJ Hall et al., pp
34–49. BSAVA Publications, Gloucester
Tams, TR (1999) Endoscopic placement of gastrostomy and jejunostomy
tubes. In: Small Animal Endoscopy, 2nd edn, ed. TR Tams, pp
341–356. Mosby, St. Louis
oran L (2 5) eeding tubes. In: anual of Canine and Feline
Gastroenterology, 2nd edn, ed. EJ Hall et al., pp 288–296. BSAVA
Publications, Gloucester
30/04/2013 09:14
 Chapter 5
Flexible endoscopy: lower
gastrointestinal tract
Introduction
The lower gastrointestinal (GI) tract of the dog and cat
is much simpler in its anatomical structure compared
with many other species, comprising a simple tube
which is divided into the caecum, colon, rectum and
anus (Figure 5.1). As a result of this simple structure
and the accessibility of the lower bowel, it is particu-
larly well suited to examination by flexible endoscopy,
which is fortunate because disease of the colon is
very commonly seen in small animal practice.
Previously, radiographs, barium studies and possibly
laparotomy to obtain biopsy samples were required,
which was time-consuming and expensive. Endoscopy
provides a simple and readily available method of
Transverse colon
Ascending colon
Descending
colon
Ileum
Caecum
Rectum
Anus
5.1 Anatomical structure of the lower GI tract.
Ch05 Endo.indd 73
Flexible endoscopy: lower gastrointestinal tract
5
James W. Simpson
examining the entire mucosal surface of the lower
bowel and permitting collection of biopsy samples to
ensure a definitive diagnosis is obtained, which has
revolutionized the diagnosis of lower bowel disorders
in most patients.
For those clinicians considering the use of endo-
scopy, examination of the lower bowel is relatively
easy to carry out and offers the best site to develop
the necessary skills needed and build confidence,
whilst at the same time obtaining diagnostic informa-
tion which will benefit the patient.
Indications
Clinical signs of lower GI disease are generally those
of diarrhoea with or without fresh blood (haemato-
chezia) and mucus, tenesmus, dyschezia and/or con-
stipation. None of these clinical signs are
pathognomonic of any individual disorder of the lower
bowel (Figure 5.2). Although many of these condi-
tions can be diagnosed endoscopically, it is very
important to start the investigation with collection of a
detailed history and to carry out a thorough physical
examination. The physical examination must include
a rectal examination to assess anal sphincter func-
tion, check for disease of the anal sacs and to exam-
ine the rectal tissue for strictures, obstruction and
deviation. The clinical examination will help to rule out
systemic disease and will support the presence of a
primary lower bowel problem.
Disorder Comments
Colitis Lymphocytic–plasmacytic; eosinophilic;
histiocytic; granulomatous
Infection Salmonella spp.; Campylobacter spp.; Yersinia
spp.; Clostridium spp.; Trichuris vulpis; Giardia;
Uncinaria spp.
Caecal disorders Typhlitis; caecal inversion; caecal abscessation;
perforation; neoplasia
Intussusception Ileocaecal; caecocolic; colocolonic
Neoplasia Adenocarcinoma; lymphoma; leiomyosarcoma
Rectal disorders Stricture; adenomatous polyps;
adenocarcinoma; foreign body
5.2 Disorders of the large intestine.
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 Chapter 5 Flexible endoscopy: lower gastrointestinal tract
Where the patient’s primary clinical signs include
rectal tenesmus and dyschezia associated with the
passage of formed faeces or ribbon-like faeces, this
suggests a partial obstruction in the distal colon, rec-
tum or anus. A rectal examination will help determine
if anal sac disease or an anal sphincter problem
exists, whilst flexible endoscopy will permit visualiza-
tion of the rectal and distal colonic mucosa in order to
observe the cause of the obstruction. Where a mass
is found, biopsy samples should be collected in order
to determine whether benign or malignant neoplasia
is present. Similarly, where a stricture is detected,
biopsy samples should be collected as these lesions
can have an underlying neoplastic aetiology.
Many patients with lower bowel disease present
with chronic diarrhoea (± blood and mucus), tenesmus
and dyschezia. The starting point in this investigation
should be a faecal analysis to look for pathogenic
bacteria and parasites. Where infection is detected,
suitable treatment should be provided and the patient
reassessed at a later date. In addition, diet should be
carefully scrutinized and where this is found to be
inappropriate, dietary corrections should be made.
In those patients where systemic disease, dietary
factors and infection have been ruled out and clinical
signs have persisted, the most likely cause of the
lower GI signs is colitis. Endoscopic examination of
the rectum, colon and caecum should now be
considered. If there is significant faecal blood loss
consideration should be given to assessing a clotting
profile, which should include: manual platelet count;
prothrombin time; and activated partial thromboplastin
time to rule out any clotting defect. Pre-anaesthetic
blood tests can be carried out at the same time.
Colitis is generally a diffuse disease, which affects
the entire colon; however, there are occasions when
only part of the colon may be affected. It is therefore
wise to examine the entire colon from rectum to
ileocaecocolic junction in all patients. Biopsy samples
should be collected both from all visually affected
tissue and from apparently normal tissue, and
submitted for histopathology.
When carrying out lower GI endoscopy it is often
possible, with careful preparation of the patient, to
reach and then enter the ileum. Where the patient
presents with vomiting and diarrhoea, and the char-
acter of the faeces does not clearly reflect large intes-
tinal disease, it is not uncommon to carry out an upper
and lower GI endoscopic examination at the same
time. Where a protein-losing enteropathy or inflam-
matory bowel disease (IBD) is suspected, this permits
both the cranial and distal small bowel to be exam-
ined and biopsy samples collected, thus improving
the chances of obtaining a definitive diagnosis.
Irritable bowel syndrome (IBS) is a condition that
has been identified in the dog but not in the cat. The
clinical signs can be identical to those seen with
colitis. As there is no definitive diagnostic test for IBS,
the only method of obtaining a definitive diagnosis is
by ruling out all other causes of the clinical signs,
especially colitis. Endoscopic examination of the
lower bowel should be used as part of the investigation.
In IBS patients, biopsy samples will reveal no evidence
of inflammation or neoplasia.
74
Ch05 Endo.indd 74
Disease of the caecum (see Figure 5.2) is rare in
dogs and cats. Typhlitis is the most common disease,
and is usually the result of whipworm infection or
severe inflammation often associated with colitis.
Endoscopy will assist in the diagnosis of typhlitis and
other caecal disorders including caecal inversion,
abscessation and neoplasia.
Flexible endoscopy of the lower GI tract is also
extremely useful for evaluating the patient’s response
to treatment, whether this be associated with inflam-
mation or neoplasia. As no surgical intervention is
involved and only a light plane of anaesthesia is
required, many owners will permit follow-up endo-
scopy. Endoscopy also permits evaluation of healing
following surgical resection.
Instrumentation
Unfortunately, in small animal practice patients range
in size from kittens to Great Danes. Consequently,
the size of the large bowel varies considerably both in
diameter and in overall length. In large breeds of dog,
the entire 1 m length of the endoscope will be required
in order to reach the ileocaecocolic junction. The
choice of endoscope will also depend on whether
upper GI endoscopy is to be carried out in the prac-
tice. It is not possible to have a single ‘universal’
endoscope which will be suitable for kittens through
to Great Danes, and for both upper and lower GI
endoscopy. A compromise will normally be made in
selecting an endoscope which will be suitable for the
majority of patients.
Endoscope specifications for lower bowel exam-
ination include an end-viewing flexible endoscope
with an outside diameter of less than 9 mm and an
insertion tube length of at least 1 m. The biopsy chan-
nel must be at least 2 mm in diameter and the endo-
scope must have an air and water (wash) facility
together with four-way tip deflection (Figure 5.3).
Such an endoscope would also be suitable for carry-
ing out upper GI examinations, although it is likely to
be too large for small breeds of dog and cats, espe-
cially when attempting intubation of the duodenum.
5.3 For carrying out an endoscopic examination of
the large bowel in both dogs and cats, a
forward-viewing endoscope should be selected, with an
insertion tube length of at least 1 m and an outside
diameter of less than 9 mm. There must be a wash and air
facility, and a biopsy channel of at least 2 mm in diameter.
4/3/08 09:40:52
 Chapter 5 Flexible endoscopy: lower gastrointestinal tract

In addition to the flexible endoscope, standard this is more difficult. To assist in sample collection
accessories required for lower bowel endoscopy from the descending colon, it is important to ensure
include a suitable light source with an air and water that it is not over distended, causing the mucosa to be
facility, and biopsy forceps. A suction unit is useful but ‘stretched’. The forceps should be advanced until the
not essential. mucosa ‘tents’ and then the forceps are closed, in this
way much more tissue is collected.
Rigid endoscopes
Although flexible endoscopes are now routinely used
for examination of the large bowel, there is a place for No Yes
the use of rigid endoscopes in the examination of the
rectum and distal colon. It can be very difficult to
visualize the rectal mucosa using a flexible endoscope
because air used to inflate the rectal lumen escapes
through the anus. Rigid endoscopy can allow the
rectal mucosa to be examined without need for air
inflation, but in some cases this is still required. This
in turn allows biopsy sample collection from this
region to be carried out more easily.
Care should be exercised in choosing the diameter
of the rigid endoscope for this procedure, to ensure
adequate visualization without causing tissue damage.
Illumination may also be a problem in some cases, as
the light beam tends to be small with these units. In
general, biopsy forceps used with rigid endoscopes Yes
allow a much larger biopsy sample to be obtained
because there is no restriction in the size of the biopsy
channel, as occurs with flexible endoscopes.

Biopsy
When first starting to collect endoscopic biopsy sam-
ples, it is not uncommon to receive reports from the
pathologist indicating the samples were undiagnostic
due to the size of the samples or due to crush arte-
fact. In order to reduce crush artefact when collecting
large bowel biopsy samples, forceps with fenestrated
cups and no central spike (Figure 5.4) should be
used. The fenestrated cups permit a captured biopsy
sample to expand through the fenestrations, so reduc-
ing tissue damage during collection. To ensure an (a)
adequate biopsy sample is obtained it is very impor-
tant to direct the biopsy forceps so they open perpen-
dicular to the mucosa (Figure 5.5). If the biopsy
forceps are used parallel to the mucosa, only the sur-
face cells will be harvested and the sample will be
non-diagnostic. Directing the biopsy forceps perpen-
dicular to the mucosa is relatively easy at the junction
between the transverse colon and the ascending or
descending colon. However, in the descending colon

(b)

5.4 Careful selection of biopsy forceps will ensure 5.5 (a) Method of collecting biopsy samples from
crush artefact is reduced to a minimum. the colon. (b) The forceps should be advanced
Forceps with a central spike should not be used; those as near perpendicular to the mucosa as possible. This will
forceps with fenestrated biopsy cups should be selected. ensure a good depth of sample is collected.

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 Chapter 5 Flexible endoscopy: lower gastrointestinal tract
Patient preparation
It cannot be overemphasized how important patient
preparation is to carrying out lower GI endoscopy. It is
simply not possible to examine the colon of a patient
with solid or liquid faecal material present (Figure
5.6). When an endoscope comes into contact with
fluid or faeces, light is refracted and ‘red-out’ occurs
(see Chapter 3), so the procedure has to be abandoned
and the patient recovered from anaesthesia.
5.6 Careful preparation of the large bowel is
essential if the entire mucosal surface is to be
thoroughly examined. The presence of faeces severely
restricts the ability to carry out this examination.
Careful preparation of the patient is essential.
Food should be withheld for 24 hours prior to the pro-
cedure to ensure that the distal small intestine is
empty and that the colon, which has been carefully
prepared by repeated enema administrations, will not
slowly refill. An oral laxative may be given at this time
to assist in emptying the small intestine (Figure 5.7).
Many references quote the use of polyethylene glycol
preparations, such as ‘Klean Prep’, which will rapidly
cleanse the bowel. However, in the author’s exper-
ience, dogs and cats find these agents distasteful
and difficult to administer in the required volume.
Type of Examples
laxative
Emollient Liquid paraffin
Bulk Sterculia
Ispaghula
Wheat bran
Osmotic Magnesium sulphate
Lactulose (1–15 ml orally q8h for dogs and
0.2–1 ml for cats)
Sodium citrate (Microlax) 1 x 5 ml tube per rectum
Phosphates
Stimulant Bisacodyl (Dulcolax) (5–20 mg/dog or
2–5 mg/cat orally
Polyethylene glycol (Klean Prep) <20 ml/kg o.s.
Laxatives which may be used in the treatment of
5.7
constipation in dogs and cats. Those in bold are
useful in preparation for large intestinal endoscopy.
76
Ch05 Endo.indd 76
Enemas should be administered using a
Higginson’s Pump (Figure 5.8); however, prior to use
it is extremely important to carry out a rectal examina-
tion to ensure it is safe to insert the pump into the rec-
tum. It is also important not to induce damage to the
rectal mucosa whilst carrying out an enema, as this
may be mistaken for pathological change when carry-
ing out the endoscopy. Lastly, the solution used must
be non irritant, otherwise the mucosa will become
hyperaemic and inflamed, resulting in difficulty in vis-
ual interpretation of the mucosa. The author finds
warm water enemas extremely satisfactory at no
more than 15 ml/kg. Individual patients and especially
small breeds may require smaller volumes to prevent
rupture of the colon. Ideally, the first enema should be
given on the day prior to the endoscopy with two fol-
low-up enemas given on the morning of the proce-
dure. However, it is also acceptable to give two or
three enemas on the morning of the procedure until
the material voided by the patient is free of faeces.
Thorough preparation of the large bowel for
5.8
endoscopy is essential. A Higginson’s pump is a
very effective method of administering an enema, although
commercial enema preparations may also be used.
Premedication and anaesthesia
Although lower GI endoscopy is carried out without
anaesthesia in humans, this is rarely the case in
canine practice and never in feline practice. The author
has tried various sedative combinations in dogs and
has found the use of acepromazine maleate (ACP) at
20 µg/kg together with buprenorphine at 20 µg/kg i.m.
an effective method of restraint where the risk of gen-
eral anaesthesia is high. However, in the majority of
patients and always in those undergoing both upper
and lower GI endoscopy, a general anaesthetic should
be used. Following successful enema administration,
the patient should receive a premedicant followed by
induction with an intravenous agent before intubation
and maintenance on gaseous agents.
Patient positioning
Where flexible endoscopy is used, the patient should
always be placed in left lateral recumbency (Figure
5.9) as this ensures the descending colon lies
4/3/08 09:40:54
 Chapter 5
ventrally, which aids intubation of the transverse and
ascending colon and assists in drainage of any fluid
from the transverse and ascending colon. However,
where rigid endoscopy is used, right lateral
recumbency is preferred. It is useful to lightly tie a
linen bandage round the tail from its base to the tip,
especially in long-haired breeds, as this prevents
soiling and aids visualization of the anus.
Procedure
The distal 20 cm of the insertion tube should be lightly
lubricated using KY Jelly, taking care to avoid the lens,
as this will reduce friction and aid forward movement
of the endoscope in the colon. The tip of the insertion
tube should be inserted into the rectum for about 10
cm, so long as there is no resistance to movement.
The rectum should now be inflated but the endoscope
should not be advanced until the mucosa of the
descending colon can be clearly seen (Figure 5.10).
Occasionally, air will escape through the anus
preventing dilation of the bowel. In this situation it
may be necessary to pinch the anus to make the
rectum air tight. The descending colon should now be
clearly seen directly in front of the endoscope tip. The
mucosa should appear pale pink in colour, thin and
transparent so that the submucosal blood vessels
can be observed (Figure 5.11). Inexperienced
5.9 To aid intubation of the transverse and ascending colon, and to ensure that any residual fluid does not interfere
with the endoscopy, the patient should always be placed in left lateral recumbency.
Ch05 Endo.indd 77
Flexible endoscopy: lower gastrointestinal tract
endoscopists sometimes consider detection of these
blood vessels as a sign of inflammation; this is not the
case. In fact failure to see these blood vessels often
suggests thickening of the mucosa, which may be
due to either inflammation or neoplasia.
Once the lumen of the descending colon has been
observed, the endoscope can be advanced examin-
ing the entire circumference carefully for pathological
change. If this is not done, damage to the mucosa
caused by passage of the endoscope may later be
misdiagnosed as pathological. The junction between
the descending and transverse colon will be readily
detected as an obvious ‘bend’ at the end of the straight
descending colon (Figure 5.12). The tip of the endo-
scope should be moved in the direction of the bend
and advanced slowly. It is not uncommon to induce
‘red-out’ whilst doing this, as the endoscope brushes
along the mucosa. Once in the transverse colon an
image of the mucosa should be re-established and
the procedure continued as before. The next ‘bend’
marks the junction of the transverse and ascending
colon, and the endoscope should be manoeuvred as
before to enter the ascending colon. Again visualiza-
tion of the luminal circumference should be estab-
lished before proceeding. More air may be required
whilst carrying out these two procedures. There is lit-
tle danger of over-distension so long as the anus is
not continually occluded, as it will act as a safety valve
to relieve pressure.
5.10 Once the
endoscope has
been advanced into the
rectum, the lumen should
be inflated with air. It
should now be possible to
visualize the descending
colon extending in front of
the endoscope.
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 Chapter 5 Flexible endoscopy: lower gastrointestinal tract

The ascending colon is short and ends at the

ileocaecocolic junction (Figure 5.13). This is readily
identified by the opening into the blind-ended caecum
and the raised prominent and usually red ileocolic
sphincter.

5.13
The ascending colon
is short and ends at
the ileocaecocolic
junction. The ileum
appears as a raised
red button-shaped
structure whilst the
caecum is a blind-
ending sac.

5.11 The mucosa of the colon should appear pale

pink in colour and the submucosal blood vessels
should be clearly visible through the thin mucosal layer.

5.12
As the endoscope is
advanced along the
descending colon,
eventually a ‘bend’ will
be observed, which
represents the flexure
between the
descending and
transverse colon. This
is a normal anatomical
landmark, which will
be observed on a
second occasion as
the endoscope
reaches the flexure
separating the
transverse and
ascending colon.

The caecum should be carefully examined as this

can become inflamed (typhlitis) or may contain the
nematode Trichuris vulpis. If the ileum is to be exam-
ined, the tip of the endoscope should be directed
towards the ileocolic junction and advanced. However,
it is extremely unlikely that the ileum will be intubated
unless the insertion tube diameter of the endoscope is
less than 7 mm, except in large breeds of dog. Another
limiting factor in large dogs is where the entire length
of the insertion tube is required to reach the ileocaeco-
colic junction, leaving no available length to intubate
the ileum. Under these circumstances it is permissible
to advance biopsy forceps ‘blindly’ into the ileum and
collect biopsy samples. This must be done with care
and where any resistance to forward movement is
detected, the procedure should be stopped.

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 Chapter 5 Flexible endoscopy: lower gastrointestinal tract

Following examination of the entire large bowel, the Lymphocytic–plasmacytic colitis

endoscope is withdrawn slowly and biopsy samples Lymphocytic–plasmacytic colitis is the most common
are collected. In areas where no gross lesions have form of colitis seen in the dog and cat. It is character-
been found, 2 or 3 biopsy samples should be collected ized by an infiltration of the mucosa with lymphocytes
from the ascending and transverse colons and a further and plasma cells. There appears to be a breed predis-
4 or 5 from the descending colon. This will give a good position in the Golden Retriever. Macroscopically, this
representative sample for the pathologist to judge the may be suspected by the presence of hyperplastic
health of the colon. Where a specific lesion is detected, lymphoid tissue, which can appear like small ‘dough-
biopsy samples should be collected from the ‘lesion’ nuts’ on the mucosa (Figure 5.14) and where the sub-
and from surrounding apparently ‘normal’ tissue. These mucosal blood vessels can no longer be seen. It is
specimens should be placed in separate pots, so the very unusual for ulceration to be observed in this form
pathologist can compare tissue samples. The exact of the disease and the mucosa is not usually friable.
location of any lesion should be carefully noted by
recording the distance marked on the insertion tube at
the anus, which is given in centimetres. This will be
useful in any follow-up endoscopy so the exact site of
the lesion can be quickly found.
The rectum is difficult to examine as the endo-
scope is inserted through the anus. As previously
described, air often leaks out through the anus, mak-
ing dilation of the rectum extremely difficult. Even
quite large tumours can be missed if the rectum is
visualized as the endoscope is inserted, due to folds
in the rectal mucosa. Therefore, the author has found
that inserting the endoscope through the rectum and
into the distal descending colon, then inflating the
lumen with air and slowly withdrawing the endoscope
while maintaining air inflation, allows good visualiza-
tion of the rectal mucosa. Retroflexing the endoscope Lymphocytic–plasmacytic colitis results in
5.14
is another method of examining the rectum but can thickening of the mucosa so submucosal blood
only be successfully carried out in larger dogs. vessels can no longer be seen, and in many cases
Where a stricture is detected in the rectum or lymphoid hyperplasia will be observed as raised
colon, it is often extremely difficult to advance the ‘doughnut’-shaped structures.
endoscope. This is because the stricture forms a ‘lip’
around the circumference, which catches the The mucosa in some cases, particularly those with
endoscope and prevents further forward movement. a long history of disease, may become much more
Although most strictures are inflammatory in origin, severely affected, with marked proliferative changes
some may be due to neoplasia, and so collection of suggestive of a neoplastic disease (Figure 5.15). It is
biopsy samples from the base of strictures is essential very important not to assume that neoplasia is present
prior to deciding on appropriate treatment.

Pathological conditions
Colitis
Colitis is the commonest form of large intestinal dis-
ease seen in the dog and cat. Although bacterial
pathogens and parasitic infections can be inciting
causes, in the majority of patients the clinical signs
are chronic and no underlying aetiology is deter-
mined. Colitis is generally a diffuse disease involving
the entire colon, and may also occur in conjunction
with similar changes in the small intestine. These
changes, whether purely large bowel or involving
both the small and large bowel, come under the
umbrella of inflammatory bowel disease. At this time
no aetiological agent has been found for IBD, which
is usually classified according to the predominant
cell type present: lymphocytic–plasmacytic; eosino-
philic; histiocytic. 5.15 Occasionally, lymphocytic–plasmacytic colitis
may be severe. In such cases proliferative
Rarely, granulomatous colitis is detected, which changes may be observed suggesting the possible
differs from the other forms of colitis because it is presence of neoplasia. It is essential to collect biopsy
often a focal disease and involves only a small section samples for histopathology and not to over interpret the
of the large bowel. visual changes.

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 Chapter 5 Flexible endoscopy: lower gastrointestinal tract

and biopsy samples should always be collected for

histopathology, in order to confirm which type of
disease is present. Biopsy samples reveal this form of
colitis is associated with increased numbers of plasma
cells and lymphocytes, activation of CD4 T helper
cells and an increased production of Th1 cytokines. In
some cases, crypt abscessation has also been
reported and increased numbers of goblet cells and/
or fibrosis may also be observed, depending on the
chronicity of the case.
However, occasionally lymphoma and
lymphocytic–plasmacytic colitis may appear grossly
and histologically very similar. Where a uniform
population of lymphocytes are present and lymphoma
is suspected, immunocytochemistry should be carried
out to determine the type of cells present. If a
monoclonal population of lymphocytes is present then 5.17 Histiocytic colitis may appear very similar to
a diagnosis of lymphoma may be made. eosinophilic colitis. Ulceration, friability and
bleeding are common. Proliferative changes may also be
Eosinophilic colitis observed.
Eosinophilic colitis is less common than lymphocytic–
plasmacytic colitis and is mainly seen in the dog. plasma cells, MHC class II cells and PAS cells in the
Cats rarely develop this form of colitis. Macroscopically, lamina propria. Neutrophils may also be observed
eosinophilic colitis is characterized by the presence and there is usually a reduction in the number of
of mucosal erosion and ulceration, loss of submucosal goblet cells.
blood vessels, and the mucosa is much more friable,
bleeding easily when the endoscope touches it Granulomatous colitis
(Figure 5.16). Histologically, it is quite common for Granulomatous colitis is the rarest form of colitis in the
there to be an increased numbers of plasma cells dog and is not seen in the cat. This form of colitis often
and lymphocytes together with a predominance of only involves one small region of the colon. The major-
eosinophils. Where ulceration is severe it is not ity of the colon will look grossly normal on endoscopy,
uncommon to detect varying numbers of neutrophils but often in the transverse or ascending colon a rela-
in the biopsy samples as well. tively small area of mucosal proliferation will be found,
which bulges into the lumen of the colon occluding fur-
ther forward viewing. These proliferative changes are
often accompanied by ulceration and bleeding. It is
not normally possible to pass the endoscope further
along the colon in these patients (Figure 5.18). The
main differential diagnosis in these cases is neoplasia.
Therefore, it is essential to collect biopsy samples to
rule out neoplasia, particularly adenocarcinoma.

5.16 Eosinophilic colitis results in destructive

changes to the mucosa. There are frequently
small erosions and/or ulcers present. The mucosa is more
friable and bleeds easily on manipulation.

Histiocytic colitis
Histiocytic colitis is a rare form of colitis in the dog
and never seen in the cat. It is most often seen in
young adult Boxers and French Bulldogs, although
the author has seen histiocytic colitis in other breeds
as well. In this form of colitis there are gross and 5.18 Where granulomatous colitis is found, the
diffuse changes to the mucosa, which can be severe majority of the colon will appear normal and
only a small section of the colon will be affected. The
with frank bleeding and marked proliferative changes lumen of the bowel may appear occluded by proliferative
suggestive of neoplasia (Figure 5.17). Biopsy reveals change and bleeding is not uncommon. This must be
the presence of a mixed cell population with differentiated from neoplasia by collection and
significantly increased numbers of CD3 T cells, IgG examination of biopsy samples.

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 Chapter 5
Irritable bowel syndrome
This is a condition which was first recognized in
humans and has subsequently been strongly
suspected as occurring in the dog but not the cat.
Working dogs in particular appear to be predisposed
to this condition and present with clinical signs typical
of colitis, namely, chronic small volume diarrhoea
often containing mucus and sometimes with
accompanying rectal tenesmus. Haematochezia is
not a feature of this condition. Some dogs may appear
to exhibit abdominal pain, which is thought to be
associated with colonic spasm. As the majority of
these dogs are working dogs, it has been observed
that resting them from their duties results in resolution
of the clinical signs. Pet dogs of a highly nervous
disposition should also be suspected of having IBS.
Unfortunately, there is no definitive diagnostic test
for IBS, so the only way in which a diagnosis can be
made is by ruling out all other causes of large intestinal
disease. Therefore, a full clinical examination should
be carried out to rule out systemic disease, followed
by faecal analysis and routine blood haematology
and biochemistry. These diagnostic tests will rule out
infections and systemic disease.
This should be followed by endoscopy to rule out
IBD (colitis), which is the most likely differential
diagnosis. In patients with IBS, no gross mucosal
lesions will be observed during the endoscopic
examination and biopsy samples for histopathology
will usually reveal normal mucosa, but in some cases
increased numbers of goblet cells may be present.
However, at endoscopy it may be noticed that there
are large amounts of mucus adhering to the mucosa
(Figure 5.19) and the colon itself may be difficult to
dilate due to colonic spasm. Both these clinical signs
are typical of the IBS patient.
5.19 IBS is difficult to diagnose as there are no visual
or pathological changes present. However, at
endoscopy the bowel may be difficult to dilate and an
excessive amount of mucus may be observed.
Neoplasia
Colonic neoplasia is most often associated with
lymphoma or adenocarcinoma in the dog and cat,
although leiomyosarcoma may rarely be diagnosed,
Ch05 Endo.indd 81
Flexible endoscopy: lower gastrointestinal tract
especially in the caecum. Lymphoma is generally a
diffuse condition that affects the entire colon and
may appear very similar to lymphocytic–plasmacytic
colitis. In some cases, pathologists may find the
differentiation between lymphocytic–plasmacytic
colitis and lymphoma difficult. In such cases,
immunocytostaining to determine whether a
monoclonal population of lymphocytes is present
allows the differentiation to be made. The author has
observed cases where lymphocytic–plasmacytic
colitis has been diagnosed but on follow-up
endoscopy lymphoma has been diagnosed. Such
cases may not truly reflect a progression from one
disease to another, but difficulty in differentiation.
The lumen of the bowel is rarely occluded but
thickened, and bleeding is not normally a feature.
Therefore, it is rarely possible to make a diagnosis
from visual examination of the colon, and biopsy
samples should be collected in order to reach a
definitive diagnosis.
Adenocarcinoma is normally a more focal disease
of the colon and may appear very similar to
granulomatous colitis (described above). The majority
of the colon will appear macroscopically normal, but
an area of proliferative change and bleeding, which
may occlude the lumen of the colon, will be found
(Figure 5.20). The mass may be very friable and
irregular in outline, and secondary infection is
common. Consequently, superficial biopsy samples
often only reveal inflammation and infection. In order
to confirm neoplasia deeper biopsy samples are
essential. This is achieved by carefully collecting
several biopsy samples from the same site within the
mass. The superficial samples may reveal only
evidence of inflammation, whilst deeper samples may
be more typical of neoplasia. Great care is required
when carrying out this ‘mining’ for tissue, to ensure
that only the proliferative mass is sampled and the
bowel is not perforated.
5.20 Adenocarcinoma is an aggressive tumour,
which invades the lumen of the colon. The
tumour will appear irregular and proliferative in
appearance, may bleed easily and may even appear very
friable to touch. The remainder of the colon usually
remains unaffected.
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 Chapter 5 Flexible endoscopy: lower gastrointestinal tract
Colonic vascular ectasia
This is a very rare condition of the canine colon, which
has been observed sporadically throughout the world;
it has not been described in the cat. Patients present
with a history of acute episodes of passing large
amounts of fresh blood in their faeces. There is often
an associated anaemia but no other evidence of
systemic disease or coagulopathy. Endoscopy will
reveal a focal area where there are enlarged, dilated
mucosal blood vessels, whilst the remaining colon
appears completely normal. Biopsy is not
recommended in these cases due to the risk of
inducing a major haemorrhage. Patients should be
referred for surgical exploration and resection of the
affected bowel. It is therefore very important to
measure the exact location of the lesion, using the
insertion tube ruler, in order to assist the surgeon in
locating the lesion at laparotomy. In humans, laser
cautery using diode or argon lasers may be used to
treat these cases, although this has not been reported
in the dog. See Chapter 14 for more information on
endoscopic laser surgery.
A similar condition has been observed in both
humans and animals, and no obvious underlying
cause has been identified. This lack of agreement as
to what type of change is being observed in these
patients has resulted in considerable variations in
terminology used to describe the lesions, which
includes angiodysplasia, arteriovenous malformation
and vascular ectasia.
Caecal disorders
Typhlitis, although rare, may be diagnosed on its own,
associated with whipworm, or in conjunction with
severe colitis. Whipworms (Trichuris vulpis) will be
observed at endoscopy and biopsy samples will
reveal evidence of inflammation with similar cellular
infiltrations to those found in the colon.
When a mass is found within the caecum this may
be due to neoplasia or abscessation. Great care is
therefore required in collecting biopsy samples in this
situation, and surgery may be considered the safer
option for obtaining a definitive diagnosis and
correcting the problem.
Intussusception
Both ileocolic and ileocaecal intussusception occur
in the dog and cat, although the former is more
common than the latter. In both cases, patients may
present with chronic diarrhoea with or without blood.
Therefore, it is not unreasonable for endoscopy to
be used in the investigation of these cases.
Intussusception is readily recognized at endoscopy
(Figure 5.21) and, when found, the endoscopic
examination should be immediately halted and the
patient referred for surgery.
Constipation
Endoscopy in constipated animals is rarely carried
out for the obvious reason that it is impossible in the
presence of large volumes of faecal material. However,
constipation carries a large list of differential
diagnoses, which includes partial obstruction of the
distal colon and rectum. In such cases, once the
82
Ch05 Endo.indd 82
Observation of an intusussception when
5.21
carrying out large bowel endoscopy is rare.
However, when present the ileum will appear as a normal
pink colour filling the lumen of the colon, with no bleeding
or ulceration in the majority of cases.
faecal mass has been cleared, endoscopy may be a
useful method of examining the distal large bowel for
evidence of disease.
Rectal adenomatous polyps
Rectal polyps are a common cause of rectal tenesmus,
haematochezia and malformed faeces in the dog.
They most often occur in the older dog and in the
smaller breeds, especially the West Highland White
Terrier. A rectal examination may detect a mass but
because polyps are friable and soft in consistency,
they can sometimes be difficult to palpate. Where a
polyp is suspected, endoscopic examination to assess
the extent of the lesion and to collect biopsy samples
is essential. Some of these rectal masses are benign
adenomatous polyps, whilst other may be malignant
carcinomas.
Enemas administered prior to proctoscopy must
be carried out with great care, and in some cases
should be avoided due to the risk of tissue damage
and induction of bleeding. Each case must be
individually assessed for risk and in some patients
endoscopy may have to be carried out with little
preparation.
In order to examine the rectum thoroughly, the dis-
tal end of the endoscope should be lubricated (as pre-
viously described) and gently inserted into the rectum
to about 10 cm. If resistance is felt the procedure
should be halted, and in some cases a gloved finger
may assist in directing the endoscope into the rectum.
Once at the 10 cm mark, the colon should be inflated
with air until the descending colon can be clearly
seen; the endoscope should then be gently withdrawn
under positive air insufflation whilst viewing the entire
circumference of the rectum. The polyp will come into
view during this procedure and its size and its exact
position can be determined (Figure 5.22). The mass
is usually markedly proliferative, partially obstructs
the lumen of the rectum, bleeds readily and appears
very friable. Biopsy samples can be taken from the
proliferative mass but additional samples must be
taken from the base of the mass where it attaches to
4/3/08 09:41:01
 Chapter 5
5.22 Rectal adenomatous polyps can be diagnosed
easily with the aid of endoscopy. They appear
very similar to adenocarcinoma and must be differentiated
from the latter.
the mucosa. The reason for this second biopsy site is
to help determine its malignancy. Samples from the
main mass are often difficult to interpret due to the
amount of secondary infection present. This differen-
tiation is not possible from visual assessment of the
mass alone as both malignant and benign tumours
can look very similar. Clearly, making such a differen-
tiation has major prognostic implications.
Rectal stricture
Strictures of the rectum occur reasonably commonly
in dogs but less so in cats. Although the aetiology in
the majority of cases is rarely determined, it is
assumed that the majority are the result of trauma or
inflammation, which heal by fibrosis. However, there
is a significant minority which may be due to neoplasia.
So, where a rectal stricture has been detected by
rectal examination, it is wise to carry out an endoscopic
examination of the tissues to assess the mucosal
changes present (Figure 5.23) and to collect biopsy
samples to rule out neoplasia, prior to treatment.
Ch05 Endo.indd 83
Flexible endoscopy: lower gastrointestinal tract
Rectal strictures often appear as an obvious
5.23
narrowing of the lumen and a circumferential lip
may prevent forward movement of the endoscope past the
stricture.
References and further reading
Fan TM, Simpson KW, Polack E, Dykes N and Harvery J (1999) Intestinal
haemorrhage associated with colonic vascular ectasia (angiodysplasia)
in a dog. Journal of Small Animal Practice 40, 25–30
German AJ, Hall EJ, Kelly DF, Watson AD and Day MJ (2000) An
immunohistochemical study of histiocytic ulcerative colitis in Boxer
dogs. Journal of Comparative Pathology 122, 163–175
Hall EJ, Rutgers HC, Scholes SFE, et al. (1994) Histiocytic ulcerative
colitis in Boxer dogs in the UK. Journal of Small Animal Practice 35,
509–515
Jamieson PM, Simpson JW, Kirby BM and Else RW (2002) Association
between anal furunculosis and colitis in the dog: preliminary
observations. Journal of Small Animal Practice 43, 109–114
Knottenbelt CM, Simpson JW, Tasker S, et al. (2000) Preliminary clinical
observations on the use of piroxicam in the management of rectal
tubulopapillary polyps. Journal of Small Animal Practice 41, 393–
397
Ridyard AE, Nuttall TJ, Else RW, Simpson JW and Miller HR (2002)
Evaluation of Th1, Th2 and immunosuppressive cytokine mRNA
expression within the colonic mucosa of dogs with idiopathic
lymphocytic–plasmacytic colitis. Veterinary Immunology and
Immunopathology 86, 205–214
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 Chapter 6 Flexible endoscopy: respiratory tract
6
Flexible endoscopy:
respiratory tract
Diane Levitan and Susan Kimmel
Introduction
Flexible endoscopy of the respiratory tract can be a
valuable therapeutic, diagnostic and prognostic tool
for most patients with respiratory disease. Endoscopy
can be used for diagnostic evaluation of the airways,
including the nasal passages, nasopharynx, dorsal
soft palate, pharynx, larynx, trachea and pulmonary
tree, and to assess laryngeal function. Collection of
tissue and fluid samples can be performed for micro-
biological or histopathological evaluation. The broncho-
scope is also a valuable therapeutic tool and can be
used to remove foreign objects from the pharynx, tra-
chea and bronchi. It can also be used to place and
evaluate airway stents. Visualization of airway injury
or chronic airway changes can be monitored over time
and will aid in determining the prognosis of conditions.
Bronchoscopy is most rewarding when the veterinary
surgeon has a good understanding of airway anatomy,
use of equipment, anaesthetic protocols and tech-
niques. As with any skill, practice is essential.
Dogs and cats with chronic unilateral or bilateral
nasal discharge, chronic sneezing or reverse
sneezing, chronic stridor or stertor are seen regularly
by veterinary surgeons. Evaluation of these problems
often includes imaging techniques such as radiography,
computed tomography (CT) and magnetic resonance
imaging (MRI). These are useful for evaluation of the
location and extent of lesions in the upper respiratory
tract; however, tissue biopsy, cytology and cultures
are essential for definitive diagnosis of most disease
processes. Rhinoscopy is often an essential diagnostic
procedure and is discussed in detail in Chapter 8.
Indications
The indications for flexible endoscopy of the respiratory
tract are given in Figure 6.1.
A thorough evaluation of the oral cavity, orophar-
ynx, nasopharynx, posterior nasal cavity, larynx,
trachea and lower airway can be performed in one
quick procedure using a flexible endoscope. Foreign
objects can be identified and possibly removed.
Tracheobronchial collapse can be definitively diag-
nosed as the dynamics of the airway lumen can be
directly observed.
Bronchoscopy, combined with bronchoalveolar
lavage (BAL) and airway brush cytology, is used to
aid in the diagnosis and aetiology of many disorders,
84
Ch06 Endo.indd 84
Flexible endoscopy is used for the evaluation and management of:
Posterior nasal passages, pharynx, nasopharyngeal and laryngeal
disorders:
• Chronic nasal dischar e snee in or re erse snee in
• Dyspha ia
• espiratory stertor or stridor
• aryn eal f nction
• De elopmental abnormalities
• Chronic a in
• cessi e sali ation
Tracheal and lower airway disorders:
• Ac te co h
• Assessment of airway inte rity
• Chronic bronchitis
• Chronic co h
• Chronic halitosis
• racheobronchial collapse
• lmonary in ltrati e disease
• ec rrent pne monia
• eoplastic conditions
• aemoptysis
• Ciliary dys inesia
• ntratracheal de ice monitorin
• lacement of airway stents
• Airway strict re l n lobe torsion or bronchiectasis
• orei n body e al ation retrie al
• racheal airway tra ma
6.1 Indications for flexible endoscopy of the
respiratory tract.
such as eosinophilic airway disease, lungworm infec-
tion, toxoplasmosis, bacterial or fungal infection and
neoplastic infiltrates; other conditions can be diag-
nosed from samples collected from sites within spe-
cific lung lobes and from areas deep in the respiratory
tract. Tumours can be visualized and biopsy samples
taken. Extra-pulmonary masses can also be aspirated
or biopsied through the respiratory tract. Technological
advances in the field of interventional airway endo-
scopy are made daily in human medicine, and will
soon be commonplace in veterinary medicine.
Applications include bronchoscopic ultrasonography,
laser therapy, brachytherapy, electrocautery, cryo-
therapy, placement of airway stents, and balloon dila-
tion to relieve airway obstruction caused by lesions.
Such tools allow for improved characterization of
lesions, accurate biopsy of the airways and treatment
of various conditions.
Bronchoscopy is generally a very safe procedure
with few contraindications (Figure 6.2). The flexible
2
 Chapter 6 Flexible endoscopy: respiratory tract

There must be a channel within the endoscope to

Absolute contraindication:
• e ere hypo aemia
• nown bleedin disorder platelet dysf nction
• e ere cardiac arrhythmia
• Cardiac fail re or se ere dysf nction
i ni cant increased ris of complications
• artial tracheal obstr ction
• ar ed hypo aemia
• raemia se ere hepatic dysf nction
• lmonary hypertension
• n abscessation
• mm nos ppression
• nstable asthma
Contraindications to flexible endoscopy of the
6.2
respiratory tract.
endoscopic procedure is quick and practical, and can
also be used to follow progress, treat and aid man-
agement of many conditions of the upper respiratory
tract. The benefits of bronchoscopic evaluation must
be weighed against the potential risk of complications
based on the individual patient’s condition.
allow for the passage of instruments as well as
oxygen. The use of a video-endoscope or attachment
of a video camera system often makes visualization
and manoeuvring easier but is not necessary. Cytology
brushes (Figure 6.4) can be placed through the lumen
of the bronchoscope or can be used alongside the
endoscope to obtain samples for cytology from the
airway surfaces. Aspiration catheters (Figure 6.5) are
thin tubes with luer lock tips used for fluid collection
and suction during procedures. These can also be
placed adjacent to the endoscope or through the
lumen for procurement of sterile samples. Trans-
bronchial aspiration or biopsy can be performed using
aspiration needles (Figure 6.6). Aspiration or biopsy
of paratracheal, carinal, hilar or peripheral lung lesions
can be performed through the bronchoscope, with or
without the concurrent use of fluoroscopy.

Instrumentation
Flexible and rigid endoscopes have both been utilized (a)
for airway is ali ation owe er the fle ible endo-
scope provides the greatest advantage due to its
length and manoeuvrability.
Flexible endoscopes range in size: the ideal size
for a small airway ranges from 2.5–5 mm in diameter,
with a length of 25–85 cm; however, larger endoscopes
may be used depending on the size of the patient’s
airway ( i re ) A limitation for proced res in lar e
dogs is the length of the endoscope; however, there is
a 5 mm diameter, 85 cm long endoscope available
that is ideal for cats and large dogs. In giant-breed
dogs, a paediatric gastroscope is an excellent tool, as
the 7.8–8 mm diameter is tolerated and the length of
107–160 cm allows for diagnostic procedures deep in (b)
the airways.
6.4 (a) Cytology brush in sheath (top) and in
extended position (bottom). (b) Use of a
cytology brush in an airway.

2.5 mm
4 mm
8 mm

6.3 Flexible endoscopes in several different sizes 6.5 Aspiration/lavage catheter.

are available.

85

Ch06 Endo.indd 85 2
 Chapter 6 Flexible endoscopy: respiratory tract
(a)
(b)
6.6 (a) Transbronchial biopsy needle.
(b) Transbronchial aspiration needle.
In the near future, interventional bronchoscopy
will be as commonplace in veterinary medicine as it is
in human medicine. The ultrasonic broncho-fibre-
videoscope is an example of a tool used for both
interventional and non-interventional flexible endo-
scopy of the respiratory tract. These are called hybrid
endoscopes as they incorporate an ultrasound
transducer into the video-bronchoscope, all within a
small-diameter insertion t be ( 2 mm) sin or general anaesthesia. Without deep sedation, elici-
these endoscopes, a dedicated aspiration needle can
be passed through the biopsy channel and the position
of the needle tip can be confirmed in real-time during
the puncturing procedure via the ultrasound feature.
Several of these endoscopes have a Doppler
capability, which enables the user to check blood flow
conditions before puncturing. With the combined
ultrasound features, more information can be obtained
about the thickness and character of lesions.
A swivel tip T-adaptor attached to the endotracheal
tube allows for anaesthetic gas to be continuously
delivered whilst the bronchoscope is passed through
the endotracheal t be ( i re ) se of an to bronchoscopy (see Figure 6.2).
endotracheal tube depends on the size of the patient’s
airway relative to the size of the endoscope; therefore,
in small patients, intubation may not be possible.
Cleaning
The bronchoscope should be sterilized prior to each
usage according to the manufacturer’s recommen-
dations (see Chapter 2).
Handling
Bronchoscopes are very delicate and should be
handled with the utmost care to avoid damage (see
Chapters 2 and )
86
Ch06 Endo.indd 86
A swivel tip T-adaptor attached to an
6.7
endotracheal tube. It has a rubber valve at the
top of the port, which opens enough to allow the
fibrescope into the airway without allowing gas to escape
into the environment. This allows maintenance of oxygen
and anaesthetic gas flow to the patient.
Premedication and anaesthesia
Evaluation of the respiratory tract with any endoscope
must be performed under deep intravenous sedation
tation of reflexes causing laryngospasm, coughing,
sneezing and gagging will result in trauma to the
patient and will likely cause damage to the endo-
scope A protecti e intraoral de ice (mo th spec l m
mouth gag) will prevent trauma to the endoscopic
equipment from accidental biting. Each patient should
be cleared for anaesthesia and an anaesthetic proto-
col should be selected on a case-by-case basis.
Patient risk increases greatly with general anaesthe-
sia if there is pre-existing hypoxia, cardiac disease or
cardiac arrhythmia. Coagulopathy, severe arrhythmia,
heart failure or severe hypoxia are contraindications
All patients should have ECG, pulse oximetry and
cardiovascular parameter monitoring before, during
and for a period following anaesthesia. End-tidal
capnography can be helpful in prolonged procedures.
Pre-oxygenation is very helpful, especially when there
is compromised oxygenation. Pre-oxygenation can be
provided through nasal oxygen delivery or via a mask.
Topical 2% lidocaine will help prevent laryngospasm
upon introduction of the endoscope and endotracheal
tube in dogs and cats.
Inhalation anaesthesia is recommended for most
procedures; however, if the patient is too small to
have an endoscope passed through an endotracheal
2

tube, intravenous anaesthesia must be used.
Intubation should only be performed if the endoscope
can fit easily through the endotracheal tube, allowing
for movement of air and the endoscope at the same
time. This is dependent on the size of the patient’s
trachea and the luminal diameter of the endotracheal
tube. The ability of the endoscope to move easily in
the endotracheal tube should be tested prior to
initiation of the procedure. A swivel tip T-adaptor (see
Figure 6.7) can be used to allow constant gas
anaesthesia whilst the endoscope is passed through
the endotracheal tube.
Endoscopes should not remain in an airway for
lon er than seconds as they interfere with
ventilation, and could result in hypercarbia and over-
inflation of the lungs, trauma or bronchospasm. It
should be remembered that if oxygen is being con-
stantly delivered through the channel, carbon dioxide
cannot escape through that same channel. Oxygen
should be delivered through an endotracheal tube or
through the ports on the endoscope during proce-
dures. Oxygen can also be delivered nasally or
through a red rubber catheter placed into the trachea
alon side the endoscope low ol mes of litres
per min te can be safely sed i her flows ha e Tracheobronchoscopy
been associated with over-inflation of the small air-
ways, ruptured alveoli and pneumothorax. Adequate
ventilation during procedures is imperative. Anaes-
thetic protocols should be designed to minimize
cardiopulmonary depression. The anaesthetist should
be prepared in case of an emergency before, during
and after a procedure, as rapid respiratory or cardio-
vascular decompensation can occur in these patients.
The anaesthetist should be prepared to intubate in
case of respiratory difficulty during the procedure or
for the delivery of oxygen after a procedure. Drugs for
the reversal of anaesthetics (if applicable) should be
readily available in case of an emergency.
Evaluation of laryngeal function should be per-
formed prior to other diagnostic examinations, as it
requires a lighter plane of anaesthesia. Small amounts
of ultra-short-acting barbiturates, acepromazine, nar-
cotics or propofol can be used. The amount of anaes-
thetic must be titrated carefully, as moderate or deep
levels of anaesthesia will result in complete absence
of laryngeal motion. Examination of the oropharynx,
larynx and proximal trachea should be undertaken
prior to intubation in order to visualize these struc-
tures. After adequate visualization, intubation can
take place if indicated. Visualization of the dorsal soft
palate, nasopharynx and nasal cavity require intuba-
tion and should be performed after bronchoscopy to
avoid contamination of the bronchoscope.
Prior to anaesthetizing a patient for any proce-
dure, all necessary instruments should be set up
and inspected to be certain they are in perfect work-
ing condition.
Patient positioning
For most airway evaluations, the patient is placed in
sternal recumbency with the head elevated and the
neck extended. For oropharyngeal and nasopharyn-
Ch06 Endo.indd 87
Chapter 6 Flexible endoscopy: respiratory tract
geal examination and biopsy procedures, the patient
should be intubated with a cuffed endotracheal tube.
In addition, packing the back of the throat (Figure 6.8)
is useful to catch blood, secretions and potential
biopsy or fungal samples that may drop into the phar-
ynx. On completion of the procedure, the packing can
be used to remove blood and blood clots from the
throat, which should be examined for tissue or par-
ticulate matter that may be valuable for diagnosis.
6.8 A Babcock forceps with gauze squares is used
to protect from aspiration of blood or particulate
matter during posterior rhinoscopy.
Procedure
Tracheobronchoscopy is an excellent technique for
diagnosis and management of disorders of the
respiratory tract. Successful outcomes require
knowledge of the instrumentation, airway anatomy,
normal appearance of respiratory tract structures,
appropriate anaesthetic protocols and monitoring,
and acquisition of adequate diagnostic samples
during procedures. A standard method of evaluation
should be used each time tracheobronchoscopy is
performed. This should include standard reporting
methods for all findings, standard diagnostic testing
and a standard method of navigation through the
airways to ensure a complete evaluation. Canine and
feline airway anatomy is very similar; however, the
feline airways are much smaller and therefore
visualization of the deeper airways is more difficult.
he map of the airways ( i re ) sho ld be ept in
mind and referred to during evaluation.
Right lung Left lung
Cranial Cranial
lobe lobe
Middle
lobe
Caudal Caudal
lobe lobe
Accessory
lobe
6.9 Lung and airway anatomy.
87
 Chapter 6 Flexible endoscopy: respiratory tract

Larynx Thin, crisp vocal folds Fine vascular pattern

The examination begins with the endoscope being
advanced to the larynx (the tongue may need to be
pulled forward to aid visualization). The soft palate
length should not extend into the larynx or interfere
with respiration. The laryngeal anatomy, function and
motion should be assessed. Laryngeal motion must
be evaluated under a light plane of anaesthesia (see
abo e) ormal laryn eal m cosa sho ld be pin and
a fine vascular pattern should be visible (Figure 6.10a).
There should be no masses, nodules or irregularities.
Laryngeal saccules should not be everted and there
should be crisp vocal fold edges. There should be no
excessive salivary secretions. Everted laryngeal
saccules, an elongated soft palate and an accumulation
of salivary secretions are classic findings in dogs with
brachycephalic syndrome (Figure 6.10b). Laryngeal
paralysis (Figure 6.10c) results in thickened arytenoids,
blunted vocal fold edges and loss of the mucosal fine
vascular pattern, resulting in hyperaemic mucosal (a)
surfaces and often the accumulation of excessive
foamy salivary secretions in the larynx. In the normal
patient, the arytenoid cartilages should abduct during Accumulation of foamy secretions
inspiration and then return to a paramedian position
during expiration. The arytenoid cartilages (left, right
or both) may have decreased motion or may not move
at all during inspiration. If paralysis is complete, motion
paradoxical to the phase of respiration can be seen.

Trachea
The anaesthetic plane should be deepened to continue
the bronchoscopic evaluation. If the patient is to be
intubated, the proximal trachea should be evaluated
prior to intubation. The endoscope should be passed
through the larynx into the proximal trachea. The
tracheal cartilages appear as C-shaped rings that are
connected dorsally by the dorsal tracheal membrane. (b)
The trachea should look uniform throughout its length.
The dorsal tracheal membrane should be seen as a Everted laryngeal saccules
taut, flat mucosal surface connecting the ends of the
Hyperaemic mucous membranes
C-shaped cartilaginous tracheal rings. This membrane
is very helpful to establish proper orientation inside the Thickened arytenoids
lumen, as it is centrally located in the dorsal most part
of the trachea (Figure 6.11).
Intubation can performed after evaluation of the
length of trachea that would otherwise be covered by
the endotracheal tube. The normal trachea is free of
masses and excessive secretions. There should be
smooth mucosal surfaces through which normal small
blood vessels can be visualized. Mucosal oedema or
excessive secretions result in poor visualization of the
normal mucosa and vasculature, indicating inflam-
mation. The tracheal lumen should be relatively round
and there should be no excessive dipping of the
dorsal tracheal membrane or collapse of the C-shaped
rings. The endoscope should always be centred as it
is advanced and care should be taken not to irritate (c)
the surface of the trachea with the endoscope by
rubbing or pressing it into the mucosal surface. The Thickened vocal folds
mucosa can be easily scraped by the bronchoscope,
6.10 (a) Normal larynx of a dog. (Courtesy of
resulting in a distinct line of hyperaemia or occasionally B McKeirnan) (b) Everted laryngeal saccules
a small superficial mucosal tear. This should be kept and an accumulation of foamy saliva are common findings
in mind when evaluating areas that the endoscope in brachycephalic dog breeds. (c) Larynx of a dog with
has passed. laryngeal paralysis. (b,c Courtesy of T McCarthy)

88

Ch06 Endo.indd 88
 Chapter 6 Flexible endoscopy: respiratory tract

6.11 Tracheal
anatomy. Note
Dorsal tracheal the distinct C-shaped
membrane cartilages and the
smooth, taut dorsal
Normal tracheal membrane.
C-shaped (Photograph courtesy of
tracheal T McCarthy)
rings

Mainstem bronchi attachment should be checked to ensure that it is in

As the endoscope is advanced, the carina or
bifurcation of the trachea will come into view. The
patient’s right side is on the operator’s left side;
therefore, if the endoscope and camera are correctly
positioned, the right mainstem bronchus will be seen
on the left side of the image. The bronchial tree should
be evaluated as thoroughly and as systematically as
possible. If orientation is lost, the endoscope should
be withdrawn to the level of the carina, which acts as
a point of reference, and, if applicable, the video
Strand of mucus
Strand of mucus in the normal airway. (Courtesy
6.12
of T McCarthy)
the proper position. If possible, the normal tissues
should be evaluated prior to the abnormal areas of
the lung. All segments of the airways should be round
and maintain a shiny, smooth, fine vascular mucosa
free of excessive mucus, oedema or lesions.
Occasionally, strands or small clumps of mucus can
be seen in the normal airways (Figure 6.12). The
airways should be evaluated for collapse, masses,
mucosal irregularities and external compression.
The left and right mainstem or principal bronchi
branch off crisply with sharp ed es ( i re a)
The principal bronchi branch into lobar bronchi, each
of which ventilates a lung lobe. Each lobar bronchus
then gives rise to many smaller segmental bronchi.
The smaller airways that branch from the segmental
bronchi (sub-segmental bronchi) can be visualized in
large dogs. The right mainstem bronchus is in line
with the trachea ( i re b) he first lobar
bronchus encountered is of the right cranial lung lobe
( i re c) Ad acent is the second lobar bronch s
of the ri ht middle l n lobe ( i re d) he
accessory l n lobe bronch s ( i re e) branches
next, and the right main bronchus ends at the caudal
l n lobe ( i re f) e mental and s b-
segmental airways should be visualized if possible.
After a thorough systematic evaluation of the airways
on the right, the endoscope should be withdrawn
enough to enter the opposite mainstem bronchus.

Entrance to Entrance to Septum between

right cranial right caudal right and left
lobe lobe mainstem bronchi

Right Left
(a) (b)

Entrance to right Entrance to

middle lobe accessory lobe

6.13 (a) Bifurcation of the trachea. The left and right mainstem bronchi are clearly visible. (b) Right mainstem
bronchus. (Photographs courtesy of T McCarthy) (continues)

89

Ch ndo indd
 Chapter 6 Flexible endoscopy: respiratory tract

(c) (d)

(e,i) (e,ii) (f)

6.13 (continued) (c) Right cranial lung lobe. (d) Right middle lung lobe. (e) (i) Entrance to the right accessory lung
lobe. (ii) Inside the right accessory lung lobe. (f) Right caudal lung lobe.

The left mainstem bronchus branches at an angle
(Figure 6.14a). The first lobar bronchus encountered
leads to the left cranial lung lobe (Figure 6.14b),
where it branches further. Past the first lobar
bronchus, the left mainstem bronchus becomes the
left caudal lobar bronchus (Figure 6.14c), which also
branches significantly. Segmental and sub-segmental
airways (Figure 6.14d) on the left side should be
visualized if possible. Although there are many lobes
and branches to evaluate, the entire procedure
should not take more than approximately 7–10
minutes, including the time required for diagnostic
procedures.
Once the airways have been visualized, diagnostic
procedures such as BAL, brush cytology and biopsy
should be performed.

Entrance to left
caudal lobe

Entrance to left
cranial lobe

(a)

(b) (c) (d)

6.14 (a) Left mainstem brochus. (b) Inside the left cranial lung lobe. (c) Inside the left caudal lung lobe. (d) Deep
sub-segmental airways.

90

Ch ndo indd

Bronchoalveolar lavage
BAL is a technique used to sample the small airways
of patients with lung disease and can be performed
routinely in patients undergoing bronchoscopy. It
differs from tracheal washes that collect material from
the larger airways only. Therefore, BAL can be a
valuable technique for evaluating patients with lung
disease involving the small airways, alveoli and
interstitial lung. BAL requires the patient to undergo
general anaesthesia and therefore is not appropriate
for patients in respiratory distress. BAL may not be
necessary for all patients with small airway disease.
For example, a tracheal wash is sufficient for the
diagnosis of most cases of pneumonia without the
need to place the patient under general anaesthesia.
Although BAL has therapeutic applications in humans,
at this time it is used mainly as a diagnostic tool in
small animals.
As BAL is typically performed during broncho-
scopy, the animal should already be anaesthetized,
positioned and monitored. All supplies and equip-
ment (Figure 6.15) needed should be set up prior
to anaesthetizing the patient to ensure a quick and
safe procedure.
6.15 Equipment required to perform a BAL.
Technique
terile saline ( sodi m chloride) sho ld be may be difficult.
used to perform a BAL. The saline should be non-
bacteriostatic to allow bacterial growth during cul-
ture. A diagnostic yield from a BAL requires a
seemingly large volume of fluid to be instilled into an
airway in order to reach the alveoli. This volume is
not standardized; however, as much as 50 ml or
more total volume is commonly used in dogs and
cats. The total volume is typically divided between
2 boluses in dogs and 2–4 boluses in cats. The first
bolus typically contains the most contamination
from larger airways and therefore at least 2 boluses
are recommended.
The preferred technique for BAL requires the use
of a flexible bronchoscope with a sampling channel.
A bronchoscope with a 4.8 mm outer diameter is
versatile enough for most patients, but an 8 mm outer
diameter gastroscope may be used in large dogs.
Too large an endoscope will make reaching the
Ch ndo indd 2
Chapter 6 Flexible endoscopy: respiratory tract
deeper, smaller airways difficult and therefore the
diagnostic yield may be limited. BAL is performed
following bronchoscopic evaluation so that airway
evaluation will not be affected by the saline infused
and so that grossly affected lung lobes may be
selected for A owe er br sh cytolo y and or
biopsy should be delayed until after BAL to prevent
altering the fluid retrieved.
Ideally, at least two lung lobes should be evalu-
ated to increase the chance of retrieving representa-
tive samples. Once the lung lobes to be sampled
have been selected, either by bronchoscopic evalua-
tion or based on radiographic findings, the broncho-
scope should be passed into successively smaller
airways until it is seated snugly. Sterile saline that
has been pre-drawn into syringes should then be
instilled via the bronchoscope channel and gently
suctioned back through the same channel also using
a sterile syringe. Alternatively, the procedure can be
performed using a lavage catheter (see Figure 6.5)
passed through the biopsy channel into the deeper
smaller airways e ati e press re d rin aspira-
tion would indicate the need to decrease suction to
avoid airway collapse. If necessary, the broncho-
scope can be repositioned slightly, taking care not
to dislodge the tip of the bronchoscope from the air-
way in which it is wedged. In dogs with a bodyweight
of over 10 kg, 2 boluses of 25 ml each have been
used successfully. In cats and dogs with a body-
weight of less than 10 kg, 2–4 boluses of 10 ml each
typically pro ide satisfactory res lts deally
of fluid instilled should be retrieved. Fluid is typically
slightly turbid with a foamy layer at the top, repre-
sentative of surfactant.
Fluid obtained from a BAL can be evaluated
cytologically and microbiologically. Samples for
culture can be combined from several boluses or
lobes in most cases. Quantitative aerobic bacterial
culture, and in certain cases, fungal culture,
Mycoplasma culture, and anaerobic culture may be
warranted. Generally, the first bolus from each lobe
should be evaluated separately as it may be
more representative of the larger airways (e.g.
trachea, bronchi). Cell counts can be obtained from
undiluted BAL fluid but interpretation of such counts
Bronchial and bronchiolar brush cytology
Analysis of bronchial brushings provides information
about airway inflammation in some dogs and cats
with chronic cough, and is a more sensitive indicator
of airway inflammation than cytological examination
of BAL fluid. The procedure is very simple and has
a high yield. A sterile sheathed brush (see Figure
6.4) is passed through the biopsy channel of the
endoscope to the area of interest and the brush is
advanced, rubbing lightly on the tissue. The brush
is brought back into the sheath and then removed
from the channel. The brush is then advanced again
and rubbed gently on to a slide for interpretation
(Figure 6.16). This is a very safe and quick proce-
dure, and identifies cells that do not exfoliate into the
BAL fluid. It is also an excellent way to evaluate
the bronchial epithelium.
91
 Chapter 6 Flexible endoscopy: respiratory tract

Biopsy within the airway must be performed with

caution and consideration of potentially severe
bleeding or development of pneumothorax post-
biopsy. The benefit and risk must be considered in
each circumstance.

6.16 Bronchial brush cytology sampling technique.
Biopsy
Bronchoscopic biopsy may be useful to obtain
samples for histopathology when endobronchial
lesions are identified. Samples are obtained under
direct visualization using forceps passed through the
biopsy channel of the bronchoscope. Transbronchial
aspiration and biopsy can be performed, with or
witho t the assistance of fl oroscopy owe er d e brushing, BAL and biopsy are used to sample tissues
to the risk of haemorrhage and pneumothorax,
transbronchial lung biopsy is not routinely performed.
Pathological conditions
Tracheobronchitis
Tracheobronchitis is commonly diagnosed in the dog
and cat. It is characterized by inflammation, hyper-
aemia and oedema in the tracheal and bronchial
mucosa. Often the mucosal surfaces are mottled with
excessive secretions, accumulations of mucus or
mucopurulent debris, epithelial polyp formation and,
sometimes, bleeding. The irregular nodular surfaces,
epithelial polyps and mucosal nodules (Figures 6.17
and 6.18) result from the normal process of tissue
repair after chronic damage from inflammation, which
is growth of fibroblasts and production of fibrous
tissue. These changes should not be confused with
neoplastic or granulomatous lesions. Tracheo-
bronchitis can have a number of aetiologies, such as
chronic allergic airway disease or infection; however,
many times the aetiology is idiopathic. Bronchial
and obtain cultures for complete assessment and
appropriate therapy.

Hyperaemic mucous
membranes
Hyperaemic
mucous Severe hyperaemia
membranes

Epithelial Foamy Accumulation

polyps secretions Nodular changes of mucus Mucosal oedema
(a) (b) in mucosa (c)

6.17 Changes in the trachea

associated with
tracheobronchitis. (Courtesy of
T McCarthy)

(d) (e)

6.18 Mucopurulent secretions in

the trachea of a cat with
tracheobronchitis. (Courtesy of
T McCarthy)

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 Chapter 6 Flexible endoscopy: respiratory tract

Tracheal collapse
Tracheal collapse is a progressive, degenerative
disease of the cartilage rings which leads to dynamic
tracheal collapse during ventilation. Collapse can
occ r in the cer ical and or thoracic trachea and may
extend into the smaller airways. Cervical tracheal
collapse is most evident on inspiration; collapse of the
intrathoracic trachea or mainstem bronchi is seen
best on e piration ( i res to 2 ) n do s with
tracheal collapse, the dorsal tracheal membrane
becomes pendulous and the rings become flattened,
resulting in airway obstruction and irritation.
Obstruction can be mild or can be so severe that it
creates a double lumen effect.
Cervical tracheal collapse can be addressed
surgically by placement of an extraluminal
polypropylene ring (or spiral) prostheses to open and
stabili e the trachea pre entin collapse ew
techniques, such as placement of intraluminal stents, 6.21 Dog with severe extrathoracic and intrathoracic
are used to open and stabilize the trachea. A number tracheal collapse, chronic cough and dyspnoea.
of stents have been evaluated in the canine and feline
trachea, including both balloon-expandable and self- 6.22
expanding stents. There can be significant compli-
Severe
cations after stent placement; however, stents can be intrathoracic
well tolerated. Stenting is available for patients that collapse.
are refractory to medical management and have (Courtesy of
extensive cervical and or intrathoracic collapse T McCarthy)
(Figure 6.24).

6.19
Mild cervical
tracheal
collapse.
(Courtesy of
T McCarthy)

6.20
Moderate
intrathoracic
tracheal
collapse.
(Courtesy of
T McCarthy)

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6.23 6.25
Mainstem (a) Deformed
bronchus tracheal rings
collapse. and (b) foamy
(Courtesy of airway secretions
T McCarthy) in a brachy-
cephalic puppy
with tracheal
hypoplasia.
(Courtesy of
(a) T McCarthy)

Foamy airway secretions

6.24
(a) Severe
intrathoracic
tracheal collapse
in a dog.
(b) Following
placement of an
intraluminal
stent. (Courtesy (b)
of T McCarthy)
(a)

with the lung worm Oslerus osleri results in small,

irregular polypoid lesions on the tracheal and carinal
mucosa (Figure 6.26a). Deformation of the carina
can also occur due to extramural compression
(Figure 6.26b). This can be caused by hilar lymph-
adenopathy or extraluminal masses such as a granu-
lomas, abscesses or neoplasia. Transbronchial
needle aspiration or biopsy can be used to obtain a
diagnosis in these cases.

(b)

Brachycephalic airway obstruction

syndrome
Brachycephalic airway obstruction syndrome in small
brachycephalic breeds is associated with classic
airway changes as a result of chronic excessive effort
upon inhalation. The most common breeds affected
are English Bulldogs, Boston Terriers, Pugs and
Pekingese. The syndrome is characterized by the (a)
presence of one or all of these features:

• tenotic nares
• lon ated soft palate
• erted laryn eal sacc les
• ypoplastic trachea

Tracheal hypoplasia can affect segments or the

entire length of the trachea. With hypoplasia, there is
overlapping of the ends of the tracheal rings, creating
a misshapen and narrowed trachea. Common find-
ings in brachycephalic breeds are excessive foamy
airway secretions (Figure 6.25), a long soft palate that
extends into the larynx, and everted laryngeal sac-
cules (see Figure 6.10b).
(b)
Other (a) Tracheal mucosal surface with Oslerus
6.26
Other tracheal abnormalities include tears, neopla- osleri nodules. (b) Severe airway collapse at
sia, granulomas and parasitic infections. Infection the carina caused by an extraluminal mass.

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 Chapter 6 Flexible endoscopy: respiratory tract

Rounding or blunting of the airway bifurcations
can be caused by chronic inflammation, infiltration or
oedema of the lung tissue (Figure 6.27). Biopsy and
cytology of irregularities in the mucosal surface are
essential. Tracheobronchoscopy can also be used to
identify sources of bleeding in the airways, lung lobe
torsion and causes of airway obstruction. Pulmonary
abscessation, granulomatous disease, fungal infec-
tion, pneumonia and bronchiectasis are also identi-
fiable. Pulmonary oedema can be seen in the airways
in the presence of heart failure (Figure 6.28).
basket, rat-tooth, alligator, net and polyp snare-type
forceps may be useful for removal of a variety of
foreign objects, such as rocks, teeth, plastic, plant
material and food (Figure 6.29). Care must be taken
to provide adequate ventilation during the retrieval
procedure because ventilation will be compromised if
the bronchoscope blocks the airways for prolonged
periods of time. Care should be taken to ensure that
the endoscope does not completely fill the lumen.
The veterinary surgeon should be prepared to stop
and refer the patient for surgery if the procedure
becomes prolonged. Smooth, round objects are often
very difficult to remove with the limited instrumentation
that can fit into the channels and may be best left for
surgical removal.

Deep airway foreign body

(a) Retrieval device

6.27
(a) Carinal
blunting is seen in
this chronically
irritated airway.
(b) Granulomatous
inflammation from
coccidioidomycosis 6.29 Removal of a deep airway foreign body.
in a young dog.
(Courtesy of
K Gulikers) Postoperative care
(b) Following bronchoscopy, the patient should remain
intubated and allowed to breathe 100% oxygen for 10
minutes. This is to resolve the hypoxaemia that may
6.28 occur secondary to procedures performed during the
bronchoscopy. Pulse oximetry should be utilized to
Pulmonary measure the patient’s oxygenation throughout the
oedema seen in
the airways due
recovery from anaesthesia and during the post-
to heart failure. operative period. This is especially important in
patients with chronic obstructive pulmonary disease,
where airway collapse is common. Temperature,
respiratory rate, respiratory effort and depth, and
auscultation should be performed serially. Crackles
may be heard on auscultation for up to 24 hours in
patients that have undergone BAL.

Foreign body removal
Tracheobronchial foreign material is commonly
retrieved under direct bronchoscopic visualization.
Removal of foreign bodies from the airways is often
very challenging, depending on the shape and location
of the object. Foreign body retrieval forceps including
Complications
When performed properly, serious complications are
uncommon. Complications can include those related
to anaesthesia (arrhythmia, hypotension, oeso-
phagitis, tracheitis), as well as the endoscopic pro-
cedure itself. Complications of bronchoscopy include
hypoxaemia, bleeding and infection. Hypoxaemia is
typically transient, bleeding is uncommon with gentle

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Ch06 Endo.indd 95 4/3/08 11:47:02

 Chapter 6 Flexible endoscopy: respiratory tract
bronchoscopic manipulation, and infection is rare
when the equipment is properly sterilized and stored
prior to the procedure. Other potential complications
include exacerbation of coughing and bronchospasm
secondary to irritation from the procedures and
manoeuvring of the bronchoscope in the airway.
Bronchospasm can be treated with a bronchodilator;
in fact, it may be helpful to pre-treat asthmatic cats
with a bronchodilator to decrease bronchospasm
(terb taline m s c min tes prior to America: Small Animal Practice 31(4),
procedure). Coughing is typically transient but, in
some dogs with airway obstruction exacerbated by
coughing, 1–2% lidocaine may be instilled at the carina
prior to the completion of the bronchoscopic procedure
to decrease coughing. Rarely, pneumothorax can
occur from trauma to diseased airways caused by the
endoscope or the diagnostic procedures performed.
When performed properly, flexible endoscopy of
the respiratory tract is a very low-risk, high-yield
diagnostic tool. Careful planning, thorough and con-
sistent examination technique, and use of all possible
diagnostics are essential elements of successful flex-
ible endoscopic evaluation of the respiratory tract.
Many new exciting diagnostic and treatment possibili-
ties lie ahead for the veterinary patient as veterinary
endoscopists embrace the expanding field of inter-
ventional endoscopy.
Acknowledgements
The authors would like to thank Robert C Denovo,
Dr orrester e en il ers te e ill imothy choanae in do s and cats cases (
C cCarthy and rendan c iernan for their al -
able assistance with the preparation of many of the
figures for this chapter.
96
Ch ndo indd 2
References and further reading
Andreasen C (2 ) ronchoal eolar la a e Veterinary Clinics of North
America: Small Animal Practice ( )
olli er C and ath r (2 ) nter entional bronchoscopy Progress
in Respiratory Research Vol me ed C olli er and ath r
pp ar er asel
Coolman arretta c iernan C and achary ( ) Choanal
atresia and secondary nasopharyngeal stenosis in a dog. Journal of
the American Animal Hospital Association 34,
http www olymp samerica com
ohnson (2 ) mall animal bronchoscopy Veterinary Clinics of North
ohnson and ales (2 ) Clinical and microbiolo ic findin s in
do s with bronchoscopically dia nosed tracheal collapse cases
( ) Journal of the American Veterinary Medical Association
219, 1247–1250
in (2 ) Textbook of Respiratory Disease in Dogs and Cats.
Elsevier, St Louis
e itan D at indlen C and ister D ( ) reatment of
Oslerus osleri infestation in a dog: case report and literature review.
Journal of the American Animal Hospital Association 2( )
McCarthy TC (2005) Veterinary Endoscopy for the Small Animal
Practitioner. Elsevier, St Louis
c iernan C (2 ) Dia nosis and treatment of canine chronic
bronchitis: twenty years of experience. Veterinary Clinics of North
America: Small Animal Practice 30, 1267–1278
ehta AC ra ash arland et al. (2005) American College of
Chest Physicians and American Association for Bronchoscopy
Consensus Statement: prevention of flexible bronchoscopy-
associated infection. Chest 128, 1742–1755
Padrid P (2000) Feline asthma: diagnosis and treatment. Veterinary Clinics
of North America: Small Animal Practice 30, 2 2
ayne D ehler and eisse C (2 ) racheal collapse Compendium
on Continuing Education for the Practicing Veterinarian 28(5),
2
ha and ahony ( ) ronchoscopy in small animal medicine
indications, instrumentation and techniques. Clinical Techniques in
Small Animal Practice 14(4), 207–212
o deb sh ( ) racheobronchoscopy Veterinary Clinics of North
America: Small Animal Practice 20(5), 2
illard D and adlins y A ( ) ndoscopic e amination of the
) Journal of the
American Veterinary Medical Association 215,
 Chapter 7
Rigid endoscopy and
endosurgery: principles
Philip Lhermette and David Sobel
Introduction
Whereas the use of flexible endoscopes is largely
confined to the gastrointestinal and respiratory tracts,
where the ability to follow a tortuous lumen is
paramount, rigid endoscopes can be introduced into
any appropriate body orifice – and if a suitable orifice
can’t be found, then the surgeon can make one!
Laparoscopy and thoracoscopy have challenged the
traditional paradigms in human surgery and have
revolutionized the treatment of many common
conditions, such as gallbladder disease, reproductive
tract disorders, bowel cancer and heart disease.
The advantages of minimally invasive surgery
are as valid in veterinary medicine as they have
been proved to be in human medicine, but some
caution must be exercised. Minimally invasive tech-
niques should only be considered when the pro-
cedure can be carried out at least as safely and
effectively as with open surgery. In many cases mini-
mally invasive techniques are safer and more effec-
tive than traditional alternatives, but they do require
adequate training and practice in order to be safe
and effective.
Anaesthesia will be required for nearly all rigid
endoscopic procedures, with the possible exception
of reproductive vaginoscopy and some otoscopy. An
anaesthetist is therefore required and should be
experienced in monitoring patients undergoing
endosurgery. Some laparoscopic and thoracoscopic
procedures will also require a surgical assistant to act
as camera operator, freeing the surgeon to use both
hands to manipulate the instruments. It is therefore
essential that other members of the team are
sufficiently trained in manipulation of endoscopic
instruments and endoscopes before embarking on
these procedures.
Health and safety considerations
Effective and timely cleaning and sterilization of
endoscopes is essential to prevent cross-
contamination between patients and possible infection
of the endoscopist (see Chapter 2).
For many endosurgical procedures, particularly
laparoscopy and thoracoscopy, the same precautions
are taken as for traditional sterile open surgery. The
surgeon is gowned and gloved and a face mask is
worn as appropriate.
Ch07 Endo.indd 97
Rigid endoscopy and endosurgery: principles
7
Other procedures, such as otoscopy, rhinoscopy
and urethrocystoscopy, have particular requirements
for operator and patient safety, not least because they
are not completely ‘sterile procedures’ and the
operator may be exposed to body fluids and exudates,
often diluted by copious amounts of saline. The
potential for zoonoses should always be appreciated
and the use of surgical gloves, face mask and eye
protection is advised, together with a surgical gown –
preferably worn over a non-absorbent plastic apron.
Anaesthetic considerations
Any surgery requiring anaesthesia or sedation
requires a thorough knowledge of the condition of the
patient and the risks and benefits of various regimes
and protocols available. The reader is referred to the
BSAVA Manual of Canine and Feline Anaesthesia
and Analgesia for comprehensive coverage of the
subject. There are, however, specific considerations
that should be taken into account when embarking
upon some forms of endoscopic or minimally invasive
surgery, in particular relating to endoscopy of the
respiratory tract, laparoscopy and thoracoscopy.
Respiratory tract
Anaesthetic technique and airway management will
depend entirely on the location of the lesion and the
proposed procedure. Adequate monitoring will always
include pulse oximetry, with the addition of capno-
graphy if available.
Bronchoscopy
For rigid tracheobronchoscopy the usual prerequisites
for general anaesthesia apply. Food should be with-
held overnight and water for 3–4 hours. Since many
procedures are undertaken without the reassurance
of a protected airway in the form of an endotracheal
tube, an empty stomach should be considered essen-
tial to prevent regurgitation during anaesthesia and
possible aspiration of stomach contents.
Premedication with butorphanol/acepromazine
helps give a smoother induction and recovery, whilst
helping to reduce gagging reflexes. In cats, due to the
sensitive nature of the larynx, topical anaesthesia
with 1% lidocaine spray is advisable.
In most cases it is desirable to examine the post-
erior pharynx and larynx prior to bronchoscopy, and
preferably prior to intubation. For this reason it is often
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 Chapter 7 Rigid endoscopy and endosurgery: principles
preferable to use intravenous propofol for induction,
followed by total intravenous anaesthesia (TIVA) with
continuous infusion or intermittent boluses of propofol
and/or isoflurane by mask to maintain anaesthesia.
All patients should receive 100% oxygen by mask
for 10 minutes or so before starting the procedure,
since the presence of the endoscope in the airway will
inevitably result in some degree of hypoxia. In routine
cases where the procedure is not likely to be
prolonged, intubation is unnecessary, but if the
procedure is likely to be prolonged, as in the case of
foreign body removal, intermittent intubation should
be considered.
An alternative method of maintaining adequate
oxygenation during bronchoscopy is to pass a canine
urinary catheter or small feeding tube into the trachea
alongside the bronchoscope and attach this to the
anaesthetic machine. This does not interfere with
visualization of the larynx, and in medium and smaller
dogs allows oxygen and anaesthetic gases to be
delivered throughout the procedure. Alternatively, in
larger dogs, the endoscope may be passed through
the lumen of the endotracheal tube via a T-piece
connector. Care should be taken that there is sufficient
space to allow adequate gas flow around the
endoscope (between the endoscope and the catheter
or between the endoscope and endotracheal tube), or
an increase in pulmonary pressure could occur
resulting in alveolar rupture. It is not possible to
maintain the anaesthetic gas concentration in the
lungs accurately using these methods, since room air
is also being breathed in around the endoscope, and
so they should not be relied upon exclusively to
maintain anaesthesia. Intermittent intubation, mask
inhalation or intravenous propofol may be required to
maintain adequate anaesthesia.
Use of pulse oximetry or capnography is strongly
advised in all cases, and the patient should be
maintained on 100% oxygen for 10 minutes or so
following the procedure.
Rhinoscopy
In addition to the usual prerequisites for general
anaesthesia, rhinoscopy requires endotracheal
intubation, with close attention to adequate cuff
inflation and pharyngeal packing to prevent inhalation
of fluid and debris from the nose during saline irrigation
(see Chapter 8).
Thoracoscopy
Thoracoscopy requires the induction of a
pneumothorax in order to collapse the lungs and
provide a space in which to operate. Thus, the same
anaesthetic procedures and precautions will be
required as in open chest surgery, with intermittent
positive pressure ventilation and careful monitoring of
blood and respiratory gases. Occasionally it may be
necessary to perform single lung intubation in order to
maintain an adequate operative field on the relevant
side of the chest. Insufflation of the chest has been
described but is rarely necessary in the authors’
experience. Pressures as low as 5 mmHg significantly
reduce cardiac output with very little improvement in
visual field.
98
Ch07 Endo.indd 98
Patient positioning
Manipulation of tissues and organs can be
accomplished to a large extent using grasping forceps
or a palpation probe. However, careful patient
positioning can facilitate surgery by moving viscera
out of the field of view. A rotating cradle or operating
table that can be moved in three planes is ideal.
Placing the patient in a head-down Trendelenberg
position is useful when operating on the caudal abdo-
men to move the viscera towards the diaphragm. It is
also used to move the spleen out of the way when
introducing the Veress needle for insufflation (see
below). Venous return is increased but angulations
should not be more than about 15 degrees, as this
position increases pressure on the diaphragm,
increasing the respiratory effects of pneumoperito-
neum. Alternatively, a reverse Trendelenberg posi-
tion, with the head up, facilitates surgery on the
anterior abdomen but with a consequent reduction in
cardiac return.
Rotating the patient to the left or right exposes the
kidney on the elevated side and, in bitches, the ovary.
The left lateral position is also useful for visualizing
the pancreas and gives good access to the liver,
avoiding the falciform fat. In some laparoscopic
surgery, such as ovariohysterectomy, the patient’s
position is changed intraoperatively to enable access
to both sides of the abdomen.
During thoracoscopy from a paraxiphoid
transdiaphragmatic approach, rotation of the patient
can be useful to move the lungs out of the way,
enabling the surgeon to access more of the lateral
chest wall and the lateral and dorsal lung surfaces.
Manipulation of the bladder through the abdo-
minal wall can be helpful during urethrocystoscopy,
especially in large patients where the length of the
endoscope can become an issue. A slight reverse
Trendelenberg position helps move the bladder cau-
dally and facilitates entry into the trigone when using
a relatively short endoscope such as the 2.7 mm
30 degree cystoscope.
Insufflation
The peritoneum is a potential space. In the normal
animal the mucosal surfaces are in close contact and
the peritoneal space contains just a little fluid. If an
endoscope were placed into this space, the end of the
instrument would abut various organs and tissues
and ‘red out’ would result – a diffuse pale red image
over the whole screen. In order to see anything mean-
ingful it is necessary to fill the peritoneal cavity with an
inert gas and create a space in which to work – a
pneumoperitoneum. Air has been used successfully
in the past but is poorly absorbed and therefore car-
ries a higher risk of embolism. The use of pure oxy-
gen is ill advised as an insufflation gas as it is highly
combustible in the presence of cautery or lasers. The
most commonly used gas is carbon dioxide, as it is
cheap, readily available and safe. Any remaining gas
left in the abdomen following the procedure is
absorbed by the bloodstream and expelled by the
4/3/08 09:42:29
 Chapter 7
lungs, and carbon dioxide does not support combus-
tion if using laser or electrosurgical techniques.
An insufflator is therefore essential for laparoscopy.
It is used to create a pneumoperitoneum in the first
place, to maintain it, and to control the gas pressure
during the procedure. It may also be required to vent
smoke plume from laser or electrosurgery and replace
it with fresh gas.
Gas is supplied from a high-pressure cylinder
either directly to the patient, through a pressure reduc-
tion valve in the insufflator, or into a reservoir tank
within the insufflator and thence to the patient. A flow
control valve regulates the delivery of gas and moni-
tors intra-abdominal pressure. If the pressure falls
below that set by the operator, the valve opens and
allows more gas to flow. When the pressure reaches
the set pressure, the valve closes. Most electronic
insufflators allow different flow rates to be set. The
lowest flow rate of 1 litre/minute is used for initial insuf-
flation to allow the patient to adapt to the increased
abdominal pressure slowly. Once insufflation pressure
is reached, the flow rate can be increased so that sud-
den drops in pressure are less likely as instruments
are inserted and removed. Insufflators will usually
measure the total gas delivered during the operation
and also monitor the pressure in the carbon dioxide
cylinder itself to warn of low gas supply.
In cats and small dogs it is recommended to
insufflate the abdomen to a maximum of 12 mmHg,
and in larger dogs no higher than 14 mmHg. These
pressures are often used initially when inserting the
operating ports, as they give maximum distance
between the abdominal wall and underlying viscera,
and reduce the ventral deformation of the abdominal
wall that inevitably occurs when introducing a cannula.
Once the operating cannulae are inserted, intra-
abdominal pressure may be lowered to 10 mmHg or
below, as all that is required is a sufficient space to
visualize the site of interest.
Technique
The most common method of inducing the initial
insufflation of the abdominal cavity requires a Veress
needle (see Figure 2.32). Alternatively, the surgeon
may choose to use a Hasson or ‘modified Hasson’
technique, which avoids the blind insertion of the
sharp Veress needle into the peritoneal space.
Cannulae used for the Hasson technique have a blunt
trocar. This technique should minimize the risk of
trauma to the abdominal organ, which can occur with
a Veress needle. Details of these techniques are
given in Chapter 11.
Complications
Penetrating a viscus can be a potential problem; the
initial insufflation pressure will be high, alerting the
operator. Penetration itself is rarely a problem unless
a major vessel is damaged, but attempting to insufflate
the spleen can result in a fatal gas embolism. The
abdomen should always be palpated underneath the
insertion point and the tip of the Veress needle
directed away from the spleen. If blood is found on
insertion of the Veress needle, it should be removed
and repositioned before insufflation.
Ch07 Endo.indd 99
Rigid endoscopy and endosurgery: principles
Raised intra-abdominal pressure inevitably has
physiological effects, such as aiding capillary venous
haemostasis (which can be useful), but care should
be taken to ensure that bleeding does not increase
once pressure is reduced at the end of the procedure.
In practice this is rarely a problem. However, pressure
on the caudal vena cava can reduce venous return to
the heart and thus decrease ejection volume.
Pressure on the diaphragm increases intrathoracic
pressure and not only reduces lung capacity, with a
corresponding increase in physiological dead space,
it also reduces diaphragmatic excursion during
breathing and reduces tidal volume. Carbon dioxide
is highly soluble and can form carbonic acid on serosal
surfaces, resulting in postoperative discomfort. It can
also be absorbed into the bloodstream and potentially
cause hypercapnia and respiratory acidosis. However,
these effects are relatively minor at the pressures
used for laparoscopy and should not cause problems
for the vast majority of patients.
Pressures above 15 mmHg can reduce abdomi-
nal organ perfusion, particularly in the kidney, bowel
and hepatic portal system. They can also activate the
renin–angiotensin system, causing renal vasocon-
striction. Relatively healthy patients compensate for
these changes readily, and an intra-abdominal
pressure of <15 mmHg is of no consequence, but
the surgeon should always be aware of increases in
abdominal pressure and use the lowest pressure
necessary to perform the procedure. Haemodynamic
effects are most marked during induction of the
pneumoperitoneum, and insufflation should be
kept slow to allow the cardiovascular system to
adapt. Preoperative fluid volume loading can help
limit the haemodynamic effects, especially in the
dehydrated patient.
Since many insufflators do not heat the gas,
prolonged procedures can result in hypothermia, and
monitoring of rectal temperature is useful, especially
in small patients.
Choice of endoscope
The simplest endoscope to use when starting to
perform laparoscopy or thoracoscopy is the 0 degree
endoscope. This gives a true view along the axis of
the endoscope, and instruments introduced through
operative ports enter the field of view at the expected
angle.
Thirty degree endoscopes can be very useful,
especially in tight spaces, since they allow the
endoscope to be kept somewhat out of the way of the
instrumentation and allow the surgeon to look around
organs or structures that would otherwise be in the
way. However, the angle of view makes manipulation
of instruments a little more complicated. If the
endoscope is oriented with the axis of view upwards,
instruments introduced from the side will appear on
the monitor to be coming in from below and to the
side. This takes a little getting used to and requires
practice. Thirty degree endoscopes are commonly
used in the nose, joints and bladder, where
manipulation of the endoscope is restricted in a small
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 Chapter 7 Rigid endoscopy and endosurgery: principles

space and the angle of view can be exploited to see
around corners and enlarge the field of view by
rotating the endoscope around its long axis. In the
nose and bladder the endoscope is invariably used in
a sheath, which usually incorporates an instrument
channel, so instruments pass directly into the field of
view and manipulation does not present a problem.
Special considerations for
endosurgery
Endoscopic surgery differs from conventional open
surgery in several important ways:
• he s r ical field is iewed in two dimensions on can be inserted. Simple exercises can then be per-
a television monitor
• he iew is ma nified and the an le of iew may other, placing small objects into a rubber glove or bag,
not be along the long axis of the endoscope
• nstr ments are often lon and held at a point drawn pattern. A piece of chicken breast, complete
distant from the point of interest
• here is a lac of direct tactile feedbac to the technique, cutting tissues and suturing. All these
surgeon
• anip lation of the position of the patient d rin technique and improve manual dexterity. It is essen-
the operation can be advantageous
• here is limited opport nity to mo e the positions Attending wet labs and practising on cadavers should
of the instruments once ports have been placed.
Positioning
Correct positioning of the patient (see above),
equipment and monitor in relation to the surgeon is
essential. The endoscopy trolley should be positioned
such that it is directly in front of the surgeon, with the
monitor at head height. During some procedures it
may be necessary for the surgeon to change sides of
the patient, and if this is so the endoscopy trolley
should also be moved to afford the optimum view.
Camera orientation
Camera heads are attached to the endoscope by a
releasable collar, which allows the endoscope to rotate
in relation to the camera. This is useful when using an
endoscope with an angled view, such as 30 degrees,
since it affords a larger field of view as the endoscope
is rotated and enables the surgeon to look around cor-
ners. However, it is vital that the camera head itself
is kept in the correct orientation. The camera is, in
effect, the surgeon’s eyes; if it is rotated inadvertently
through 90 degrees this has the same effect as the
surgeon turning on their side. If this is not noticed it
can be very confusing as lateral movements of instru-
ments in the field of view become vertical on the moni-
tor. Most camera heads have a flat surface or buttons
on the top that designate the correct orientation.
Use of instruments
One of the first obstacles the new endoscopist must
overcome is learning to operate in a two-dimensional
environment with unfamiliar long instrumentation.
Appreciation of depth and distance can be difficult at
first, especially in view of the high magnification
afforded by the endoscope, which exaggerates the
smallest movements. Moving the endoscope further
away from the point of interest to give a more pano-
ramic view is helpful when moving instrumentation
towards the point of interest, and moving the endo-
scope close to the point of interest helps appreciation
of fine movements and depth of view.
Practice is essential and the need for training can-
not be overemphasized. The use of a laparoscopy
‘trainer’ is extremely helpful in acquiring the skills to
manipulate laparoscopic instruments in a two-dimen-
sional video environment. Commercial laparoscopy
trainers can be purchased but are expensive. A sim-
ple laparoscopy ‘trainer’ can be manufactured from
an opaque plastic box about the size of a dog’s abdo-
men, with holes cut into the top at the site of common
port placement. These holes should be covered with
thick cloth-covered neoprene through which cannulae
formed, such as stacking sugar lumps on top of each
or dissecting holes in pieces of paper following a pre-
with skin, makes a good model for practising biopsy
exercises help to familiarize the surgeon with camera
tial that these basic techniques are mastered.
always precede live surgery. Assisting a proficient
endoscopic surgeon in live procedures is an extremely
useful way to become acquainted with the necessary
techniques in a more realistic environment.
Tactile information
Tactile feedback is used in open surgery to locate
solid masses in fat, to differentiate solid from cystic
masses, or to detect variations in texture of a solid
organ such as the liver that may indicate a pathological
change. To some extent this can be appreciated
during laparoscopy by the use of a palpation probe, a
blunt-ended probe that can be run over the surface of
an organ or used to ballot a cystic structure. With
practice a good degree of tactile information can be
obtained in this way.
Demisting
Placing a cold endoscope in a warm humid abdomen
or thorax can often lead to misting of the lens. Whilst
this can usually be cured by gently wiping the lens on
a serosal surface, it is useful to try and prevent it
occurring, as far as possible, by prewarming the
instrument. Placing the endoscope in warm sterile
distilled water for a minute or two is ideal, or even just
warming the tip of the endoscope in the hand can be
effective. Commercial demisting solutions are
available and effective, but not really necessary;
povidone–iodine is a good substitute.
Portal placement
Laparoscopic and thoracoscopic cannulae are often
called ‘ports’ or operative ports. The correct placing of
ports is vital to a successful surgical outcome.
Placement will vary according to the size of patient as
well as the procedure to be undertaken. Several
general principles must be applied:

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 Chapter 7 Rigid endoscopy and endosurgery: principles

• efore embar in pon laparoscopy or along the axis of the cannula can act as a stop to
thoracoscopy, port placement must be carefully prevent too rapid penetration. Holding the upper end
planned so that additional ports do not have to be of the cannula in the palm of the hand, pressure is
placed during the procedure exerted in a twisting motion until the tip of the cannula
• orts m st be placed s fficiently distant from the enters the peritoneal space. The trocar is removed
site of interest so as not to overcrowd the area but and the cannula can be pushed gently into the abdo-
not so far that instruments cannot reach easily men a little further. The valve in the cannula closes as
• he camera port is placed first and soon as the trocar is removed to prevent escape of
instrumentation or operative ports placed to the gas. An endoscope with camera attached is then
sides, sufficiently far apart that instruments do inserted into the cannula and the area immediately
not interfere with each other, and so that underneath the entry point is inspected for iatrogenic
instruments can triangulate down to a focus at damage. The endoscope can then be directed to the
the site of interest at a comfortable angle – site of interest for further inspection.
usually around 60–90 degrees. This is the normal The gas inlet tubing from the insufflator can be
position in which a surgeon would hold hand transferred from the Veress needle to the inlet port of
instruments during an open procedure. the cannula. This allows removal of the Veress needle
• here two operatin ports are sed they sho ld and gas flow is directed away from the endoscope
be equidistant from the camera port (Figure 7.1). lens, helping keep it clear. Cold gas can, however,
sometimes increase fogging of the endoscope lens. If
The exact position on the abdomen or thorax in this is a problem, touching the lens to a serosal surface
relation to landmarks such as the umbilicus or specific in the abdomen will clear the fogging. Moving the gas
ribs will vary according to patient size: 2 cm caudal to inflow to the operative port may also help if the problem
the umbilicus is very different in a cat and a Great persists. Occasionally it may be necessary to remove
Dane! It is important to visualize the operative site in the endoscope and wipe the tip with sterile saline-
three dimensions and plan the port sites accordingly soaked gauze to remove blood, fat or tissue debris.
in each case. Endoscopes should be introduced through the
rubber grommet on laparoscopy ports and then the
trapdoor seal should be opened manually before
Procedure inserting the endoscope through the port. Opening
the trapdoor simply by pushing the endoscope through
With the abdomen insufflated (see above) there it will eventually damage the lens resulting in costly
should be a reasonable space between the abdo- repair. The same procedure is used for introducing
minal wall and the underlying viscera, but care sharp trocars into the port, to prevent blunting. Care
should still be taken not to stab the trocar into the should also be taken here to ensure the sharp tip is
abdomen too forcefully. A middle finger extended centrally placed when passing through the grommet

7.1
Port placement for
triangulation in
laparoscopy.
X marks the site of
surgical interest.

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 Chapter 7 Rigid endoscopy and endosurgery: principles
as cuts to the rubber grommet result in leakage of
abdominal gas. Other instruments can generally be
passed through directly.
In thoracoscopy, following insertion of a port and
removal of the trocar, the valve mechanism of the
cannula is also removed, leaving unsealed access to
the thorax. Unlike laparoscopy, where a good gas-
tight seal is obligatory, in the thorax a gas-tight seal is
not required. On the contrary, air needs to flow in and
out of the thorax as the lungs are inflated and deflated
by positive pressure ventilation. Failure to allow this
risks creating a tension pneumothorax.
It is usually necessary to create a second port in
order to introduce instrumentation, e.g. biopsy
forceps. For operative surgery a third port may be
required. Additional ports are always inserted under
direct visualization through the endoscope and the
site is chosen with respect to the area of interest.
The tip of the endoscope is brought up to the
proposed site to transilluminate the skin. This allows
larger vessels in the skin to be seen and a relatively
avascular area selected. Local anaesthetic is injected
and a 5 mm skin incision is made as before. A cannula
is introduced through the incision, only this time under
direct visualization through the endoscope to avoid
penetration of the spleen or other viscera. The trocar
is removed and replaced by a blunt palpation probe.
If instrumentation or probes are smaller than the port
diameter, a reducing valve must be used to maintain
a gas-tight seal.
Whenever possible, instruments of any kind are
introduced into the abdomen under direct visualization,
with the jaws closed, to prevent trauma to abdominal
viscera. The tip of the instrument can then be guided
down to the point of interest under visual control.
Retracting the endoscope to give a wide angle survey
view is often useful as instruments are introduced.
The endoscope can then be advanced along with the
instrument to the point of interest to allow a more
close up view for fine manipulation.
Rigid endoscopes, particularly those smaller than
4 mm in diameter, are fragile and are easily broken by
rough handling or sharp knocks. Endoscopes <4 mm
should always be used in a protective sheath of some
kind. Failure to do so may result in permanent
damage. Torsion or bending of the shaft of the
endoscope is the most common problem and occurs
most often during arthroscopy or rhinoscopy, where
the endoscope is manipulated in a small, rigidly
enclosed space. The appearance of a dark semilunar
shadow at the edge of the image on the video monitor
is an indication that excessive torsion is being used
and disaster is imminent.
Dissection and haemostasis
All the tissue manipulations that are undertaken in
open surgery can be accomplished endoscopically.
l nt dissection with forceps or sharp dissection with without significant loss of insufflation. The operative
scissors enables lesions to be isolated from surround-
ing tissues. A wide variety of endoscopic instrument-
ation is available (see Chapter 2). Many endoscopic
instruments are insulated and have attachments for
102
Ch07 Endo.indd 102
monopolar or bipolar electrosurgery units, enabling
bleeding points to be grasped and cauterized.
Monopolar dissecting hooks are useful for fine dis-
section and in some cases can obviate the need to
change instruments when cauterizing and cutting.
Commercially available Endoloops™ (Ethicon)
are pre-tied loops of suture material (Vicryl or PDS)
attached to a rigid plastic shaft that acts as a knot
pusher to cinch the knot down once the loop has been
positioned around the tissue. These can be used for
isolating a pedicle of tissue for biopsy or small mass
removal in the liver or periphery of the lung, or for
encircling a bleeding point or organ such as the uter-
ine stump.
Haemostatic gauze such as Collostypt™ can be
placed at biopsy sites to reduce haemorrhage, but this
is rarely necessary. Haemorrhage can be controlled
by simple pressure from a palpation probe, or small
tonsillar swabs can be introduced down the operative
port and used to apply pressure and remove small
quantities of blood. It should be remembered that
haemorrhage always looks considerably worse under
the magnifying lens of the endoscope. In practice it is
rarely a problem and is usually easily controlled.
Commercially available dissecting and coagulating
instruments such as the harmonic scalpel™ (Ethicon)
and the LigaSure™ (Tyco/ValleyLabs) enable sealing
and sectioning of vessels 5–7 mm in diameter, greatly
facilitating dissection using only one instrument.
However, these instruments are currently extremely
costly and outside the budget of most general practi-
tioners. A more cost-effective alternative is the Patton
Hotblade™ – a single use disposable instrument
that can be attached to a standard electrosurgery unit.
This instrument can be reused if cleaned with care
and gas-sterilized.
Endoscopic staplers and clip appliers are a rapid
and simple way to ligate vessels and ligate and divide
tissues. Most of these are 10 mm instruments,
although 5 mm clip appliers are available. A 10 mm
linear cutter type endoscopic stapler can be very
useful in resecting lung lobes or anastomosing bowel.
These instruments place 4–6 rows of titanium staples
on either side of a blade that simultaneously cuts and
divides the tissue when the stapler is fired. Staple
cartridges are quite costly, and although these are
generally single use instruments, they can often be
reused after ethylene oxide gas sterilization.
Clip appliers usually contain around 20 stainless
steel or titanium clips, which can be applied individually
to ligate vessels.
Suction and irrigation
Removal of ascitic fluid, blood or thoracic exudates
requires suction. Laparoscopic suction/irrigation
devices designed to fit the laparoscopic cannulae
(5 mm) enable suction and irrigation to be carried out
site can be irrigated with sterile saline and clots and
free blood removed by suction to give a clear view of
the operative field, and ensure that adequate
haemostasis has been accomplished.
4/3/08 09:42:31
 Chapter 7 Rigid endoscopy and endosurgery: principles

Specimen retrieval skills, a great deal of practice is required to become

Concern over seeding of tumour cells at abdominal
and thoracic portal sites has led to the more common
use of retrieval bags. Purpose-made endoscopic
retrieval bags can be purchased in a number of sizes.
They are rolled into a 5 mm or 10 mm tube for inser-
tion down a standard port; when deployed in the
abdomen, the mouth of the bag opens up by means
of a plastic spring-loaded mechanism to allow easy
insertion of tissue. The mouth is then closed with a
drawstring and the port removed, allowing the bag to
be withdrawn through the abdominal incision, which
can be slightly enlarged if necessary. When larger
solid organs or tissues are to be removed, a macera-
tor can be introduced into the retrieval bag whilst still
inside the abdomen, and the tissue macerated to
allow easier removal through a small incision.
If commercial retrieval bags are not available,
sterile ziplock bags or a cut-off finger from a surgeon’s
glove can make a good substitute.
Knot tying techniques
Those new to minimally invasive surgery are frequently
keen to learn suturing and knot tying techniques. The
vast majority of procedures can be carried out with
the aid of electrosurgical haemostasis (monopolar or
bipolar) or with the use of haemostatic clips or
Endoloops™ but knot tying can have specific uses in
advanced surgery and may become more useful as
procedures are developed. Like most endoscopic
accomplished at suturing and knot tying using
laparoscopic instrumentation. These skills should be
practised using an endoscopic ‘trainer’ (see above)
before attempting to operate on a live patient. Some
basic knot tying techniques are included here; more
detail can be found in Freeman (1999). Knot tying can
be extracorporeal or intracorporeal.
Extracorporeal knots
The suture material and needle are placed into the
abdomen through an abdominal port (usually 10 mm)
with the free end remaining outside the body. The
suture material is grasped just behind the needle to
facilitate passage through the port and the needle
holders are then repositioned to grasp the needle
once in the abdomen. The needle can then be passed
through or around the tissue to be ligated and brought
back out through the same cannula, leaving both free
ends outside the body.
Extracorporeal knots are formed by pushing
individual throws of a surgeon’s knot down into the
body with a knot pusher, to cinch them down on to the
tissue, or by forming a slip knot and introducing that in
a similar manner. Alternatively, preformed knotted
sutures such as Endoloops™ (Ethicon) may be used
which incorporate a disposable knot pusher and a
pre-tied slip knot. Once the knot is positioned correctly
the free ends of the suture material are cut off.
A standard surgeon’s knot can be tied
extracorporeally and seated down using laparoscopic
abcoc forceps ( i re 2)

(a) (b)

(c) (d)

7.2 Extracorporeal knot tied using Babcock forceps. The needle is passed down through the port and around the
tissue to be ligated. The needle is then brought out of the port such that both ends of the suture material are
outside the body. (a) A single or double half hitch is tied as usual and the free ends of the suture are threaded through the
holes in the jaws of the forceps from the inside to the outside. (b) Slight tension is applied to the free ends. (c, d) The knot
is slid down into the abdomen with the jaws of the Babcock forceps closed. (continues)

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 Chapter 7 Rigid endoscopy and endosurgery: principles

(e) (f)

(g) (h)

(i)

7.2 (continued) (e) Once the knot is in place, opening the jaws of the Babcock forceps applies tension to the knot to
cinch it down. (f, g) The Babcock forceps are then gently withdrawn and one end of the suture unthreaded from
the jaws. (h) A second half hitch is formed, the Babcock forceps are rotated and the free end re-inserted through the jaws
as before. (i) The second throw is then pushed down into the abdomen and cinched tight as before.

A commonly used extracorporeal slip knot is the
Roeder knot (Figure 7.3). A modified Roeder knot
incorporating an initial double half hitch and two final
wraps around just one limb of the suture loop may
also be used for added security. The knot is loosely
tightened and, with the standing end held under
tension, the knot is slid down on to the tissue with a
knot pusher and cinched down.
Intracorporeal knots
These require a laparoscopic needle holder and
grasping forceps. Whereas extracorporeal knot tying
requires a long length of suture material, this can be
cumbersome when suturing inside the body, and
suture length is usually cut to 10–20 cm or so to
facilitate handling. The whole length of suture material
and needle are introduced into the abdomen. Tissue
is grasped and sutured in a similar manner as for
open surgical techniques.
Standard suture materials can be used with 3/8 cir-
cle, 1/2 circle straight or ½ curved ‘ski’ needles. Needle
size is dictated by the cannula size; it is normally nec-
essary to use a 10 mm cannula with a suitable reducer
for endoscopic suturing. Half-circle needles up to
CT-1 can be used with 10 mm cannulae.
Endoscopic needle holders are usually 5 mm in
diameter and should have an in-line handle as
opposed to a pistol grip, since this facilitates rotation
and manipulation of the needle. They should also
have a locking ratchet mechanism. A 5 mm reducing
valve will be required when using a 10 mm cannula.
The needle holders are passed through the reducing
valve and the suture material is grasped 1–2 cm away
from the swaged-on needle. The needle holders are

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 Chapter 7 Rigid endoscopy and endosurgery: principles

(a) (b) (c)

(d) (e) (f)

7.3 Roeder knot. (a–d) This is formed by throwing a half hitch which is then held between the index finger and
thumb of the left hand. (e) The free end of the suture is then wrapped three times around the two limbs of the
loop between the half hitch and the tissue to be ligated. (f) This free end is then wrapped around just one limb of the loop
and brought back through the last loop so created.

then introduced into the 10 mm operating cannula
and the reducing valve is attached to avoid loss of
pneumoperitoneum. The valve of the operating
cannula should be opened manually to permit passage
of the needle and needle holder.
Suturing is easiest with the suture line running
from 11 o’clock to 5 o’clock for a right-handed surgeon,
or from 1 o’clock to 7 o’clock if left handed (Figure
7.4). The monitor should be placed directly ahead of
the surgeon.
Once in the abdomen, the needle is manoeuvred
into a suitable position and grasped halfway to two-
thirds from the tip. The tissue to be sutured is grasped
with the grasping forceps and the needle passed
through in the usual fashion. The open jaws of the
grasping forceps can be placed on to the tissue
adjacent to the exit point of the needle to stabilize it if
required. The needle is then grasped with the grasping
forceps and the open jaws of the needle holders can
be applied to the tissue adjacent to the needle to
apply counter pressure as required. If long lengths of
suture material are used or space is very limited, then
it is often easier to grasp the needle with the needle
holders again and wrap the suture around the closed
grasping forceps so they act as a pulley (Figure 7.5).
In this way the needle is pulled away from the wound
but the direction of pull on the wound is maintained
and tissue trauma is less likely.

7.4 Intracorporeal knot tying: direction of suture 7.5 Applying tension around a pulley.
line.

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 Chapter 7 Rigid endoscopy and endosurgery: principles

Intracorporeal knots are tied in a similar manner to create a slip knot to aid in tissue apposition. A square
that for conventional open surgery (Figure 7.6). knot can be converted to two half hitches and then slid
On some occasions it may be an advantage to down onto the tissue to tighten a ligature (Figure 7.7).

(a) (b)

(c) (d) (e)

(f) (g) (h)

7.6 Tying an intracorporeal square knot. (a) With the needle passed through the tissue from right to left, the needle is
brought back over to the right to form a ‘C’ loop. The grasping forceps are introduced over the suture material
and into the loop from the left. (b–d) The suture material is grasped by the needle holders and wrapped around the
grasping forceps, which then grasp the free end of the suture to form the first half hitch as the instruments are drawn apart.
(e) The needle or long part of the suture material is then grasped again by the needle holders and brought over to the left
to create a reverse ‘C’ loop. (f–h) The suture material is then grasped by the grasping forceps and wrapped around the
needle holders, which are advanced to grasp the free end and complete the second half hitch.

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 Chapter 7 Rigid endoscopy and endosurgery: principles

(a) (b)

(c) (d)

7.7 Converting a square knot to a half hitch. (a) With a loose square knot in place and the long end of the suture
grasped in the left hand and the free end to the right, the suture material is grasped between the knot and the
tissue on the same side as the long end, i.e. the left, and tension applied to the knot by moving the graspers and needle
holders apart. This converts the knot to two half hitches. (b, c) Maintaining tension with the graspers in the left hand, the
needle holders can be placed above the knot and used to slide the knot down on to the tissue. (d) Grasping the free end
with the needle holders, and applying sharp tension to both ends of the suture, converts the knot back to a square knot for
security; an additional throw can be formed.

Closure All thoracic ports should be closed in at least two

Most laparoscopic ports require minimal closure.
Ternamian EndoTIP® cannulae dissect through tissue
planes as they are inserted and allow tissues to
re-appose on removal, forming an effective deal.
Even traditional 5 mm cannulae do not generally
result in large enough wounds to allow herniation, so
5 mm or smaller abdominal ports may be closed in
one layer with a simple interrupted suture. Alternatively,
the skin may be closed with tissue adhesive. All ports
placed in the linea alba, where the abdominal wall is
thinnest and healing delayed, should be closed in two
layers to reduce the risk of herniation. Ports of 10 mm
should be closed in two layers: deeper layers with
absorbable material such as Vicryl; and skin with
tissue glue or non-absorbable polyamide skin suture.
If ascites is present all abdominal incisions should be
closed in several layers to prevent seepage of fluid.
layers to ensure an airtight seal.
Postoperative care
For the most part, postoperative care is similar to that
for conventional open surgical cases, and recovery is
usually more rapid. Pain relief should be administered
for the first 24 hours postoperatively and then as
required depending on the procedure.
Following laparoscopy the abdomen is fully
deflated but carbon dioxide continues to be absorbed
during the recovery period and the patient should be
monitored until completely recovered. Embolisms are
rare but can occur, even in recovery. Insufflation results
in pressure on abdominal vasculature and an increase
in peripheral vascular resistance. As the abdominal
pressure drops on desufflation, vascular resistance

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 Chapter 7 Rigid endoscopy and endosurgery: principles

decreases and there is a resultant hypotension. Most References and further reading
patients compensate readily but this can be potentially
Freeman LJ (1999) Veterinary Endosurgery. Mosby, St Louis
dangerous in hypovolaemic patients or patients with McCarthy TC (2005) Veterinary Endoscopy for the Small Animal
pre-existing cardiovascular compromise. Practitioner. Elsevier Saunders, St Louis
Release of intra-abdominal pressure can also
rarely lead to increased intra-abdominal bleeding as
pressure on the capillaries is reduced.

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 Chapter 8 Rigid endoscopy: rhinoscopy

Rigid endoscopy: rhinoscopy

Philip Lhermette and David Sobel

Introduction
Nasal disease is common in the dog and cat, often pre-
senting as a nasal discharge, with or without sneezing,
stertor or stridor. Epistaxis may or may not be a feature,
and can be present alone. Access to the rhinarium is
difficult, since it is entirely encased in bone apart from at
either end, and contains numerous turbinate scrolls
forming many blind-ending channels in which foreign
bodies or pathological changes can be hidden. Excellent
coverage of nasal diseases and pathology can be found
in the BSAVA Manual of Head, Neck and Thoracic
Surgery and the reader is referred to this manual for
detailed coverage of nasal conditions.
There are only a limited number of direct physical
approaches to the nasal cavity: dorsal rhinotomy;
ventral rhinotomy; and rhinoscopy. Rhinoscopy is
minimally invasive, providing reduced morbidity over
other surgical options, and affords the best option for
visualizing lesions and taking biopsy samples for
diagnostic work, either for initial diagnosis or to
confirm a suspected diagnosis. A rhinoscopic
approach may also be used for the removal of foreign
bodies and for treatment such as tumour ablation or
debulking, using the diode laser or, in cases of nasal
aspergillosis, debriding fungal plaques and instilling
antifungal solutions. Indeed, rhinoscopy is the only
manner by which a full direct visual examination of
the nose can be carried out and it is therefore the gold
standard for diagnosis of intranasal disease.
For the beginning endoscopist, rhinoscopy is one
of the more accessible and easily learned procedures.
Nasal and sinus disease are commonly presented to
the first opinion veterinary surgeon and are often of
significant concern to the owner. Thus, rhinoscopy
tends to be amongst the first and most useful
procedures to be added to the repertoire of the small
animal practitioner.
Anatomical considerations
The diagnosis and management of diseases of the
rhinarium and associated sinuses is complicated by
the anatomy of the region. The close quarters of so
many critical structures, the bony encasement of the
more physiologically important structures, and the
relative similarity of the presenting signs of most nasal
diseases make it difficult to easily access nasal and
sinus pathology. A sound appreciation of the anatomy
of the nose and sinuses is therefore essential before
embarking on any procedure. Although different from
the standpoint of aesthetics and external appearance,
the nose of the dog and cat serves similar physiological
functions and the anatomy will therefore be considered
here together (Figure 8.1).

Nasal bone Dorsal nasal meatus 8.1

Dorsal nasal concha (a) Transverse
Nasal process of incisive bone section to show
Middle nasal meatus the anatomy of
the canine/feline
Maxilla Common nasal
meatus nose. (continues)
Ventral nasal
concha

Canine tooth Cartilage of

nasal septum

Ventral nasal
Vestibule meatus

Vascular plexus
Lip of hard palate

First premolar
Palatine process of maxilla Vomeronasal organ
(a) Palatine process of incisive bone Vomeronasal cartilage

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 Chapter 8 Rigid endoscopy: rhinoscopy

Lateral part of frontal sinus 8.1

Cribriform plate
(continued)
Medial part of frontal sinus (b) Longitudinal
section to show
the anatomy of
Dorsal nasal concha the canine/feline
nose.
Ventral nasal concha

Entrance to maxillary recess Ethmoidal labyrinth

(b)

The nose of the dog and cat is formed rostrally by posteriormost aspect of the dorsal nasal meatus
the nasal planum, which surrounds the nostrils and forms the cribriform plate of the ethmoid bone, through
leads into the nasal vestibule on each side. The which the olfactory nerves pass to terminate at the
paired nasal bones form the dorsal limits of the nares, olfactory bulb of the brain.
whilst the lateral and ventral limits are formed by the
maxillary and palatine bones, respectively. Any or all
of these bony structures may be damaged by Indications
aggressive nasal disease. Often, gross changes in
either of these two bony locales lead to the initial Patients with primary nasal disease may be presented
suspicion of disease in the nasal cavities. to the clinic in a variety of forms, from acute respiratory
The left and right nasal cavities are separated by distress to the chronic long-standing disease state.
a midline nasal septum and each is divided by dorsal, The presenting problems that should prompt the
ventral and ethmoidal nasal conchae into the dorsal, diagnostic work-up for nasal disease are listed in
middle, ventral and common nasal meatuses. The Figure 8.2.
ventral nasal concha extends rostrally into the lateral
part of the vestibule, where it forms the alar cartilage
just inside the nasal planum. Located at the Common indications
ventralmost aspect of the alar cartilage is the punctum Nasal discharge: unilateral/bilateral; mucoid/mucopurulent
of the nasolacrimal duct. In disease, nasolacrimal History of foreign body
duct transit is often interrupted, resulting in epiphora.
The complex scrolling of the bone and resulting Other signs affecting the nares
diverticula make full exploration of every part of the
Sneezing/reverse sneezing
nose impossible. However, the majority of the dorsal Stertor (snoring/snorting)
and common meatuses and all of the ventral meatus Stridor (inspiratory noise/wheezing)
will be accessible in most patients. Epiphora, through blockage of the nasolacrimal ducts
The paranasal sinuses are a series of small, air- Facial swelling or deformity
filled, mucous membrane-lined bony spaces that Epistaxis
communicate to varying degrees with the nasal Other clinical signs
cavities. With reference to respiratory disease, the
only sinuses that have frequent clinical significance Halitosis in the absence of dental disease
are the frontal sinuses, as their natural drainage into Dental disease
the ethmoid concha is often pathologically obstructed Exophthalmos
Dysphagia
in the diseased state. The paired frontal sinuses are
Head shaking
divided by a median septum and further subdivided Pawing at the nose
into three chambers on each side – lateral, medial Rubbing the face on the ground
and rostral – which communicate with the nares by
separate nasofrontal openings. In the majority of
dogs and cats the sinuses are not directly accessible 8.2 Indications for rhinoscopy.
to a rigid rhinoscope.
The mucous membrane of the nose is well
vascularized and lined with ciliated columnar Clinical history
epithelium. This, coupled with the large surface area A carefully taken history is essential. For example, a
of the conchae, results in warming and humidifying of history of sniffing up a foreign body or acute onset of
inspired air and the trapping of airborne particles in a signs after walking through long grass may suggest a
thin layer of nasal mucus, which can then be carried possible diagnosis. A history should include careful
to the outside by the action of the cilia. The discussion with the owner concerning:

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 Chapter 8 Rigid endoscopy: rhinoscopy

• Duration of clinical signs glass slide to demonstrate airflow. Careful and

• Age at onset delicate percussion of the rhinarium and sinuses may
• Laterality of clinical signs help localize fluid and inspissated mucoid debris or
• Progression versus waxing and waning even tissue masses.
• Use of the animal (e.g. hunting, field work) A careful aural examination can identify evidence
• Environmental exposure to toxins of inflammatory or infectious disease that has
• Travel history extended to, or arisen from, the middle or inner ear.
• Trauma On occasion, nasopharyngeal polyps can be identified
• Other concurrent illnesses. on examination of the middle ear, without having to
embark on a full nasal examination.
Figure 8.3 summarizes the diagnostic significance Any evidence of epistaxis should give the clinician
of these questions. cause to look carefully for evidence of coagulopathies,
specifically of platelet dysfunction. Examination of the
oral mucosa, the ocular tissues, and urogenital
Characteristic Differential diagnoses and comments tissues for evidence of ecchymoses or petechiation
may corroborate suspicions.
Acute versus chronic onset Dental disease is a common cause of secondary
Acute Foreign body; trauma bacterial rhinitis and a careful examination for
periodontal disease is indicated. If the conscious
Chronic Neoplasia; fungal rhinitis; lymphoplasmacytic patient will allow, examination of the oropharynx can
rhinitis (allergic or immune-mediated); trauma/ occasionally identify pathology at the level of the
foreign body; coagulopathy; hypertension; posterior nares. Not infrequently, mass lesions that
hyperadrenocorticism (rare)
arise from the posterior nares can be found hanging
Unilateral versus bilateral over the caudal aspect of the soft palate.
Figure 8.4 summarizes the diagnostic significance
Unilateral Neoplasia; foreign body; localized infection; tooth of clinical findings.
root infection; early aspergillosis

Bilateral Lymphoplasmacytic rhinitis; infection (viral/

bacterial); allergy; bronchial infection and
coughing leading to secondary nasopharyngeal
infection. NB Early unilateral infections such as Procedure Findings and diagnostic
aspergillosis or invasive neoplasia may progress indications
from unilateral to bilateral as the infection/mass
breaches the nasal septum Look for discharge Serous: inflammatory;
mucopurulent; epistaxis
Age at onset
Look for epiphora Mass or infection affecting
Young (0–7 Infection, trauma, allergy, infection or foreign body nasolacrimal duct
years) more likely
Look for swellings or deformity; Trauma; neoplasia; inflammation;
Old (>7 years) Neoplasia increasingly likely compare sides invasive fungal rhinitis

Waxing and Allergic: may be seasonal or geographical; Auscultate lungs, trachea and Lower airway disease; reduced
waning intermittent exposure to toxins, e.g. smoke, dust both sides of rhinarium airflow in one/both nares; stertor;
stridor
Species/breed
Listen for airflow, particularly Neoplasia; foreign body
Cats Cats prone to grass foreign bodies sneezed for discrepancies between
forward over the soft palate. Oriental cats more nostrils. Place small twist of
prone to sinusitis cotton wool in front of nares to
assess flow. Place mirror in
Dogs Dogs tend to sniff up foreign bodies. Dogs more front of nares and look for
prone to aspergillosis. Dolichocephalic breeds: misting
increased incidence of neoplasia. German
Shepherd Dog: increased incidence of Palpate eyes Retrobulbar abscess; neoplasia
aspergillosis
Palpate rhinarium for signs of Trauma; aspergillosis; neoplasia
Historical factors and their diagnostic pain/discomfort
8.3
significance.
Percuss sinuses and rhinarium Space-occupying lesion: mass/
fluid/fungal plaques

Clinical examination Oral examination, especially Dental disease; invasive neoplasia

palate and teeth
Careful auscultation of inspiratory and expiratory
airflow from the nose may reveal the magnitude and Aural examination for polyps or Auropharyngeal polyps
definitive lateralization of the pathology. A neonatal otitis media
stethoscope is useful for listening to airflow over the
dorsum of the rhinarium, its lateral aspects, and over
8.4 Clinical examination.
the frontal sinuses. Some clinicians use misting on a

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 Chapter 8 Rigid endoscopy: rhinoscopy
In common clinical practice, a first presentation
of bilateral nasal disease in a young otherwise
healthy pet is often managed with empirical use of
antimicrobials. However, certain findings always
suggest the need for further diagnostics. Epistaxis, a
consistently unilateral discharge, unilateral nasal
discharge progressing to bilateral discharge, facial
asymmetry, facial pain, or lack of response to
previous rational therapy indicate the need for
further diagnostics.
Preoperative diagnostic work-up
Blood pressure measurement
Epistaxis may be a result of hypertension. This is
especially the case in cats, where hypertension
secondary to hyperthyroidism is not uncommon.
Blood pressure measurement should be carried out in
a calm and quiet environment and repeated several
times to get a representative result. The underlying
cause of hypertension should be investigated prior to
rhinoscopy unless otherwise warranted. In cats a T4
analysis may be useful to rule out hyperthyroidism as
a contributory cause of hypertension.
Clinical pathology
Full haematology and serum biochemistry screens
should be carried out prior to rhinoscopy. If epistaxis
is a predominant feature, investigation of primary
and secondary clotting pathways is essential. It is
important not only to rule out clotting disorders as a
primary cause, but also to alert the surgeon to com-
plications likely to result from the rhinoscopy proce-
dure. The nose is a very vascular organ and some
haemorrhage is to be expected during rhinoscopy,
even in a normal patient. Clotting disorders may
result in severe uncontrollable haemorrhage and
may need to be addressed before continuing with the
procedure. Assessment should include at least a
platelet count and buccal mucosal bleeding time; if
epistaxis is severe, activated clotting time or pro-
thrombin time and activated partial thromboplastin
time should be determined.
Adrenocortical function testing (adrenocortico-
tropic hormone stimulation or dexamethasone
suppression test) may be useful to detect hyper-
adrenocorticism if this is suspected.
Serological assays for aspergillosis may be use-
ful but single samples are of limited use: a 70%
cross-reactivity with non-fungal disease, including
neoplasia, may lead to false positives, and failure to
seroconvert may lead to false negatives. However,
serology can corroborate other findings during the
course of the work-up and may therefore be useful. A
paired rising titre is required to demonstrate infection
with any certainty.
Microbiology
Bacterial culture from the nose is generally unhelpful
due to the large number of commensal organisms
found there. Most infections tend to be secondary and
opportunistic rather than a primary cause of disease,
but culture may be useful if a focal area of infection is
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Ch08 Endo.indd 112
found. Any swabs taken for culture and sensitivity
testing must be taken prior to rhinoscopy, as focal
areas of infection may be washed away or contami-
nated during the procedure.
Primary bacterial rhinitis is very rarely found.
Aspergillus may be cultured from swabs taken from
normal dogs, as it is ubiquitous in the environment;
conversely, it may not be found in swabs from infected
dogs as it is not always shed in large numbers in
exudates, so false positives and negatives are
common. Pharyngeal swabs for feline respiratory
diseases (feline calicivirus, feline herpesvirus,
Chlamydophila) may be useful; these are a common
cause of chronic rhinitis in cats. Full details of testing
methodology can be found in the BSAVA Manual of
Canine and Feline Clinical Pathology.
Intraoperative diagnostic work-up
(under general anaesthesia)
Diagnostic imaging
Radiography is extremely useful for assessing the
location, extent and possible cause of disease (Figure
8.5). Several views should be taken as a routine:
• Intraoral dorsoventral occlusal (Figure 8.6)
• Ventrodorsal open mouth to assess cribriform
plate
• Rostrocaudal skyline sinus view of frontal sinuses
and tympanic bullae (Figure 8.7)
• Lateral.
If dental disease is suspected, high-detail dental
radiographs or oblique lateral views should be taken
as well. Mammography cassettes are ideal for high-
detail nasal and dental views. Special attention should
be paid to the apical areas of tooth roots for evidence
of infection.
Radiographic finding Possible causes
Dogs
Loss of trabecular pattern Fungal infection; neoplasia;
(ethmoturbinates/ trauma
maxillary)
Increased soft tissue density:
Maxilla Neoplasia; foreign body; blood
clot; mucus
Sinus Mucus; neoplasia; fungal plaque
Lucency Fungal rhinitis
Septal deviation Neoplasia
Tympanic bulla opacity Polyp; infection
Cats
Unilateral lucency Neoplasia
Bilateral lucency Chronic rhinitis
Common radiographic findings and their
8.5
significance.
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 Chapter 8 Rigid endoscopy: rhinoscopy

Radiography or MRI techniques should ideally

always be carried out prior to endoscopy. Once the
nasal cavity has been flushed with saline, and the
turbinates have been partially obscured with blood
clots from intraoperative haemorrhage, radiography
will not be possible for a couple of days.

Dental examination
Dental disease is common in dogs and cats and can
often be the cause of, confused with, or contribute to,
nasal pathology. The deep dorsal recesses of the
upper arcade of tooth roots abut the ventral surface of
the hard palate and are thus closely associated
anatomically with the ventral meatus of the nasal
cavity. The intervening bone and mucosa are easily
Intraoral radiograph, showing soft tissue opacity breached by trauma or infection. Periodontal disease,
8.6
in right caudal nares. resulting in resorption of alveolar bone and the
progressive deepening of periodontal pockets, may
lead to communication with the nasal cavity or
maxillary sinus. Alternatively, endodontic disease
may lead to lysis of the periapical bone at the tooth
root and associated rhinitis.
A full dental examination can only be carried out
under general anaesthesia. The periodontal pockets
of each tooth should be explored with a suitable
dental probe to assess their depth and evidence of
infection, which may have tracked into the nasal
cavity. Haemorrhage should be noted. If probing
provokes ipsilateral epistaxis, fistula formation is
confirmed, though lack of haemorrhage does not
rule this out. Any suspicion of dental involvement
should be confirmed radiographically. Further details
can be found in the BSAVA Manual of Canine and
Feline Dentistry.

Detailed oropharyngeal examination

Examination of the pharynx and larynx may reveal
the presence of trauma or foreign bodies. Tonsillar
enlargement (Figure 8.8) is common in chronic
disease. Discharge may be seen passing back from
the nose into the oropharynx, whereas it may not be
Radiographic skyline view of the tympanic obvious at the nares. Examination and digital
8.7 palpation of the hard and soft palate may reveal
bullae and frontal sinuses in the cat.
masses either on the surface or palpable through the
Thoracic radiography is used to look for dissemi- soft tissues of the soft palate. A spay hook can be
nated infectious or neoplastic disease within the pul- used to pull the free edge of the soft palate rostrally
monary parenchyma and pleural space (see BSAVA and enable limited examination of the nasopharynx
Manual of Canine and Feline Thoracic Imaging). for foreign bodies or neoplasia.
Computed tomography (CT) or magnetic reso-
nance imaging (MRI) are very valuable modalities for
examination of the rhinarium (Saunders JH et al.,
2004; Lefebvre et al., 2005). The detail visible and the 8.8
acute ability to localize pathology can be of tremen- Tonsillar
dous benefit; limiting factors are often availability inflammation/
and timely access, though there is a rapid increase in enlargement in the
dog. The tonsils
veterinary-specific CT and MRI in both private clinical can be examined in
practice and in teaching hospitals. CT and MRI scans detail with a rigid
can be helpful in differentiating neoplasia from infec- endoscope. The
tion and give a more precise image of the limits of a tonsillar crypt
mass, which may help in planning surgical debulking should be explored
and/or radiotherapy. The ability to take multiple with forceps under
direct visualization
images at regular spacing and in different planes,
to exclude foreign
allows a virtual three-dimensional image of the area bodies.
to be built up.

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 Chapter 8 Rigid endoscopy: rhinoscopy
Instrumentation
A full discussion of endoscopic equipment and its
care is provided in Chapter 2. Figure 8.9 lists the
equipment required for rhinoscopy and specific
considerations are discussed in the later sections on
procedures. An endoscopic video camera is essential
for performing any operative or sterile work. Some
endoscopists do prefer to look through the oculus of
the endoscope, but the field is commonly obliterated
by fluid and blood and is difficult to see without the
enlargement the camera affords.
Camera and monitor
Xenon, metal halide or halogen light source
3.5–8 mm flexible endoscope
Fibreoptic light guide cable
(Dental mirror)
2.7 mm 18 cm HOPKINS 30 degree endoscope
14.5 Fr cystoscopy sheath with 5 Fr instrument channel
High-flow arthroscopy sheath
(1.9–2.4 mm HOPKINS 30 degree endoscope for small cats, with
appropriate sheaths)
7 Fr 40 cm biopsy forceps
7 Fr 40 cm grasping forceps
3 mm cup biopsy forceps
‘Cell-safe’ biopsy sample frames
Giving set
Normal saline (1 litre +)
8.9 Equipment required for rhinoscopy.
WARNING
Endoscopes sold as ‘Autoclavable’ are designed
for human hospital autoclaves with a slow heat
and cooling cycle. Most veterinary autoclaves
heat up and cool down too quickly and will
reduce the life of these endoscopes consider-
ably. It is not advisable to autoclave endo-
scopes in veterinary practice.
Premedication and anaesthesia
General anaesthesia is required for rhinoscopy.
Standard preparation for general anaesthesia is
undertaken, including withholding food for 12 hours. A
catheter is placed for intravenous fluids and venous
access if needed. Anaesthetic protocols are used that
are standard to the practice given the clinical scenario,
although premedication with acepromazine helps to
lower blood pressure and reduce haemorrhage, as
well as providing a calm recovery. A combination of
acepromazine 0.02 mg/kg and either butorphanol
0.1 mg/kg or buprenorphine 10 µg/kg by intravenous
or intramuscular injection is commonly used. Appro-
priate anticholinergic support should be provided
prior to induction.
Procedure
It is good practice to examine the nasopharynx and
choanae using caudal (posterior) rhinoscopy before
performing the rostral (anterior) procedure. Caudal
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Ch08 Endo.indd 114
rhinoscopy is performed by retroflexing a flexible
endoscope over the free edge of the soft palate, so as
to look forward, towards the choanae. Since this does
not require fluid irrigation, swabs and samples can be
obtained for culture if required, as well as biopsy
samples of nasopharyngeal and caudal nasal masses.
It may also be pertinent to perform a bronchoscopic
examination if tracheal or lower airway disease is
suspected (see Chapter 6). Following examination of
the bronchi and nasopharynx, the airway is sealed
with a well fitting, cuffed endotracheal tube, the seal is
tested and anterior rigid rhinoscopy performed under
saline irrigation to complete the examination.
Caudal (posterior, retropharyngeal)
rhinoscopy
Retropharyngeal posterior rhinoscopy is ideal for
direct examination of the retropharynx and posterior
nasal cavity. It is particularly useful for obtaining diag-
nostic tissue samples and for managing/re-assessing
the progress of problems over time. It is essential to
understand the normal anatomy (Figure 8.10) and to
distinguish normal from abnormal findings.
Caudal rhinoscopy is always performed prior to
anterior (rostral) rhinoscopy since contamination of
the nasopharynx with fluid, blood and discharge
resulting from the fluid irrigation used during ante-
rior rhinoscopy would otherwise compromise the
examination.
Instrumentation
A small flexible endoscope is required for posterior
rhinoscopy, to view the nasopharynx and choanae.
The endoscope must be capable of 180 degrees of
flexion. A 3.5 mm flexible bronchoscope is ideal for
cats and small dogs, although a larger endoscope
such as a gastroscope may be used in most dogs. In
the absence of a flexible endoscope, a dental mirror
can be used in conjunction with a light source and a
spay hook to pull the soft palate forward and view
over the soft palate towards the choanae. This is not
really feasible in cats and gives a limited view in large
dogs, but is better than nothing. However, it does not
allow biopsy sampling or the passing of instruments
into the nasopharynx. The soft palate can sometimes
be pulled forward sufficiently with a blunt spay hook
to reveal a foreign body and allow removal but this
does not obviate the need to examine the caudal
nares properly.
Patient preparation and positioning
Caudal rhinoscopy is commonly performed with the
patient in sternal recumbency, although there are
authors who advocate lateral positioning. The head is
propped up very slightly with towels to elevate the
mouth and nasal planum for easy access. A cuffed
endotracheal tube should be placed and checked to
ensure an adequate seal to protect the airway in the
event of haemorrhage or discharge. The caudal
pharynx can be additionally sealed with gauze
sponges or cut squares of feminine hygiene products
(see later).
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 Chapter 8 Rigid endoscopy: rhinoscopy

Nasopharynx
Oesophagus
Caudal nasal choanae

Nasal cavities

Soft palate

Tongue

Trachea
Oropharynx
Epiglottis

8.10 Anatomy of the retropharynx and posterior nasal cavity.

A mouth gag is essential to keep the mouth open

and prevent the patient biting down on to the
endoscope in the event of contact with the pharynx
stimulating a gag reflex.
Careful monitoring of blood pressure is needed
during rhinoscopy. Caution should be advised in
performing rhinoscopy in patients who are not cardio-
vascularly stable and are not normotensive.

Procedure
The flexible endoscope is inserted into the mouth and
the oral cavity, laryngeal apparatus and posterior
nasopharynx are evaluated. Advancing the tip of the
insertion tube towards the larynx, the free edge of the
soft palate should be passed and the endoscope
retroflexed into a ‘J’ position behind the soft palate to
view the nasopharynx (Figure 8.11a). The insertion
tube is then gradually withdrawn rostrally with the tip
still flexed, to advance the tip of the endoscope
towards the choanae (Figure 8.11b). The tip of the
endoscope can easily be viewed by transillumination
through the soft palate. As the endoscope is retro-
flexed, the view seen on the monitor is upside down
and reversed: up is down and left is right (Figure 8.12).
There is a strong gag reflex present during this
procedure, which can make manoeuvring frustrating
and difficult. This is normal and does not necessarily
mean that the patient is not anaesthetized deeply
enough. The use of topical lidocaine sprayed on to
the mucosal surfaces may help blunt this reflex, but it
should not be expected to go away. In addition,
bleeding is not uncommon due to the minor trauma Endoscope in retroflexed ‘J’ position. For
caused by the endoscope. If bleeding is expected, as 8.11
visualization of the caudal nasal choanae, the
with biopsy samples, it is recommended that a gauze endoscope must be advanced by pulling it toward the
collection system is placed in the caudal pharynx. endoscopist while keeping it retroflexed.

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 Chapter 8 Rigid endoscopy: rhinoscopy

Ventral 8.12 8.14

Normal retroflexed Haemorrhagic
view of the caudal discharge from the
nasal choanae and choana.
retropharynx.
(Courtesy of
RC Denovo)
Right Left

Dorsal
Normal appearance
During evaluation of the retropharynx, it should be
possible to visualize (Figure 8.13):
• The free edge of the soft palate
• The soft palate
• The mucosa of the dorsal nasopharyngeal wall
• The opening to the Eustachian tubes
• The choanae
• The nasal septum
• A number of the turbinates in the posterior
nasal cavity.
Normal dorsal
soft palate
Normal
nasal Normal
choanae dorsal
pharyngeal
mucosa
Normal endoscopic appearance of the dorsal
8.13
soft palate, the nasal choanae and the dorsal
pharyngeal mucosa. (Courtesy of D Levitan)
Healthy pharyngeal, palatal and retropharyngeal
tissue is usually smooth and pink, whilst diseased
tissue is often hyperaemic, irregular, friable or has
obvious masses or nodular changes. There should
be no obvious discharge from the choanae in the nor-
mal animal. Posterior nasal discharge, either haemor-
rhagic or mucopurulent, can sometimes be seen,
even in the absence of discharge from the anterior
nares (Figure 8.14), and is always pathological.
Raised nodules of benign lymphoid hyperplasia
(Figure 8.15) are quite commonly seen if sneezing
has been prolonged or if there has been some nidus
of chronic inflammation.
8.15
Nasopharyngeal
lymphoid
hyperplasia in a
Siamese cat. This
is commonly found
as the result of
chronic
inflammation.
Biopsy and other sampling
Biopsy samples may be taken from any mass or
abnormal tissue. Brushings and swabs may also be
taken for cytology or culture. Swabs or samples for
culture from the nasopharynx, choanae and nares
must all be taken before embarking on fluid-assisted
anterior rhinoscopy, since that procedure is likely to
contaminate the field and wash away debris and
infected material.
Biopsy samples can be obtained under direct
visualization using the endoscope. It is important to
remember that the endoscope should be removed
from the patient and the cytology brush, biopsy or
grasping forceps introduced whilst the tip of the
insertion tube is straight. The instrument should be
advanced until it is just at the tip of the insertion tube
before retroflexing the tube and taking the sample.
Forcing an instrument through a flexible tip in the 180
degrees flexed position, either to insert or withdraw it,
may cause expensive and often irreparable damage
to the endoscope.
Other methods occasionally used to obtain biopsy
samples include aggressive flushing techniques,
which may be especially useful for retropharyngeal
lesions. It is important to ensure that the endo-
tracheal cuff is properly inflated and that the pharynx
is packed with gauze due to the high volume of fluid
being flushed. An open-ended catheter, Foley cath-
eter or feeding tube can then be advanced retrograde
via the nares to the mass, and sterile saline flushed
manually with a syringe under high pressure.
Depending on patient size, 10–30 ml of fluid may be
instilled per flush. Any dislodged tissue can be
retrieved from the gauze used to pack the pharynx,
nares or oral cavity.

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WARNING
Caution should be exercised in taking nasal
swabs prior to anterior rhinoscopy, as this may
introduce iatrogenic artefacts that could be mis-
taken for pathology. Since true bacterial rhinitis
is rare, it may be advisable to forego swabbing
and to culture biopsy samples taken from spe-
cific sites during the rhinoscopy procedure.
Foreign body removal
Foreign bodies and tumours can be removed or
sampled accordingly. Foreign body retrieval from
the nasopharynx may be accomplished with a variety
of forceps that are made to fit through the biopsy
channel of the endoscope. In certain cases, nasal or
nasopharyngeal foreign material is best removed by
flushing. Flushing can be accomplished as described
above for diagnostic sampling. Grass that has passed
rostrally over the soft palate may be difficult to remove
via the pharynx due to the directional nature of the
hairs on the leaf itself. In these cases it is often better
to remove the leaf via anterior rhinoscopy to prevent
fragments breaking off and being left behind.
Rigid endoscopy
In some cases nasal masses at or near the choanae
can be better examined and treated using a rigid
endoscope via a pharyngostomy incision. A small
incision is made in the lateral pharyngeal pouch in the
same manner as when introducing a pharyngostomy
feeding tube. The 2.7 mm endoscope in the
cystoscopy sheath can then be introduced in a rostral
direction, giving excellent direct access to the area
above the soft palate.
Anterior (rostral) rhinoscopy
Instrumentation
Small-diameter flexible endoscopes with 2-way deflec-
tion can be used for anterior rhinoscopy and have the
advantage of easier manipulation into small crevices.
In some medium to large dogs this will allow access
to the frontal sinuses. A 2.7 mm 30 degree endoscope
and cystoscopy sheath (rhinoscope) can be used
in almost all dogs and in most cats. The oval cross-
section of the cystoscope allows easy non-traumatic
introduction into the nasal meatuses and provides for
excellent irrigation as well as an integral instrument
channel. Very small cats and kittens may require a
smaller diameter endoscope, such as a 2.4 mm or
even a 1.9 mm endoscope. These very small endo-
scopes are extremely fragile and will require a suit-
able sheath or cannula and instrumentation for any
procedure, so the cost of buying them for a minority of
cases may be prohibitive. A better solution is to invest
in an arthroscopy sheath for the 2.7 mm endoscope.
This sheath is round in cross-section and smaller
than the cystoscopy sheath, and so can be accom-
modated in smaller cats and dogs. The downside is
that there is no instrument channel, and instruments
must therefore be passed alongside the sheath in
order to take biopsy samples and so on.
Ch08 Endo.indd 117
Chapter 8 Rigid endoscopy: rhinoscopy
The disadvantages of flexible endoscopes are the
poor light transmission and image quality, coupled
with very small channel size, making diagnostic
sampling or debridement difficult. It is difficult without
a high-pressure fluid pump to flush sufficient saline
down the instrument channel to clear discharge and
haemorrhage, especially with additional diagnostic or
therapeutic instrumentation in place, so visualization
is easily compromised.
Rigid endoscopes provide a considerably better
view and allow larger instrumentation, enabling the
surgeon to obtain larger biopsy samples that provide a
much better diagnostic yield. The authors recommend
rigid endoscopes for nearly all rhinoscopy cases.
Patient preparation and positioning
Sternal recumbency is preferred as it reduces the
chance of contamination of one side by detritus from
the other, and the patient is in a more natural position
in relation to the image on the monitor. The operator
must be aware that they will be flushing with a lot of
fluid and there is likely to be some haemorrhage. If in
lateral recumbency the lower of the nares will become
filled with detritus, i.e. contaminated from above,
compromising adequate examination – so the lower
nostril should be examined first. If there is copious
discharge from one nostril, placing that side down will
prevent discharge from flowing into the less affected
side before there is a chance to examine it.
The procedure is best carried out on a wet table
due to the large volumes of irrigant used. A large tray
covered with a stainless steel grid will suffice if a wet
table is not available, and will save a lot of mopping
up! Towels placed on the floor are also useful to catch
additional spillage. Irrigation is usually provided with
bags of 0.9% saline fitted with standard giving sets. It
is best to avoid performing rhinoscopy in the sterile
operating theatre (Figure 8.16).
Theatre set up for rhinoscopy. The patient is in
8.16
ventral recumbency on a gridded table with the
chin resting on a rolled up towel. The monitor is positioned
at the caudal end of the patient, directly opposite the
surgeon.
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 Chapter 8 Rigid endoscopy: rhinoscopy
The head is propped up with towels to elevate the
nasal planum for easy access. Care should be taken
not to elevate the nose too much in an attempt to limit
the amount of excess irrigant accumulating around
the endotracheal tube cuff.
Procedure
Having examined the nasopharynx in detail, it is
important to ensure that the endotracheal tube is
well cuffed and forms a good seal with the trachea.
This is best done by gently applying pressure to the
rebreathing bag as the cuff is inflated and listening
for leakage around the endotracheal tube, so that a
good seal is achieved without overdue pressure on
the tracheal mucosa from the cuff. Large volumes
of fluids will be washed over the soft palate and
there will be a continuous flow of saline through the
nostril and out of the mouth. A gauze swab or a pad
may be placed over the larynx to protect the airway
from solid debris and clots, being careful not to
occlude the pharynx completely. Feminine hygiene
products can also be used for this purpose: their
high degree of absorbency, small size and low pro-
file are ideal. A single thin mini-pad is taken and cut
in half and a slit made in the centre. This slit is posi-
tioned around the endotracheal tube. If the patient is
larger, additional pads can be placed in the caudal
pharynx for additional absorbency. A nurse should
be charged with the task of remembering how many
pads were placed to ensure complete retrieval prior
to extubation.
The monitor is positioned at about the level of the
animal’s pelvis with the monitor facing cranially. Using
aseptic technique, the endoscope, light guide cable,
cannula/sheath and camera are assembled. (See
Chapter 2 for details of instrument sterilization
procedures.) A bag of sterile saline is hung and
connected to one of the stopcocks of the cannula;
3-litre bags, as used in large animal practice, are
preferred to avoid constantly changing bags. The
shaft of the cannula is coated with sterile water-
soluble lubricating jelly, being careful not to get any
on the lens of the endoscope.
The endoscope is held in ‘pistol’ fashion, with the
light guide cable and port facing towards the floor
and the camera oriented such that any graphics on
the camera head can be read right side up. This
will ensure that the image produced on the monitor
is true.
Rostral rhinoscopy may be carried out directly,
viewing the mucosa in air, or under vigorous saline
irrigation. Often the presence of copious discharge or
haemorrhage (iatrogenic or otherwise) obscures the
view and is difficult to remove with suction. In the
majority of cases the procedure is carried out under
saline irrigation as this washes away any debris or
haemorrhage and allows a clear view of the mucosa.
However, when viewing a relatively large cavity, such
as in the presence of extensive turbinate damage in
aspergillosis, or when entering the nasopharynx,
turbulence in the saline flow can obscure the view. In
these situations, turning off the saline flow and
reverting to direct viewing through air may greatly
improve visualization. It should be noted that the use
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Ch08 Endo.indd 118
of saline irrigation, especially with cold saline, tends
to blanch the mucosa somewhat, so the normal
appearance will be different in air to that under
irrigation. The nasal cavity is richly supplied with
blood vessels and is an ideal heat exchange
mechanism so in small animals, such as cats,
persistent flushing of the nasal cavity with cold saline
can significantly reduce core body temperature of an
anaesthetized patient, and this should be monitored if
the procedure is at all prolonged.
Control of saline flow is best adjusted with the tap
on the ingress port of the rhinoscope, so the normal
controls on the giving set may be left open.
Beginning with the normal or less affected side (as
determined by preoperative radiographs and clinical
signs), the nasal planum is deflected dorsally and the
endoscope introduced into the nose. Fluid flow is
started. The ventral nasal meatus is examined first
(Figure 8.17). Using a technique similar to that for
passing a nasogastric tube, the endoscope is pointed
ventrally and medially. Slowly, the endoscope is
advanced. The operator will appreciate the bony shelf
forming the separation between the middle and dorsal
meatuses. As the endoscope is advanced caudally,
the endoscope will fall off this shelf and into the ventral
nasal meatus. It should be possible to pass the
endoscope to the level of the posterior nares and
nasopharynx. On entering the nasopharynx, just
caudal to the posterior nares, the orifice of the
Eustachian tube can be seen on the lateral wall
(Figure 8.18a). The endoscope is retracted rostrally
and the dorsal meatus (Figure 8.18b) and ethmoid
turbinates (Figure 8.18c) examined.
8.17
Normal ventral
meatus. (a) Cat.
(b) Dog: note the
smooth pink
turbinates, which
appear almost to
interdigitate.
(a)
(b)
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 Chapter 8 Rigid endoscopy: rhinoscopy

8.18 8.19
(a) Normal Mucus is always
Eustachian tube abnormal in the
opening in the dog. anterior nares.
(b) Normal dorsal
meatus in the dog.
Note the smooth
vaulted
appearance.
(c) Normal
ethmoid turbinates
in the dog. Note the
corrugated
(a) appearance of the
turbinates on the
left compared with
the nasal septum
8.20
on the right.
Ulcerative/erosive
rhinitis with
generalized
swelling and
erythema of the
turbinates. Multiple
small erosions are
evident and bleed
easily on contact.

(b)

Haemorrhage is the bane of rhinoscopy and a

(c)
The mucous membrane should be uniform and
pink/red in colour with no obvious nasal discharge. If
thick mucus is present (Figure 8.19) and hampers the
view, it may be preferable to remove the endoscope
and forcefully flush the nose several times with saline
from a 60 ml catheter-tipped syringe before reintro-
ducing the endoscope. Alternatively, attaching a
20 ml or 60 ml syringe of saline to the free port on the
rhinoscope sheath allows more accurate direction of
a forced saline jet. It is important to close the other
ports first or the saline will be directed back up into
the bag or, worse, through the instrument port into the
surgeon’s face!
Haemorrhage occurring with little or no trauma
may be an indication of inflammation. In these cases
the meatuses are narrowed due to mucosal
congestion. Destructive rhinitis due to bacterial or
fungal infection leads to open enlarged airways and
may allow visualization of the duct into the frontal
sinuses. Ulcerative lesions (Figure 8.20) should be
noted as the endoscope is advanced for the first time,
to avoid confusion with any iatrogenic damage.
thorough examination must be completed before
biopsy samples are taken. Once the biopsy procedures
are initiated haemorrhage will be much more profuse
and will greatly obscure visualization and increase
observational artefact. Many authors and practitioners
have suggested remedies to the obfuscation that
bleeding produces but these have uniformly been of
limited value. These techniques include using very
cold refrigerated saline for irrigation and adding a
dilute solution of adrenaline (epinephrine) to the
irrigant, all in an effort to produce vasoconstriction.
Biopsy
Once a full initial exploration has been made, areas of
pathology are returned to and biopsy samples taken.
It is important to take samples from multiple sites, as
diagnosis is frequently based on histopathology and
there is little correlation between visual appearance
and specific disease entities (Johnson et al., 2004).
Inflamed mucosa can look similar with a wide range
of underlying pathology. Even normal nasal mucosa
bleeds tremendously, and that effect will be greatly
magnified by the camera. Aggressive irrigation is
imperative and, while all nasal mucosa is delicate and
tends towards haemorrhage, note should be taken of
tissue that seems to bleed easily.
Biopsy samples can be taken from the nasal
mucosa, polyps, masses, etc., at this time. The
operator can use either flexible cup-style biopsy
forceps that are introduced via the biopsy channel or
rigid biopsy forceps passed alongside the shaft of the
endoscope. Because of the highly reactive nature of
nasal mucosa, repeat and aggressive sample taking

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 Chapter 8 Rigid endoscopy: rhinoscopy
is advised. It is not unusual to find that histopatho-
logical evaluation of superficial tissues reveals only
inflammation, while deeper samples reveal more
problematic pathology. It is often helpful to take
several samples at the same spot – going through the
same hole into deeper and deeper tissues to ensure
a diagnostic sample has been achieved.
If the operator is not satisfied that he/she can get a
representative sample, it is advisable to use larger
biopsy forceps alongside the endoscope, since the
biopsy forceps designed to pass through the instru-
ment channel may be too small to get a representative
sample from deeper tissues. In these cases, 3 mm
biopsy forceps are passed along the dorsal edge of
the rhinoscope, opposite the light guide post (i.e. into
the field of view of the 30 degree endoscope) to the
site of interest. In smaller patients where it is not pos-
sible to pass forceps alongside the endoscope sheath,
it is useful to measure the position of the lesion by
assessing the direction and depth of the tip of the
endoscope, and taking samples ‘blind’. This allows
larger samples to be taken. Markings on the endo-
scope sheath allow a measurement of depth, and the
tip of the endoscope can often be seen by transillumi-
nation through the rhinarium if the room lights are kept
low. A pair of 3–5 mm biopsy forceps can then be
placed to the same premeasured depth and direction,
to obtain a large sample. It is very important, if using
this technique, to ensure that the tips of the biopsy
forceps do not pass beyond the level of the medial
canthus of the eyes. Measuring this position on the
outside of the rhinarium and marking it with a piece of
sticky tape on the forceps themselves will prevent
inadvertent penetration of the cribriform plate and sub-
sequent trauma to the frontal lobes of the brain.
Samples that have spicules of turbinate bone in
them are demonstrative of aggressive technique,
which is necessary if sufficiently deep, diagnostic
samples are to be obtained. Samples should be care-
fully placed on foam-lined endoscopic tissue cas-
settes and sent for evaluation by veterinary
pathologists experienced in the processing and eval-
uation of endoscopic samples. Biopsy samples taken
through the rhinoscope channel are necessarily small,
and can get lost in a large pot of preserving fluid or
overlooked by the histopathologist. ‘Cell-safe’ frames
(Figure 8.21) available from the external laboratory
are ideal for endoscopic samples. Biopsy specimens
are placed in the frames, which are then clipped shut
before being placed in the preservative for transport
to the laboratory. The frames are two-sided and can
be clipped together on either side, one side giving a
larger space than the other, in order to cater for differ-
ent sample sizes. The samples are fixed and pre-
pared in the frames at the laboratory, so there is no
danger of any specimens going astray. Larger sam-
ples should be left free-floating and not placed in
these frames as they may be crushed, creating com-
pression artefacts. If the sample recovery process
has been relatively atraumatic and sterile, a sample of
mucosa can be sent in sterile fashion for bacterial
culture and sensitivity testing. Interpretation must be
made cautiously, as even the best of technique rarely
maintains complete sterility in this anatomical locale.
120
Ch08 Endo.indd 120
8.21
‘Cell-safe’ frames are
ideal for preserving
small endoscopic
samples.
WARNING
Care should be exercised if using cold irrigant
solutions, especially in small patients. The
high surface area and excellent vascular
supply of the nares act like a heat sink and can
result in hypothermia if the procedure is
prolonged. Careful monitoring of core body
temperature is advisable.
Frontal sinus exploration
If the frontal sinus is diseased, based on prerhinoscopy
work-up, in particular CT, MRI or radiography (frontal
sinus skyline view), it is prudent to examine it endo-
scopically. A 2 cm x 2 cm square area at the level of the
top of the orbit, just medial to the bony prominence, is
clipped and aseptically prepared. A hole is drilled or
trephined using a Steinmann pin and Jacobs chuck, a
Hall-type air drill or a Michel trephine. The hole should
be just large enough to accommodate the endoscope
and cannula. Care needs to be taken to avoid going
too far into the sinus. The space is deceptively small,
and the wall on the far side of the sinus separates the
sinus from the calvarium. It is the authors’ experience
that, because of the relative paucity of the membranes
of the sinus as compared with the nose, the diagnostic
yield from biopsy samples taken in the frontal sinus
may be greater than for the nose when there is radio-
graphic evidence of disease in both locations.
The endoscope is introduced into the sinus and
the walls of the sinus explored. Between 5 and 7
o’clock to the point of entry into the sinus is the
aperture of the sinus into the caudal pharynx. The use
of an appropriately sterilized flexible endoscope can
facilitate examination of this small opening. In the
diseased state the aperture can be much larger,
allowing a rigid rhinoscope to be introduced, or even
allowing a flexible endoscope to be advanced
transorally or transnasally into the sinus.
Therapeutic irrigation is performed to flush the
sinus adequately. The hole is closed with a simple
interrupted skin suture and no attempt is made to
replace the resected core of bone.
Pathological conditions
This topic is covered in some depth in the BSAVA
Manual of Canine and Feline Head, Neck and Thoracic
Surgery, and the reader is referred to that publication
for additional coverage. Common conditions found in
dogs and cats are summarized in Figure 8.22.
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 Chapter 8 Rigid endoscopy: rhinoscopy

Disease Species Causes Characteristics Treatment

Lymphoplasmacytic Dogs, cats Allergy; viral/bacterial; secondary to Common. Chronic Steroids; antibiotics based on culture and
rhinitis obstructive nasal disease or foreign discharge, sneezing sensitivity; nasal drops often more
body effective

Dental disease Dogs, cats Periodontal disease; fistulas; apical Common Appropriate dental treatment, e.g.
granuloma extraction

Foreign bodies Dogs, cats Grass; grass seeds; sticks; etc. Common Removal by traction

Traumatic disease Dogs, cats Uncommon As appropriate

Nasopharyngeal Dogs, cats Uncommon Surgical: balloon dilation; stent

stenosis

Coagulation disorders Dogs, cats Genetic; drug-induced; Uncommon Medical

hyperadrenocorticism

Parasitic rhinitis Dogs, cats Capillaria aerophila Rare Ivermectin

Dogs Pneumonyssoides caninum Rare Ivermectin

Allergic rhinitis Dogs Rare Corticosteroids: systemic ± nasal drops

Ciliary dyskinesia Dogs Rare Palliative: mucolytic agents (bromhexine

hydrochloride 2 mg/kg q12h in dogs;
1 mg/kg q12h in cats)

8.22 Common nasopharyngeal conditions of dogs and cats.

Nasopharyngeal conditions 8.24

Foreign bodies are not infrequently found lodged in
(a) Aspergillus
the nasopharynx, having been coughed up over the colonies at the
free edge of the soft palate (Figure 8.23). Smaller or choanae, viewed
narrow foreign bodies, such as grass awns, may by posterior
travel rostrally down the nares and can be extracted rhinoscopy. The
using anterior rhinoscopy. endoscope is
retroflexed through
180 degrees,
8.23 giving an inverted
A blade of grass image, so this
(a) colony is in the
lodged in the
nasopharynx of a right nostril.
cat dorsal to the (b) Posterior
soft palate. rhinoscopic view
of nasal
lymphosarcoma in
a dog (same dog
as in Figure 8.28).
Note the similarity
in appearance
to (a).

(b)

In chronic rhinitis it is not unusual to see lymphoid
hyperplasia throughout the pharynx, presenting as
multiple small raised nodules in the mucosa (see
Figure 8.15). This is purely reactive and should not be
mistaken for underlying pathology.
Fungal plaques of Aspergillus can sometimes be
seen at the choanae, but the most common finding at
this site is neoplasia (Billen et al., 2006). In some
cases fungal infection may be mistaken for neoplasia
and vice versa (Figure 8.24), so diagnosis must be
based on impression smears or biopsy.
In cats auropharyngeal polyps may be seen
emerging from the Eustachian tubes and can
sometimes be exposed using a blunt spay hook to
pull the free edge of the soft palate rostrally. Gentle
traction may be all that is required for removal.
Alternatively, this can be accomplished more easily in
some cats via anterior rhinoscopy.
Rarely, nasopharyngeal stenosis is found as a
sheet of tissue almost completely occluding the
nasopharynx. This can be resected with sharp dis-
section or using a diode laser. Alternatively balloon

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 Chapter 8 Rigid endoscopy: rhinoscopy
dilation may be attempted (Berent et al., 2006),
although strictures tend to reform and repeat treat-
ments may be necessary.
Allergic rhinitis
Histopathologically this disease may present in
several forms. Any combination of lymphocytic,
plasmacytic, lymphoplasmacytic or eosinophilic
rhinitis is suggestive of primary immunological
disease. It is critical to be confident that there is no
other primary disease process concurrent to make
this diagnosis. Idiopathic lymphoplasmacytic rhinitis
is also considered to be a relatively common cause of
chronic nasal discharge in the dog and is often a
bilateral disease, even where nasal discharge is
unilateral (Windsor et al., 2004).
Corticosteroid therapy has been the mainstay of
treatment for years. Treatment is usually started at
2 mg/kg prednisolone q12h. Experience has shown
that this early aggressive immunosuppressive therapy
makes relapses later in the taper period less likely. The
dose is tapered after 3 weeks, to once-daily treatment.
Often, when steroids are the sole therapy, the induc-
tion phase of treatment can take up to 6 months. In the
authors’ experience, topical treatment using cortico-
steroid drops available for ophthalmic use can be more
effective in some cases than oral treatment, but this
does require a cooperative patient, and nasal drops
are often resented and difficult for owners to administer
in the longer term. The recent advent of steroid inhal-
ers adapted for small animal patients has made them a
more attractive option for some patients.
For patients that are poorly tolerant of steroid
therapy, a lower dose of prednisolone can be used in
conjunction with chlorambucil at a dose of 2 mg/m2
every other day. Complete blood counts should be
performed every 2 weeks to watch for leucopenia.
More frequently, with the standardization of serum
allergy testing, it has become possible to identify some
environmental allergens that may play a role in the
pathogenesis of this disease. If substantial positive
results are obtained to allergens that are likely to be in
the patient’s environment, then hyposensitization
therapy may be instituted. This takes substantial client
compliance, but when successful, this safe well
tolerated therapy may provide an opportunity to use
minimal immunomodulatory drug therapy.
Bacterial rhinitis/sinusitis
Primary bacterial rhinitis is rare in dogs and cats. When
a primarily suppurative response is noted on histo-
pathology, and no other infectious or neoplastic dis-
ease is apparent, then a diagnosis of primary bacterial
disease can be made. The clinician should always be
circumspect in making a diagnosis of primary bacterial
rhinitis. It is critical to obtain good quality samples for
bacterial culture. Both exudate and tissue should be
submitted for analysis, from multiple locations in the
nose, to confirm the presence of a single or multiple
infectious agent(s). Interpretation of these results to be
sure that the findings are not consistent with contami-
nation is necessary. When an appropriate drug is iden-
tified against the offending organism(s), long-term
antibiotic therapy is often indicated.
122
Ch08 Endo.indd 122
Unfortunately, bacterial rhinitis is one of the more
frustrating bacterial diseases to treat, and clinicians
are often forced to resort to more extreme measure to
rid their patients of the disease. Turbinectomy is an
aggressive alternative therapy to refractory rhinitis in
dogs (while this can be done in cats, they seem to
tolerate the procedure far less well). Traditionally, this
procedure has been performed in association with an
open rhinotomy. The turbinates are then removed
using rongeurs or a similar device. The rostrum can
then be left open for a period of time to allow for daily
irrigation with antimicrobial solutions before primary
closure at a later date. A similar procedure has been
attempted and is being refined using endoscopic
techniques. Using an arthroscopic shaver system (a
mechanized rotating shaving device, with a small
diameter, designed for curetting bone and cartilage
during arthroscopy) a turbinectomy can be performed
without the need for the rhinotomy. The debrided
debris is removed via the suction function of the
shaver. Different blades are available to ensure
adequate curettage. As a more refined and complete
turbinectomy can be performed with this technique,
less bleeding and postoperative pain is likely to be
encountered. Further experience is needed with this
technique before it can be routinely recommended.
Foreign body rhinitis
Nasal foreign bodies are common in both dogs (Figure
8.25) and cats. The presentation in these patients
tends to be variable, but chronic mucopurulent nasal
discharge is a common feature. Radiographically, the
soft tissue densities noted may mimic mass effects.
When rhinoscopy is performed, if the offending mate-
rial is not noted at first glance, often the only obvious
findings are thickened oedematous proliferative
mucous membranes, with substantial mucopurulent
exudates. If biopsy is performed on these tissues, the
results are likely to come back as lymphoplasmacytic
rhinitis, often with an eosinophilic or a secondary
neutrophilic component. These results can be mis-
leading and foreign material must be suspected in
cases of rhinitis that do not resolve with therapy and
that would be appropriate for the histopathological
findings. Often, multiple rhinoscopic examinations or
open nasal exploratory operations are needed to
identify the foreign material. It is worth noting that by
the time rhinoscopy is performed the offending for-
eign body has often been sneezed out and the result-
ant foreign body reaction is the only lesion seen by
the surgeon.
8.25
(a) A piece of stick
embedded in the
nose of a spaniel
(middle of the
image).
(continues)
(a)
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 Chapter 8 Rigid endoscopy: rhinoscopy

foreign bodies such as grass seeds or running on to

bits of stick.
Plant material may become very friable after a
few days incubating in a warm moist nose and,
particularly if it is barbed or rough in texture, may
be difficult to remove intact. Barbed material will
often move only in one direction and should be
removed accordingly. If the foreign body breaks up
and is impossible to remove completely, the nose
should be flushed vigorously with 60 ml of sterile
saline on each side. The throat pack should be
removed to allow fluid to drain over the soft palate
into the mouth freely (a small swab may be left over
the larynx if there is room) and the nose lowered to
allow drainage. The endotracheal cuff should be
checked to ensure a snug fit and the tip of a 60 ml
syringe introduced into the nostril. The nostril is
pinched tight around the syringe and the saline
instilled as fast as possible. Debris collected via the
mouth can be examined for further detritus. The nose
may also be flushed in a rostral direction by placing a
Foley catheter up over the soft palate, inflating the
bulb and packing the pharynx with gauze swabs to
form a seal. The procedure may be repeated on the
other nostril if necessary.

(b)
(continued) (b) A piece of stick following
8.25
removal from the nose of a spaniel.
Cats tend to present with nasopharyngeal foreign
bodies, such as grass, which have been inadvertently
coughed up over the soft palate into the caudal nares,
from where sneezing may allow passage to a variable
degree down the rhinarium. Dogs may suffer in a
similar manner but are also more prone to sniffing up
Neoplasia
It is beyond the scope of this Manual to give a detailed
treatise of the oncological management of nasal
neoplasia, and the reader is referred to the BSAVA
Manual of Canine and Feline Oncology. However, a
brief overview of the common nasal cancers (Figure
8.26) is in order. Many nasal tumours are locally
invasive and slow to metastasize. However, the gross
appearance is often misleading and histology is
always required to differentiate between benign
polyps and malignancies. Tumours may be staged to
help predict likely prognosis (Figure 8.27).

Site Disease Age affected Characteristics Treatment

Neoplasia of the Most commonly Middle–old age Locally invasive slow to metastasize Surgical resection ± radiation therapy
nasal planum squamous cell carcinoma dogs and cats

Nasal cavity Adenocarcinoma Middle–old age Locally invasive slow to metastasize Surgical resection ± radiation therapy
– dogs
Chondroscarcoma Middle–old age Locally invasive slow to metastasize Surgical resection ± radiation therapy

Osteosarcoma Middle–old age Locally invasive slow to metastasize Surgical resection ± radiation therapy

Squamous cell carcinoma Middle–old age Locally invasive slow to metastasize Surgical resection ± radiation therapy

Melanoma Middle–old age Locally invasive slow to metastasize Surgical resection ± radiation therapy

Lymphosarcoma Young–middle May be generalized Chemotherapy ± local debulking

age

Nasopharyngeal polyp Middle–old age Benign, recurrent Traction, surgical removal

Nasal Lymphosarcoma Young–middle May be generalized Check other sites and FeLV/ FIV status
cavity – cats age

Adenocarcinoma Middle–old age Locally invasive slow to metastasize Surgical resection ± radiation therapy

Nasopharyngeal polyp Middle–old age Benign, recurrent Traction, surgical removal

8.26 Common nasal tumours of dogs and cats.

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 Chapter 8 Rigid endoscopy: rhinoscopy

unless vital head structures are likely to be com-

Stage Presentation Prognosis promised by local invasion. The benefits, however, of
tumour debulking may be significant to the patient
I Unilateral Reasonable medium term with who is experiencing substantial facial/nasal pain and
surgery/radiation
difficulty breathing. The authors have used endoscopic
II Bilateral Guarded medium term with laser diode surgery to effectively debulk this type of
surgery/radiation tumour in over 60 patients. The procedure is well
tolerated, and while by no means curative, many
III Associated external Guarded short term with
mass surgery/radiation
patients achieve substantial clinical improvement.
The tumour is radiation sensitive, although cobalt
IV Brain involvement Poor prognosis linear accelerators are likely to be more effective than
orthovoltage radiotherapy. More and more success is
being reported using chemotherapy as monotherapy.
8.27 Tumour staging.
Carboplatin is used at a dose of 30 mg/m2 every
3 weeks for 3 cycles. The drug is very well tolerated,
not aggressively nephrotoxic, and easy to administer.
Lymphoma Its limiting factor is cost. There is an increasing body
Nasal lymphoma (Figure 8.28) is an occasional of evidence that photodynamic therapy may be of
manifestation. When it does occur, nasal presentation value in treating these tumours. This therapy is not
is almost always the singular manifestation. Rarely is routinely clinically available.
it multicentric. Nasal lymphoma can be treated with a
standardized L-COPA protocol with moderate
success. The authors’ anecdotal observation is that 8.29
nasal lymphomas are more frequently of a large
lymphoblastic type, and are more locally aggressive, Adenocarcinomas
in the dog.
although not as aggressively metastatic. (a) Appearance of
an adenocar-
cinoma at the
8.28 choanae viewed in
air. (b) Opaque
Nasal
irregular pale
lymphosarcoma in
adenocarcinoma
a Rottweiler.
with swelling and
(a) Initial
erythema of the
appearance of the
(a) surrounding
lesion. (b) Cut
turbinates.
surface of the
(c) Same dog as
lesion following
in (a) showing the
biopsy. Note the
appearance of an
‘cotton wool’
adenocarcinoma
appearance.
under irrigation.
The adenocar-
(a) cinoma is pale and
relatively smooth
and translucent
(compare with b),
giving the
appearance of a
polyp.

(b)

(b)

Adenocarcinoma
Nasal adenocarcinoma (Figures 8.29 to 8.32) is an
aggressive tumour of the glandular epithelium of the
nasal passages. Some surgeons have suggested
surgical debulking of these tumours prior to adjunctive
therapy but results do not bear out the utility of this
(c)
approach. Surgery should not routinely be considered

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 Chapter 8 Rigid endoscopy: rhinoscopy

8.30 Melanoma
Nasal melanoma is an unusual extension of melano-
Adenocarcinoma in mas of the skin of the rostrum and/or the mucocuta-
a cat showing pale
lobulated neous junction. This type of tumour is radiosensitive.
appearance and
vascularity. Chondrosarcoma
This is a frequent nasal tumour (Figure 8.33). Its
major clinical manifestation is based upon its space-
occupying nature. Whilst the tumour is not highly
metastatic, it is locally aggressive, and can cause

8.33
Nasal
chondrosarcomas
8.31 in the dog. Nasal
masses can
Nasal present with a
adenocarcinoma at variety of
the choanae appearances:
viewed by (a) well delineated
(a) posterior and vascular;
rhinoscopy and (b) poorly
(b) anterior delineated and
rhinoscopy. Note invasive;
the difference in (a) (c) ulcerative; and
appearance when (d) pale, almost
(a) viewed under translucent and
saline irrigation. relatively avascular.
Histopathology is
always required for
diagnosis as the
morphology is so
varied.

(b) (b)

8.32
Biopsy of
adenocarcinomas.
(a) At the choanae,
using posterior
rhinoscopy. The
biopsy forceps
should be
preplaced at the tip
of the endoscope
before retroflexing
(a) around the free (c)
edge of the soft
palate to prevent
damage to the
biopsy channel.
(b) Nasal
adenocarcinoma,
using anterior
rhinoscopy.

(b) (d)

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 Chapter 8 Rigid endoscopy: rhinoscopy

tremendous damage to facial symmetry and normal 8.35

functional anatomy of the nose and head. Again, laser
debulking (Figure 8.34) is potentially of some benefit. Osteosarcomas in
the cat: (a) at the
However, since these are relatively avascular choana; (b) well
tumours, response to laser debulking alone is often circumscribed
disappointing, with palliation resulting from removal of vascular nasal
overlying inflammatory tissue. A combination of laser mass; and
debulking with aggressive curettage removes more (c) pale, friable,
tumour tissue. Aggressive surgery could theoretically relatively avascular
appearance of a
be considered curative, but getting clean surgical nasal mass.
margins in this anatomical region is very difficult. The
tumour is moderately radiosensitive. (a)

8.34
Laser debulking of
a nasal
chondrosarcoma in
a dog.

(b)

Osteosarcoma
In the nose (Figures 8.35 and 8.36) this type of tumour
behaves similarly to osteosarcomas of the flat bones
elsewhere in the body. It is less aggressive and less
metastatic than those in the long bone, but its local
damage is considerable. Palliative surgical therapy
can be undertaken to improve nasal respiration, but
fair to good success is reported with either carboplatin
(30 mg/m2 q3weeks for 4 cycles) as monotherapy, or
in conjunction with doxorubicin (300 mg/m2) given 4 (c)
days or so prior to the carboplatin. While the use of
doxorubicin increases the potential toxicity of the
treatment (increased myelosuppression and cardio- 8.36
toxicity) its potential efficacy is controversial. The Osteosarcomas in
author does try and employ this protocol, as the two the dog: (a) at the
drugs do appear to have a synergistic cell cycle choana; (b) nasal.
benefit. Whether this is borne out statistically remains
to be seen.
Of the benign processes, both chondromas and
osteomas are occasionally seen. If they are identified
early, and surgical removal can be achieved, along
with appropriate reconstructive techniques, prognosis
can be good.
(a)
Nasopharyngeal polyps
Nasopharyngeal polyps are fairly common, especially
in cats. Often an endoscope is not necessary to
visualize them (Figure 8.37); however, when they are
small, an endoscope is useful (Figure 8.38).
These inflammatory tissues can originate in the
Eustachian tubes, the middle ear, or the ventral nasal
meatus. They can be associated with chronic inflam-
matory conditions (chronic otitis, chronic rhinitis), but
are often idiopathic. When found nasopharyngeal pol-
yps are almost always attached to the underlying tis-
(b)
sues by a thin fibrous stalk. As such, grabbing them

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 Chapter 8 Rigid endoscopy: rhinoscopy

8.37 with forceps (e.g. tonsil forceps) and applying gentle

continuous traction, almost always removes them.
(a) A When they originate within the rhinarium, laser (or
nasopharyngeal
polyp seen during electrocautery) resection can be attempted. Removal
examination above is curative, but new polyps can occur.
the soft palate with
a spay hook.
(b) The polyp after Fungal rhinitis topical therapy
removal. (Courtesy
of RC Denovo) Aspergillus is the most common nasal fungal
pathogen in the dog (and in the cat, although it is very
rare in that species; Figure 8.39) and should be
(a) suspected any time there is chronic non-resolving
rhinitis, especially with radiographic evidence of bony
destruction, mimicking neoplasia. Fungal serology is
usually included as part of the medical work-up (see
above). Swelling and depigmentation of the nasal
planum (Figure 8.40a), coupled with a mucopurulent
nasal discharge, epistaxis and pain over the rhinarium
are common clinical presenting signs.

Species Fungal Age Characteristics Treatment

(b) affected pathogens affected
Dogs Aspergillus Any Chronic unilateral, Debridement +
– and fumigatus then bilateral clotrimazole or
8.38 rarely (A. niger; mucopurulent enilconazole
cats A.nidulans; nasal discharge ± infusion
Benign nasal A. flavus; epistaxis; facial (oral
polyps in the dog. A. terreus) pain itraconazole)
(a) At the choanae
the appearance Cats Cryptococcus Any Chronic unilateral, Debridement +
may be vascular – and spp. then bilateral clotrimazole or
and erosive, rarely mucopurulent enilconazole
dogs nasal discharge ± infusion
especially in the epistaxis; facial (oral
presence of pain itraconazole)
secondary
infection. With Fungal infections of the nasal tract in dogs and
(a)
anterior rhinoscopy, 8.39
cats.
polyps may be
(b) single and
confined to a small
area or (c) present
throughout most of
the nasal passage.

(b)

(a)
(a) Swelling and depigmentation of the nasal
8.40
planum, characteristic of Aspergillus infection,
(c)
in a German Shepherd Dog. (continues)

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 Chapter 8 Rigid endoscopy: rhinoscopy

Treatment with oral fungicides such as itraconazole

at 5 mg/kg q12h is both expensive and potentially
hepatotoxic. Serial blood chemistries must be
obtained to be vigilant with regard to liver disease,
and therapy must be continued for 2–3 months.
Success rates as high as 60–70% have been reported
for oral treatment alone but this can be greatly
improved if used in conjunction with non-invasive
topical treatment (Smith et al., 1998). This compares
favourably with surgical trephination of the sinuses in
order to place indwelling cannulae in the frontal
sinuses for the application of antifungal solutions
(Mathews et al., 1998). Treatment will normally
require general anaesthesia, and can be carried out
following rhinoscopic diagnosis. It is imperative to
debride carefully as much of the fungal plaque as
possible under direct observation, prior to antifungal
treatment (Figure 8.42). This allows good exposure of
(b) remaining fungal material to the antifungal solution.
Failure to remove fungal plaques is the most common
(continued) (b) Resolution of swelling and
8.40
depigmentation 1 month after initial treatment. reason for poor response to treatment. Following
good debridement it should be possible to resolve
The rhinoscopic appearance is quite characteristic 85–90% of cases with a single treatment.
(Figure 8.41) and diagnosis is easily confirmed in the
laboratory from impression smears and/or culture. 8.42
Nasal Aspergillus
8.41 plaque (a) before
and (b) after
Nasal aspergillosis. debridement.
(a, b) Colonies in
the noses of two
dogs: (a)
demonstrating the
classic white
plaques; and (b)
showing a greenish
tinge due to
secondary (a)
infection. Note the
(a) extensive turbinate
damage, leading to
an abnormally
large airspace. In
(a) turbinate
destruction has
exposed the frontal
sinus and
Aspergillus
plaques can be
seen within the
sinus cavity (rear of
the image).
(c) Close-up view (b)
(b) of the Aspergillus
colony showing the
‘cotton wool’
appearance of the
Following debridement, the throat pack is removed
fungal hyphae. and a suitably sized Foley catheter introduced through
the mouth and retroflexed over the soft palate. The
bulb of the catheter is inflated with saline to seal off
the caudal nares from the pharynx, and a further
gauze throat pack is placed to ensure a good seal.
Tampons may also be used to good effect. A canine
urinary catheter or red rubber feeding tube is
introduced into each nostril, and a small Foley
catheter is then introduced alongside it such that the
bulb is just inside the nares. The bulbs are then
(c)
inflated with saline to seal off the nares and the Foley

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8.43 Treatment for nasal aspergillosis using an intranasal infusion of enilconazole.
catheters are all clamped shut. The nares may require
further sealing with cotton wool, cotton buds or
tampons to ensure a good seal. Enilconazole has
been used as a nasal infusion, and has been
demonstrated to be 80–90% effective, but in the
United States is available only in the chemical grade
solution, is difficult to obtain, and is very caustic to
healthy tissues. It is freely available in the UK, where
it is marketed as an antifungal wash for horses and
dogs. Enilconazole is more active in vapour form than
clotrimazole and gives good results. Care must be
taken to carefully pack off the oral and pharyngeal
cavities to minimize contact with healthy tissues.
Clotrimazole has been used extensively in the USA to
good effect and is available as a solution. The drug is
readily available in a pre-made propylene glycol
solution (marked for human athlete’s foot fungus) or
as a gel and is available without prescription.
WARNING
Formulations of clotrimazole containing alcohol
should be avoided.
Two 60 ml syringes are filled with 1–5% enilcon-
azole (or 1% clotrimazole) and attached to the urinary
catheters; 15 ml of enilconazole is then infused into
each nostril for 15 minutes. The dog is then rotated
through 90 degrees (e.g. into left lateral recumbency)
and the process repeated for 15 minutes. The dog is
Ch08 Endo.indd 129
Chapter 8 Rigid endoscopy: rhinoscopy
then rotated again into dorsal recumbency and finally
into right lateral recumbency, allowing 15 ml and 15
minutes each time. In this way almost all the nasal
mucosa and sinuses should be bathed in the
antifungal solution (Figure 8.43).
The remaining solution is drained as far as
possible through the anterior nares. Enilconazole and
clotrimazole can irritate the trachea, larynx or
oesophagus, so care should be taken to avoid
drainage back into the pharynx as much as possible.
One treatment is successful in 85–90% of cases but
some dogs may require two or three treatments for a
cure. It is always advisable to repeat the rhinoscopy
after one month (Figure 8.44) to assess the
effectiveness of treatment and repeat if necessary.
8.44
Same dog as in
Figure 8.42b, one
month after a single
enilconazole
treatment. No
fungal plaques are
visible.
129
30/04/2013 09:22
 Chapter 8 Rigid endoscopy: rhinoscopy
In some cases fungal infection may extend into
the sinuses or may even be restricted to the sinuses
with no fungal plaques to be seen on anterior
rhinoscopy. If there is evidence of disease in the
frontal sinus(es) small holes are trephined and fungal
plaques removed as before. A Michel trephine,
Steinmann pin and Jacobs chuck or Hall air drill can
be used for this purpose. Red rubber feeding tubes
are inserted, and the skin closed around the tubes to
reduce leakage. The antifungal solution is then
infused into the frontal sinuses and nasal passages,
initially with a dose of 30 ml to each side, under
pressure, and the treatment continued as before. This
topical therapy is generally well treated, with only mild
cutaneous reactions reported at the sites of infusion.
Postoperative care
Having completed the examination of the nares and
the sinuses if necessary, and taken any samples, the
endoscope is removed. If bleeding is heavy it may be
pertinent to maintain the patient under anaesthesia
for a few minutes until it has subsided. Recovery from
anaesthesia should be slow to avoid exacerbating
nasal bleeding. A postoperative dose of acepromazine
may also be given to keep the blood pressure low and
prevent excitement, thereby reducing postoperative
haemorrhage. The nose is then lowered and the
throat packing removed and the nasopharynx
swabbed or suctioned before extubation. Extubation
is left until the last minute to ensure gag and cough
reflexes will protect the airway, and the tube is
removed with the cuff partially inflated.
Some practitioners advocate cold irrigants,
infusion of dilute adrenaline or pseudoephedrine or
packing the nose to limit haemorrhage. In any event,
bleeding tends to be ongoing for several hours post-
rhinoscopy. The addition of irrigant fluid to the mucus
and blood tends to make the haemorrhage look worse
than it really is, but the inevitable sneezing that occurs
post-rhinoscopy can be alarming. In the non-
coagulopathic patient ongoing haemorrhage is rarely
of concern. If the practitioner is concerned about
potential blood loss, serial packed cell volumes can
be examined. It is prudent to advise owners to allow
for overnight hospitalization or at the very least to be
aware of the messy nature of the first day or so post-
rhinoscopy. Bleeding generally abates within 72
hours. There is inevitably some postoperative
mucosal swelling and owners should be warned that
the patient’s breathing may be worse for a day or two
postoperatively.
Postoperative discomfort in dogs and cats is
managed with buprenorphine (10–20 µg/kg i.m. q2h)
or morphine (0.2–0.5 mg/kg i.m. q2–4h). Ongoing
pain relief in dogs is provided with non-steroidal anti-
inflammatory drugs such as meloxicam (0.1 mg/kg
p.o. q24h) or carprofen (2 mg/kg p.o. q24h). ‘Off-label’
use of meloxicam at 0.05 mg/kg p.o. q24h may be
130
Ch08 Endo.indd 130
used with caution. In selected cases a single dose of
dexamethasone (0.2 mg/kg i.v., i.m.) can be given to
reduce mucosal swelling.
Complications
Haemorrhage is the commonest complication of this
procedure, but is rarely long lasting or significant. A
postoperative dose of acepromazine can help reduce
haemorrhage by reducing blood pressure and ensur-
ing a calmer recovery. Overnight hospitalization allows
a chance for haemorrhage to resolve adequately
before the excitement of returning to anxious owners
raises blood pressure and potentially dislodges a clot.
Aspiration of fluid and detritus can be prevented
by ensuring adequate inflation of the cuff on the
endotracheal tube and packing the pharynx with
gauze sponges, leaving enough space for free flow of
fluid over the free edge of the soft palate and out
through the mouth. The nose should be lowered as
the endotracheal tube is removed to prevent
accumulation of blood or fluid in the pharynx.
References and further reading
Berent AC, Kinns J and Weisse C (2006) Balloon dilatation of
nasopharyngeal stenosis in a dog. Journal of the American Veterinary
Medical Association 229, 385–388
Billen F, Day MJ and Clercx C (2006) Diagnosis of pharyngeal disorders
in dogs: a retrospective study of 67 cases. Journal of Small Animal
Practice 47, 122–129
Freeman LJ (1999) Veterinary Endosurgery. Mosby, St Louis
Johnson LR, Clarke HE, Bannasch MJ and De Cock HEV (2004)
Correlation of rhinoscopic signs of inflammation with histologic
findings in nasal biopsy specimens of cats with or without upper
respiratory tract disease. Journal of the American Veterinary Medical
Association 225, 395–400
Johnson LR, Drazenovich TL, Herrera MA and Wisner ER (2006) Results
of rhinoscopy alone or in conjunction with sinuscopy in dogs with
aspergillosis: 46 cases (2001–2004). Journal of the American
Veterinary Medical Association 228, 738–742
Lefebvre J, Kuehn NF and Wortinger A (2005) Computed tomography as
an aid in the diagnosis of chronic nasal disease in dogs. Journal of
Small Animal Practice 46, 280–285
Mathews KG, Davidson AP, Koblik PD et al. (1998) Comparison of topical
administration of clotrimazole through surgically placed versus
nonsurgically placed catheters for treatment of nasal aspergillosis in
dogs: 60 cases (1990–1996). Journal of the American Veterinary
Medical Association 213, 501–506
McCarthy TC (2005) Veterinary Endoscopy for the Small Animal
Practitioner. Elsevier Saunders, St Louis
Saunders JH, Clercx C, Snaps FR et al. (2004) Radiographic, magnetic
resonance imaging, computed tomographic, and rhinoscopic features
of nasal aspergillosis in dogs. Journal of the American Veterinary
Medical Association 22, 1703–1712
Smith SA, Andrews G and Biller DS (1998) Management of nasal
aspergillosis in a dog with a single, noninvasive intranasal infusion
of clotrimazole. Journal of the American Animal Hospital Association
34, 487–492
Tams TR (1998) Small Animal Endoscopy, 2nd edition. Mosby, St Louis
Tomsa K, Glaus TM, Zimmer C and Greene CE (2003) Fungal rhinitis and
sinusitis in three cats. Journal of the American Veterinary Medical
Association 222, 1380–1384
Windsor RC, Johnson LR, Herrgesell EJ and De Cock HEV (2004)
Idiopathic lymphoplasmacytic rhinitis in dogs: 37 cases (1997–2002).
Journal of the American Veterinary Medical Association 224, 1952–
1957
Zonderland JL, Störk CK, Saunders JH et al. (2002) Intranasal infusion of
enilconazole for treatment of sinonasal aspergillosis in dogs. Journal
of the American Veterinary Medical Association 221, 1421–1425
30/04/2013 09:22

Rigid endoscopy: otoendoscopy
Laura Ordeix and Fabia Scarampella
Introduction
Ear disease is one of the commonest conditions affect-
ing dogs and cats. Otitis externa (OE) is one of the
most common and challenging ear diseases encoun-
tered, particularly in the dog. In dogs chronic inflamma-
tion of the ear canal is frequently associated with an
extension of inflammation to deeper structures of the
ear, resulting in otitis media (OM) (82.6% of cases in
one report) or, less commonly, otitis interna (OI). Feline
OE is less prevalent and rarely progresses to OM.
More commonly, feline OM is the consequence of aeti-
ological factors that directly affect the middle ear (e.g.
inflammatory polyps, neoplasia, infection from the
upper respiratory tract).
The first diagnostic procedure that must be per-
formed on a patient with suspected ear disease is an
otoscopic examination. Otoscopy is utilized: to detect
potential causes of OE (e.g. foreign bodies, ear mites,
masses); to evaluate the presence of lesions and
exudates in the ear canal; and to assess the tympanic
membrane. Routine otoscopy alone is often not suffi-
cient to detect all changes in the tympanic membrane,
making the diagnosis of OM difficult. Video-otoscopy
(VO) systems utilize components of endoscopic tech-
nology to acquire and project video images of the
tympanic membrane, allowing a high degree of mag-
nification and detailed resolution of this structure. In
human medicine, studies have demonstrated that VO
examination of the tympanic membrane is superior to
routine otoscopy. In recent years, VO systems spe-
cifically designed for use in the canine and feline ear
have improved the quality of medical care that can be
provided to these patients.
Indications
An examination of the ear canal and tympanic
membrane is indicated for all patients that are
presented for clinical signs associated with ear
disease, such as head shaking or aural pruritus,
erythema, swelling or discharge.
VO provides significant advantages in the diagnosis
of ear disease when compared with routine otoscopy:
• he s perior optics of the V system pro ide a (Figure 9.1). The telescope has a length of around
high degree of magnification, allowing greater
visualization and detailed resolution of the ear
canal and tympanic membrane after appropriate
cleaning
Ch ndo indd
Chapter 9 Rigid endoscopy: otoendoscopy
• he li ht is positioned at the tip of the endoscopic
otoscope, allowing direct visualization while
forceps or catheters are introduced into the ear
through the working channel
• Dia nostic techni es impro ed with the se of a
VO system include sampling of exudates and
pathological tissue with biopsy forceps and
myringotomy
• he recordin capability of the V system offers
the ability to produce images for medical records.
Images are then available for comparison at
subsequent re-evaluations to compare current
findings with the prior documented findings. In
veterinary medicine, where owner compliance is
very important, images or videos are used to
improve client communication and compliance.
Video digital images may also be recorded in order
to improve the communication with veterinary
colleagues and for educational purposes.
VO is indicated in the diagnosis of diseases of the
external ear, the tympanic membrane and the middle
ear. In addition it is used in the medical therapy of
infectious OE and OM. Specifically, VO under general
anaesthesia would be appropriate in cases of:
• e ere ac te in which a forei n body is
suspected
• Chronic or rec rrent
• resence of ne rolo ical si ns compatible with
OM and/or OI.
VO can also enhance therapeutic cleansing of the
ear canal and tympanic cavities. The attachable
double-port adaptor allows the examiner to suction
and flush the ear simultaneously under constant
visualization.
Contraindications are limited to those cases in
which anaesthesia is dangerous to the life of the
patient.
Instrumentation
The standard otoendoscope is a forward-viewing
telescope of 0 degrees with a three-way stopcock
8.5 cm, tip diameter of 5 mm and a 2 mm working
channel, which is fully immersible and ethylene oxide
sterilizable. Ear curettes, biopsy forceps and grasping
forceps are suitable for the 2 mm working channel.
131
 Chapter 9 Rigid endoscopy: otoendoscopy
9.1 Veterinary otoscope set consisting of an
otoscope for dogs and cats, and a stopcock
attachment with integrated working channel. (Courtesy of
Karl Storz GmbH & Co. KG, Tuttlingen, Germany)
Alternati ely a standard 2 mm de ree Because an intact tympanic membrane does not rule
‘universal telescope’ and cystoscopy sheath can be
used. A camera system is essential to provide high-
resolution images on a monitor, and a suction/
irrigation system will allow accurate cleaning and
better visualization during the endoscopic procedures
(Figure 9.2).
9.2 VETPUMP®2, a flushing and suction apparatus.
(Courtesy of Karl Storz GmbH & Co. KG,
Tuttlingen, Germany)
Patient preparation
roper otoscopic e amination allows complete
visualization of the ear canal and tympanic membrane.
Frequently, careful examination at the level of the
tympanic membrane requires general anaesthesia
and ear flushing, particularly in reluctant patients or in
those patients with debris in the ear canal(s).
D e to the potential ris of tympanic membrane otoscope relative to the position of the animal is
rupture in any case of otitis (particularly in cases of
chronic OE and/or with neurological signs), it is
always recommended that the patient have a prop-
erly placed and inflated endotracheal tube. Flushing
could cause material to drain from the middle ear to
the nasopharynx through the auditory tube, resulting
in aspiration pneumonia.
132
Ch ndo indd 2
atient preparation sin a short co rse of sys-
temic glucocorticoids may be needed to reduce ear
canal stenosis associated with chronic OE, particu-
larly in the do Daily oral prednisolone at 2 m
for days will red ce swellin and inflammation
allowing for a more complete examination of the
ear canal. Anti-inflammatory therapy with gluco-
corticoids is anecdotally recommended to reduce
neurological complications of ear flushing and
myringotomy. Steroid administration should be
postponed until results of the preoperative work-up
have been obtained.
Preoperative diagnostic work-up
out OM, additional imaging of the middle ear is
necessary to aid diagnosis. Moreover, imaging of the
middle ear may be indicated to rule out involvement
of the tympanic bulla when a mass is observed in the
ear canal. It is important to remember that if imaging
studies and VO examination are to be performed on
the same day, ear flushing should be carried out only
after any imaging procedure, as the presence of fluid
within the bullae may mimic pathological lesions.
Radiographic assessment of the tympanic bullae
can be helpful in determining changes attributable to
OM, such as a thickened irregular bulla and soft
tissue opacities within the cavity. Unfortunately,
radiography is not very sensitive for the diagnosis
of OM, with false-negative results reported in 25% of
cases ositi e-contrast ear canalo raphy has
been described as a more sensitive method than
otoscopy or survey radiography in determining
tympanic membrane status in dogs with chronic OE
and secondary OM.
Comp ted tomo raphy (C ) has been proposed
as an alternati e to radio raphy hen a ailable C
has some advantages over conventional radiography,
including avoidance of superimposed overlying
str ct res and s perior soft tiss e contrast C has
been suggested to be more sensitive than, and as
specific as, radiography for predicting moderate to
se ere disease in do s with e ertheless C
may underestimate the presence of middle ear
disease. It has been suggested that magnetic
resonance imaging (MRI) may be useful in patients
with neurological signs relating to middle or inner ear
disease, because of its potential to detect extension
of infection into the meninges and capacity to reveal
the cochlea and semicircular canals of the inner ear.
Procedure
It is recommended that the orientation of the video-
standardized. Moreover, it is essential that the
clinician becomes familiar with the normal structures
and their otoscopic appearance before interpreting
abnormal findin s ractice ma es perfect therefore
only with repetition and experience can the practitioner
easily recognize and evaluate the different structures
of the ear.
 Chapter 9 Rigid endoscopy: otoendoscopy

The video-otoscope is inserted into the ear at the
intertragic incisure. To visualize the entire length of the
ear canal and the level of the tympanic membrane, the
ear canal needs to be straightened to minimize block-
age of the lumen by the cartilage fold that occurs at
the junction between the vertical and horizontal canals.
To achieve this objective, the pinna should be pulled
up and outward whilst inserting the video-otoscope.
Cleaning and flushing
After the patient is anaesthetized and imaging studies
have been performed, the practitioner may begin the
VO examination. In many cases, if not all, an ear flush
may be necessary before any examination is pos-
sible. In addition to allowing visualization, the ear
flush removes exudates that are irritating and capable
of inactivating some antibiotics (e.g. gentamicin, poly-
myxin B), allows sampling from the horizontal canal,
and allows sampling and cleaning of the tympanic
cavities through a ruptured tympanic membrane or
after a myringotomy. VO has facilitated this procedure
and allowed practitioners to perform more thorough
flushes and examinations, particularly in cases that
involve the middle ear. The VO system allows con-
tinuous visualization through fluid while flushing,
which is not possible with hand-held otoscopes.
The animal is placed in lateral or sternal recum-
bency. A towel may be used to elevate the caudal
head and the neck slightly in relation to the muzzle.
This allows fluid exiting the tympanic bulla through
the auditory tube to flow rostrally and out through the
nares. It is always recommended to protect the eyes
from flushing solutions containing ceruminolytic
agents and pathogens during the procedure. All the
clinicians involved in flushing procedures should wear
gloves, facemask and, ideally, eye protectors to avoid
contact with contaminated aerosols.
adherent materials. Although it is extensively reported
in the scientific literature that these agents are
contraindicated in ears with ruptured tympanic
membranes, in practice they are still used in these
patients under anaesthesia because they can be
removed completely from the ear canal and middle
ear, using flushes with an inert fluid such as sterile
saline. Moreover, in most patients undergoing ear
flushes the integrity of the tympanic membrane is
difficult to evaluate before the procedure. Because of
the higher prevalence of neurological side effects in
cats, the use of ceruminolytic agents before flushing
is not recommended.
There are many ear cleaning preparations com-
mercially available. However, the clinician should
choose the most appropriate, based on the charac-
teristics of the exudate. For mildly waxy ears (Figure
a) prod cts containin a cer minolytic s ch as
propylene glycol are suitable. Hard waxy secretions
( i re b) brea down well with an oily s alene
preparation. This organic oil is relatively safe and
unlikely to cause ototoxicity. For an ear containing
purulent exudate (Figure 9.4), a ceruminolytic sur-
factant such as dioctyl sodium sulphosuccinate

Sampling
Sampling of exudates from the ear canal for cytological
examination should take place before the preliminary
cleanin process Contrary to pre io s belief c lt re
and susceptibility testing of external ear canal exu- (a)
dates may not be necessary. In fact, in a recent pub-
lished study, different bacterial organisms were isolated
from the same sampling site of the ear canal in 20% of
cases of OE. The same bacterial organism, with differ-
ent antimicrobial susceptibility, was isolated from the
same anatomical location in 20% of the cases.
Moreover, cytological examination agreed with culture
results only 68% of the time. Furthermore, different
microbial isolates and susceptibility patterns have been
reported from the middle ear and external ear canal of
dogs with OE and OM. Therefore, to choose appro-
priate antimicrobial agents in cases of concomitant
infectious OM, bacterial culture and susceptibility test-
ing of swab specimens from both the horizontal ear
canal and middle ear should be performed.

Preliminary ear cleaning

After samples of the exudates from the ear canal have
been collected, the ear canals are filled with a (b)
ceruminolytic ear cleaner. This agent hastens the (a) Mild and (b) hard waxy secretions in the
9.3
cleaning process by breaking down waxy and ears of dogs with ceruminous OE.

133

Ch ndo indd
 Chapter 9 Rigid endoscopy: otoendoscopy
9.4 Purulent exudate in an ear of a dog with
Pseudomonas aeruginosa infection.
(D ) is probably the best option rod cts contain-
ing foaming agents, such as urea and carbamide
peroxides, are quite potent and should be reserved
for tenacious secretions.
After the ceruminolytic agent has been instilled, a
flushing solution is used to remove it completely from
the ear. Sterile isotonic (0.9%) saline and warm water
are the solutions more commonly used for this
purpose. An ear bulb syringe is first used to dislodge
large amounts of debris, gently flushing the ear until
the solution running out of it is relatively clean. The
bulb syringe should never completely occlude the ear
canal: a gap should be left between the nozzle and
the wall of the ear canal as complete occlusion may
cause excessive fluid pressure and iatrogenic rupture
of a weakened tympanic membrane. Once most of
the exudate has been removed, and before using the
video-otoscope, ear cleaning may continue using a
three-way tap connected to a syringe, saline supply
and a urinary catheter, tomcat catheter or feeding
tube of the appropriate length and diameter. The
feeding tube is preferred by the authors because it is
softer and less traumatic in case of contact with a
damaged tympanic membrane. The catheter tip is
placed at the level of the tympanic membrane under
visualization and the ear canal is flushed and
suctioned until completely clean. The ear should be
examined at this time with the video-otoscope, and
further flushing can be performed if needed.
Flushing
A relatively simple technique of suctioning and flushing
with the VO system involves using a three-way tap
connected to a long polypropylene catheter and two
20 ml syringes, one for flushing and the other for
s ctionin f a ailable a V ®
2 (see Figure
9.2), an automatic suction/irrigation system, allows
accurate and better visualization during the cleaning
procedures. The operator advances the catheter
through the working channel of the video-otoscope
until the tip is visible in the video field and directed
towards the remaining exudates (Figure 9.5). Flushing
134
Ch ndo indd
(a)
(b)
9.5 Flushing technique using a VO system.
(a) Note the polypropylene catheter targeting
tenacious debris. (b) The same ear canal after several
cycles of flushing and suctioning.
can be performed by an assistant, who fills the 20 ml
syringe with saline, attaches it to the three-way tap,
and empties the syringe in short pulses through the
catheter. The operator can then move the tip of the
catheter within the ear canal to target tenacious
debris. The fluid is then suctioned out through the
second syringe. Several cycles of flushing and
suctioning are generally needed to remove all debris
from the ear canal.
Hair or other debris that does not dislodge with
flushing may be removed with instruments, such as
grasping forceps or curettes designed specifically for
use with the video-otoscope. Although the video-
otoscope tip can only be advanced as far as the
level of the tympanic membrane, the catheter can
eventually be advanced further into the bulla if the
tympanic membrane is absent. Samples of material
from the middle ear should be obtained before middle
ear flushing.
When the tympanic membrane is absent or
spontaneously ruptured, samples from the middle ear
may be obtained with the tube technique. This
technique utilizes an open-ended sterile urinary
catheter or a r tomcat catheter or a polypro-
pylene catheter attached to a syringe placed through
the working channel of the video-otoscope. Under
visualization, the operator passes the tip ventrally into
the tympanic bulla, and applies suction with the

syringe. If necessary, 1 ml of sterile saline may be
flushed into the middle ear cavity and aspirated. The
tube is then removed and disconnected from the
syringe. The syringe is filled with air and then attached
again to the tube and the material in the tip of the tube
e pressed art of the material is then c lt red and
part is processed for cytological examination. The
role of anaerobic bacteria in recurrent OE and OM is
unknown. However, there are some recent reports of
isolation of anaerobic bacteria from the horizontal ear
canal and tympanic cavity of dogs with OM undergoing
total ear canal ablation or lateral bulla osteotomy.
Therefore, both aerobic and anaerobic cultures should
be recommended in cases of infectious OM.
If the tympanic membrane is intact but the index of
suspicion for OM is high (compatible clinical signs,
abnormal tympanic membrane or compatible results
of imaging studies) a myringotomy should be
performed for diagnostic and therapeutic purposes.
Normal findings
On VO examination, the normal ear canal of dogs and
cats appears pale pink and smooth with fine blood
vessels on its surface (Figure 9.6). Fine hairs are
frequently present at the entrance to the external ear
canal and may be present in the vertical and horizontal
canals. In some dogs a tuft of hair is present in front
of the tympanic membrane. The diameter of the ear
canal as well as hair density varies based on species,
and between breeds.
9.6 Normal canine ear canal.
A minimal amount of cerumen is present in normal
ears and the tympanic membrane is easily visualized.
Using the video-otoscope, both the pars flaccida and
pars tensa of the tympanic membrane are visible
(Figure 9.7). The normal tympanic membrane in dogs
and cats appears translucent. The pars flaccida is the
small pink region forming the upper quadrant of the
tympanic membrane. It contains small blood vessels.
In some dogs, it appears dilated and prominent. It has
been suggested that this bulging region may be a
product of increased air pressure within the middle
ear, most commonly seen in dogs with hypersen-
sitivity disorders. However, the significance of this
observation has not been completely defined.
Ch ndo indd
Chapter 9 Rigid endoscopy: otoendoscopy
A
B
C
Normal canine tympanic membrane. A = Pars
9.7
flaccida; B = Pars tensa; C = Stria mallearis.
Nevertheless, inexperienced examination of an
engorged pars flaccida may result in mistaken
identification of a mass.
The pars tensa appears as a thin, translucent,
tense portion of the tympanic membrane. This part is
the majority of what is seen of the tympanic membrane
when it is examined through the video-otoscope. The
outline of the manubrium of the malleus, the stria
mallearis, is visible through the pars tensa. In the dog,
the manubrium has a hook that points rostrally. Given
this anatomical characteristic, photographs from the
right or left canine ear can be easily recognized. Blood
vessels in the pars tensa may be seen associated
with the manubrium, and striations are often visible
radiating away from this structure (Figure 9.8).
Blood vessels in the pars tensa associated with
9.8
the manubrium.
The region of the tympanic membrane overlying
the manubrium is reported to be the location of the
germinal epithelium in dogs and cats, which is
responsible for the healing of a damaged tympanic
membrane. In a normal ear, structures of the middle
ear, other than the manubrium of the malleus, are
rarely seen. However, a whitish discoloration can
sometimes be seen through the lower to mid-section
of the tympanic membrane. This represents the bony
ridge that separates the tympanic cavity from the
tympanic bulla.
135
 Chapter 9 Rigid endoscopy: otoendoscopy

Pathological conditions
On otoscopic examination, the condition of the ear
canal should be evaluated, foreign bodies or masses
should be looked for, the presence and the character
of the discharge should be noted, and the presence
and appearance of the tympanic membrane should
be evaluated.

Abnormal appearance of the ear canal

Otitis externa
In cases of acute OE, signs of inflammation such as
oedema and erythema are evident along the skin
s rface linin the ear canal Clinically the swellin
caused by the oedema appears as stenosis of the ear
canal ro ressi e histopatholo ical chan es occ r in
chronic OE, which result in continuous reduction in the
diameter of the lumen. Sebaceous and ceruminous
glands become elongated; this may appear clinically
as a nodular or cystic dermatosis (Figure 9.9). The
subcutaneous tissues thicken due to fibrosis and, with
time, the auditory cartilages may became calcified.
Calcification manifests as a loss of fle ibility of the ear This may be accomplished using the biopsy forceps
canal and difficulty in passing the video-otoscope.
There are breed-related differences regarding the
prevalence of histopathological changes in canine
chronic OE. A recent study demonstrated that >70% of
Coc er paniels react with a land lar pattern rather otoscope can arise from any of the structures of the
than a fibrotic one, whereas the glandular pattern was
present in only of the other breed e al ated
9.10 Ulceration of the skin of the ear canal
associated with Pseudomonas aeruginosa
infection.
through the working channel on the video-otoscope
(Figure 9.11b). A mass in the ear canal can be of
neoplastic or inflammatory (e.g. inflammatory polyps)
origin. Neoplastic lesions observed through the video-
ear canal, with or without progression into the
tympanic cavities, or from a tumour in the middle ear.
Therefore, in addition to the histopathological diag-
nosis, imaging studies for detection of middle ear
involvement may be necessary for therapeutic pur-
poses. Inflammatory polyps originate from the middle
ear mucosa. They appear as pink to red smooth-
surfaced nodular pedunculated lesions (Figure 9.12).
This structure is clinically characteristic, though in
some instances they may appear irregular and
multinodular. Therefore, histopathological differen-
tiation from a neoplastic lesion arising from the
tympanic bulla is mandatory.

9.9 Glandular proliferation of the horizontal ear

canal of a dog with a history of chronic OE.

Ulceration
Ulceration of the skin of the ear canal is associated
with bacterial infection, particularly with rod-shaped
bacteria, such as Pseudomonas aeruginosa (Figure
9.10).

Masses
Occasionally, when evaluating a dog or a cat for OE (a)
(after proper cleaning of the ear canal), a mass may (a) Mass of neoplastic origin discovered using
9.11
be observed (Figure 9.11a). Any mass in the ear canal video-otoscopy in the ear canal of a cat.
should be sampled for histopathological examination. (continues)

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 Chapter 9 Rigid endoscopy: otoendoscopy

(b)
(continued) (b) Biopsy of the mass using
9.11
biopsy forceps (visible at the top of the image)
placed through the working channel on the video-
otoscope. Histopathologically the mass was identified as
ceruminal gland carcinoma.
9.13 A hard concretion at the eardrum of a dog.
removed using the grasping forceps through the work-
ing channel of the video-otoscope. Because they are
frequently attached to the lateral wall of the tympanic
membrane, removal of these aggregates may be asso-
ciated with iatrogenic perforation of the tympanum.

Discharge
A crucial step during otoscopy is the evaluation of otic
discharge. The amount, consistency and colour of
exudates should be recorded. Although the character
of the exudates may suggest a cause, the practitioner
should always confirm the suspicion with appropriate
diagnostic tests, such as microscopic and cytological
examination of the debris.

Abnormal appearance of the tympanic

membrane
Examination of the tympanic membrane is a critical
step in the diagnosis of OM. In obvious cases the
tympanic membrane is not present. To confirm true
absence, inexperienced operators should compare
9.12 Inflammatory polyp in a cat. Note the pink to red the diseased ear with the healthy contralateral ear;
smooth surface. however, if the tympanic membrane is not seen when
the video-otoscope tip is advanced as far as possible,
Foreign bodies it is likely to be absent (Figure 9.14).
Foreign bodies may be observed in the ear canal or in
the middle ear. Some of the more common foreign
bodies incl de plant awns and impacted wa lant
awns may be removed using the grasping forceps
through the working channel of the video-otoscope.
Impacted wax occurs more commonly in older patients
and in those that have been affected with OE in the
past ( i re )
Usually impacted wax is responsible for clinical
signs analogous to those observed in OE (e.g. aural
pruritus, head shaking) but signs of inflammation are
absent on otoscopic examination. It is suggested that
in these animals a decrease in the physiological migra-
tion of the epithelium present on the lateral surface of
the tympanic membrane occurs, leading to the accu-
mulation of cerumen, hairs and cellular detritus.
Impacted wax should be dissolved with a ceruminolytic
agent and then gently flushed out of the ear canal. In OM in a dog. Note the absence of the tympanic
9.14
some instances, the impacted wax needs to be membrane.

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 Chapter 9 Rigid endoscopy: otoendoscopy

Sometimes a small ring of granulation tissue may

be seen at the annulus fibrosus, where the tympanic
membrane attaches to the ear canal. The medial wall
of the tympanic cavity appears like a dark space at the
end of the canal. Viewed using a video-otoscope, the
mucoperiosteum lining the clean tympanic cavity may
occasionally reflect enough light to appear shiny and
white. This may be interpreted as a diseased but intact
tympanic membrane. To determine the nature of the
structure, a small-diameter soft feeding tube can be
gently advanced and directed to the ventral portion of
the observed object until it stops. If the tympanic mem-
brane is intact, it resists gentle pressure and may dis-
tort slightly. On the other hand, if the tympanic
membrane is absent, the tip of the tube disappears
ventrally into the tympanic bulla. Absence of the mem-
brane can also be inferred if fluid used for flushing
exits through the nostrils when the ears are flushed.
The practitioner must be aware of a condition
described in dogs called a ‘false middle ear’. In some
instances, the examiner may have the impression
that the tympanic membrane is absent when in fact
the tympanic membrane has been displaced medially
into the middle ear cavity. This alteration may develop
as a result of two changes that occur simultaneously.
First, increased pressure on the tympanic membrane
secondary to obstruction along the horizontal ear
canal from inflammation, neoplasia, impacted wax or
hypertrophic or cystic glands will stretch and bulge
the tympanic membrane into the middle ear cavity.
Secondly, negative pressure inside the tympanic bulla
as an effect of poor air movement through the auditory
tube will pull the tympanic membrane even further
into the middle ear cavity. This condition may be
reco ni ed sin C which re eals a fin er lesion canine OM.
protruding into the bulla. However, dogs with this
alteration are often misdiagnosed as having OM.
These patients can be retrospectively diagnosed at a
2-week recheck after ear canal cleaning, when the
previously unseen tympanic membrane returns to a
normal location. The normal tympanic membrane has
been shown e perimentally to heal in 2 days Frequently, a healed or diseased tympanic membrane
Therefore, if the tympanic membrane was truly
absent, a recheck performed 2 weeks later should
show the membrane to be incomplete.
In some cases of OM the tympanic membrane is
ruptured (Figure 9.15). However, integrity of the
membrane can be difficult to assess visually, even
with the increased resolution and magnification
provided by the video-otoscope, and holes or partial
tears may go undiagnosed. An easy technique for
evaluating the integrity of a visualized but diseased
tympanic membrane is to fill the ear canal with sterile
saline while the patient is placed in lateral recumbency
with the suspected ruptured membrane uppermost.
The tip of the video-otoscope is then positioned under
the fluid near the membrane. If small perforations are
present, air from the tympanic cavity escapes from
the middle ear and air bubbles are visualized by the
examiner any time the animal breathes.
It may be difficult to visualize the tympanic
membrane otoscopically in some dogs with chronic
OE due to stenotic or occluded ear canals. The
tympanic membrane was visible by routine otoscopic
9.15 OM with rupture of the tympanic membrane.
examination in 28%, 40% and 66% of dogs with
chronic OE in three different published studies. Other
techniques, such as positive-contrast ear canalo-
graphy and tympanometry have been performed to
determine the integrity of the tympanic membrane
when it cannot be visualized. Tympanometry uses a
sensor that measures the compliance of the tympanic
membrane in response to sound waves. It is used
frequently in evaluation of OM in human patients, but
it has poor sensitivity and specificity in evaluating
An intact tympanic membrane does not rule out
OM, particularly in dogs with chronic OE. One study
revealed an intact tympanic membrane in up to 72.5%
of canine ears with OM. These patients may have had
a ruptured tympanic membrane that healed, trapping
microorganisms and exudates in the middle ear.
appears altered in colour/opacity or outline. However,
it may also change colour in response to inflammation
due to chronic otitis. It may appear opaque, white,
brown or grey. Sometimes there is fluid behind the
tympanic membrane (e.g. infectious OM, primary
secretory OM), resulting in a bulged appearance
(Figure 9.16). It is therefore recommended that in any
case with an abnormal tympanic membrane and
suspected secondary OM, a surgical incision
(myringotomy) of the diseased tympanic membrane
should be performed to rule out middle ear disease.
Iatrogenic focal rupture of the tympanic membrane
may be done with either the hand-held otoscope or
the video-otoscope. However, the VO system allows
continual visualization and accurate positioning for
the myringotomy procedure. The site elected for
performing the myringotomy incision is very important.
It is essential to make the incision in the caudoventral
portion of the pars tensa (at 6 to 7 o’clock; Figure
9.17) to avoid damaging the tympanic germinal
epithelium and the structures of the middle ear such
as the middle ear ossicles or the promontory.

138

Ch ndo indd

9.16 The bulged appearance of a tympanic
membrane in a dog with empyema of the bulla.
C R
V
9.17 Proper position for performing a myringotomy,
using an open-ended tomcat catheter.
The incision is made in the caudoventral portion of the
pars tensa (at 6 to 7 o’clock). C = Caudal; D = Dorsal;
R = Rostral; V = Ventral.
After cleaning and drying the ear canal, a 3.5 Fr
tomcat catheter or polypropylene catheter is placed
through the working channel of the video-otoscope.
The instrument selected depends on the length of the
ear canal: a myringotomy in a German Shepherd Dog
is rarely done using a tomcat catheter because it
would be too short. The tip of the catheter is cut at an
angle to make it sharper and used to make the incision
into the caudoventral quadrant of the pars tensa.
Once the tip has been passed through the medial part
of the tympanic membrane into the middle ear, an
assistant should infuse 1 ml of sterile saline solution
into the bulla and then aspirate. The fluid obtained is
then used to make cytological preparations and for
culture and susceptibility. After sample collection, the
Ch09 Endo.indd 139
Chapter 9 Rigid endoscopy: otoendoscopy
tympanic cavities should be gently flushed using
sterile saline instilled through a ventrally directed
catheter through the incision until the fluid aspirated
back is clear.
Abnormal appearance of the middle ear
Cholesteatoma has been rarely described in dogs
with OM. This pathological condition is an epidermoid
cyst within the middle ear cavity, composed of
abundant keratin lamellae produced by the stratified
squamous epithelium of the lateral wall of the tympanic
membrane, which migrates into the tympanic cavities.
In the dog it is usually associated with a moderate to
severe stenosis of the ear canal. It is difficult, if not
impossible, to visualize this structure with routine
otoscopy. In some instances VO examination may be
suggestive, but definitive diagnosis requires CT scan
and histopathological examination (Figure 9.18).
(a)
(b)
9.18 (a) CT scan of left cholesteatoma in a male
8-year-old Afghan Hound. There is enlargement
of the middle ear cavity, complete loss of air contrast and
early mild lytic changes to the bulla wall. (Courtesy of M Di
Giancamillo) (b) Removal of a huge quantity of keratinic
debris from the tympanic cavity of a 10-year-old male
Flat-coated Retriever with right cholesteatoma during a
total ear canal ablation procedure. (Courtesy of
CM Mortellaro)
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 Chapter 9 Rigid endoscopy: otoendoscopy

Postoperative care will allow continuous flushing of the tympanic bulla as

long as the tympanic membrane is perforated. The
Oral glucocorticoid therapy is started before the video- authors prefer to use an antimicrobial solution such
otoscopic examination and continued during the as ris- D A to dil te antibiotics and to fl sh the ear
recovery phase to reduce inflammation and pain. The canals and tympanic bullae. The reader is referred to
period of time under systemic glucocorticoid therapy other articles for discussion of specific systemic and
depends on the ear disease present. For acute topical antibiotic medications for infectious OM.
disease in which the primary cause of the inflammation In cases of infectious OM, therapy can only be
is removed (e.g. foreign body) or medically controlled discontinued when weekly examination reveals no
(e.g. ear mites), a few days on a once-daily dose of signs of inflammation in the ear canal and the results
corticosteroids is sufficient before discontinuation. On of cytological examination are negative for the
the other hand, systemic corticosteroids may be used presence of microorganisms and inflammatory cells.
for a few weeks in cases of OE with secondary OM. At this point, regular cleansing of the affected ears is
Corticosteroids aid in red cin the inflammation and recommended Complete healin of the tympanic
pain of the ear canal in cases of OE. In addition, they membrane should not be a curative criterion because,
slow the inflammation and exudation in middle ear in some cases, the tympanic membrane may not
disease and the amount and viscosity of mucus regenerate (e.g. damaged germinal epithelium or
prod ced in the b lla Chan in the ality of the vascular supply from the pars flaccida).
m c s aids in its remo al Corticosteroids also red ce
the swelling present in the auditory tube, increasing
the drainage of mucus into the nasopharynx. Oral Complications
prednisolone is administered daily at 2 m for 2
weeks then decreased to 0.5 mg/kg every other day Complications of the V system refer mainly to those
until discontinuation. caused by otic flushing and myringotomy. These
Successful medical management of infectious problems are infrequent in dogs but more common in
re ires lon -term treatment ( wee s) with cats ain and head sha in after the proced re may
systemically administered antimicrobial drugs be a result of aggressive flushing and inadequate
selected on the basis of susceptibility tests, in addi- analgesia. Neurological signs may be a consequence
tion to topical antimicrobial therapy. After flushing, of mechanical trauma from instruments used to clean
antibiotic therapy based on cytological results should the middle ear or high fluid pressure on the nerves in
be started. However, systemic therapy should be or in close pro imity to the middle ear Clinical si ns
modified once the results of the antibiotic suscept- may include enophthalmos, ptosis, miosis and protru-
ibility tests are obtained. Efficacy of systemic anti- sion of the nictitating membrane (Horner’s syndrome)
bacterial therapy for OM relies on the low levels of or drooped lip and ear, inability to close the eyelid,
antibiotics arriving in the middle ear by haemato- and decreased palpebral reflex (facial nerve injury).
genous spread or through inflammatory cells. Severe neurological signs such as head tilt, imbal-
Antimicrobial selection based on the results of sus- ance and circling (vestibular syndrome) and deafness
ceptibility tests that measure the minimum inhibitory may be a result of overly aggressive irrigation of the
concentration ( C) or the se of ma imal doses of tympanic cavities or the use of ototoxic agents that
oral antibiotics increases therapeutic success. are not removed appropriately from the ear.
Topical antibiotics placed into the middle ear can Most complications are transient but owners should
achie e many times the blood C Altho h it has be aware that possible complications may occur and
been suggested in a recent report that topical anti- that some of them may be permanent. Moreover, own-
biotic treatment alone following a thorough lavage of ers should be aware of the need for myringotomy to
the tympanic bulla can be quite successful, combined evaluate and treat middle ear disease in many cases.
systemic and topical therapy is still the ideal thera- Therefore, ear flushing should never be done in a
peutic option. There are several techniques for sup- patient under anaesthesia for another purpose without
plying topical antibiotics into the bulla. Gotthelf (2004) the owner’s written consent; the owner should be
describes a technique to infuse drugs into the bulla, made aware that a similar risk of complications some-
providing high concentrations directly to the bulla. times also arises from untreated ear diseases.
One millilitre of an aqueous solution containing non-
toxic antibiotics can be placed directly on to the
infected mucoperiosteum through a small catheter
placed into the bulla. Most of the topical antibiotic References and further reading
solutions can remain within the bulla for several days An s C and Campbell (2 ) ses and indications for ideo-otoscopy
after infusion; however, the entire procedure of flush- in small animal practice. Veterinary Clinics of North America: Small
Animal Practice 31 2
ing, suctioning and bulla infusion should be repeated An s C ichtenstei er C Campbell and chaeffer D (2 2) Breed
weekly during therapy. Others recommend perform- variations in histopathologic features of chronic severe otitis externa
ing one video-otoscopic lavage of the tympanic bulla in dogs: 80 cases (1995-2001). Journal of the American Veterinary
Medical Association 221
followed by the application of 2 ml of the a eo s Cole (2 ) toscopic e al ation of the ear canal Veterinary Clinics
solution of the antibiotic every 12 hours and applica- of North America: Small Animal Practice 34
tion of a hi h ol me (2 ml) of an antiseptic sol tion Cole woch a illier A et al. (2 ) Comparasion of bacterial
organisms from otic exudate and ear tissue from the middle ear of
at least every 48 hours by the owner into the ear untreated and enrofloxacin-treated dogs with chronic end-stage otitis.
canal. Application of this amount of aqueous solution Veterinary Dermatology 15 (suppl.1) 9 (abstract)

140

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 Chapter 9 Rigid endoscopy: otoendoscopy

Cole woch a illier A et al. (2005) Comparison of bacterial American Animal Hospital Association 227
organisms and their susceptibility patterns from otic exudate and ear in a (2 ) tic fl shin Veterinary Clinics of North America: Small
tissue from the vertical ear canal of dogs undergoing a total ear canal Animal Practice 34,
ablation. Veterinary Therapeutics 6 2 2 2 ittle C ane ibbs C and earson ( ) nflammatory middle
Cole woch a owals i and illier A ( ) icrobial flora and ear disease of the dog: the clinical and pathological features of
antimicrobial susceptibility patterns of isolated pathogens from the cholesteatoma, a complication of otitis media. Veterinary Record 128,
horizontal ear canal and middle ear in dogs with otitis media. Journal 22
of the American Veterinary Medical Association 212 orris D (2 ) edical therapy of otitis e terna and otitis media
Cole woch a odell iller A and mea DD (2 2) al ation Veterinary Clinics of North America: Small Animal Practice 34,
of radiography, otoscopy, pneumatoscopy, impedance audiometry
and endoscopy for the diagnosis of otitis media in the dog. Advances ttall and Cole (2 ) ar cleanin the and perspecti e
in Veterinary Dermatology 4 Veterinary Dermatology 15 2
otthelf (2 ) Dia nosis and treatment of otitis media in do s and almeiro orris D iemelt and hofer (2 ) al ation
cats. Veterinary Clinics of North America: Small Animal Practice 34, of outcome of otitis media after lavage of the tympanic bulla and
lon -term antimicrobial dr treatment in do s cases ( 2 2)
riffin C (2 ) titis techni es to impro e practice Clinical Techniques Journal of the American Veterinary Medical Association 225
in Small Animal Practice 21
Hettlich BE, Boothe HW, Simpson RB et al. (2005) Effect of tympanic Scott Jones W (2006) Video otoscopy: bringing otoscopy out of the “black
cavity evacuation and flushing on microbial isolates during total ear box”. International Journal of Pediatric Otorhinolaryngology 70,
canal ablation with lateral bulla osteotomy in dogs. Journal of the

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 Chapter 10 Rigid endoscopy: urethrocystoscopy and vaginoscopy
10
Rigid endoscopy: urethrocystoscopy
and vaginoscopy
Alasdair Hotston Moore and Gary England
Introduction
Examination of the lower urinary tract and reproduc-
tive tract is a core part of the diagnosis of various
medical and surgical disorders of small animals.
Historically, radiographic examinations were almost
the sole way to investigate structural abnormalities,
but more recently both ultrasonography and endo-
scopy have become essential additional modalities
for diagnosis. Anatomical considerations limit the
application of urethroscopy in male animals, espe-
cially the cat, but in females the entire urethra and
the bladder are readily accessible to endoscopic
evaluation. In the male, examination of the urethra
may be possible in some dogs, using highly special-
ized equipment; the bladder of male dogs and cats is
accessible via a transabdominal approach (laparo-
scopic or laparoscopically assisted cystoscopy).
Interventional procedures in the lower urinary tract
are still limited in application, but urolith removal and
ablation, tissue biopsy, injection of bulking agents
into the urethral wall, and palliation of urethral neo-
plasia have been reported.
Anatomical considerations
A key difference between the sexes is the relatively
long, narrow and curved urethra of the male. This
limits the application of rigid endoscopy in particular,
and only the distal penile urethra can be examined
with this equipment in the male dog. In the tomcat, the
penile urethra is extremely narrow and urethroscopy
is virtually impossible with the equipment currently in
common use.
In the bitch (Figure 10.1) and queen, the anatomy
lends itself to endoscopic examination. Apart from the
difference in size, the anatomy is practically identical
in both species. The caudal urogenital tract in the
female is bordered by the lips of the vulva, which are
positioned ventral to the bony pelvis. The clitoris is
housed under a thin frenular band within the ventral
commissure of the vulva. Opening within the vulval
lips, the vestibule is common to both urinary and
reproductive tracts. The normal mucosa is pale pink,
with little evidence of vascularization. The vestibule is
angled dorsally and at its cranial limit the urethral
orifice is found on the ventral floor, marking the
vulvovaginal junction (see Figure 10.5).
142
Ch10 Endo.indd 142
Cervix External urethral
Pseudocervix orifice
Vagina
Cervical os Urethra
Vestibule
10.1 Schematic representation of the caudal
urogenital tract of the bitch.
In most animals the vagina is continuous with the
vestibule, although the mucosa is paler in appearance
and has the typical redundant folds. There is a small
blind-ending pouch, approximately 5 mm deep, on
either side of the urethral orifice. The vagina runs
cranially and lies parallel with the pelvic floor (changing
direction from the vestibule).
In a significant number of bitches there is a distinct
narrowing at this level, termed vestibulovaginal sten-
osis. The clinical importance of this condition is often
minimal; although it has been reported to be associ-
ated with urinary incontinence, the epidemiological
evidence for this is poor. In other animals there may
be vertical bands of mucosa across the vagina at this
level; these probably represent incomplete recession
of the embryonic cloacal membrane. The clinical sig-
nificance of these is also unknown. Around the ure-
thral orifice, the endoscopist may notice a number of
small pits, the function of which is unknown.
The caudal vagina has a smooth pink mucosa that
is arranged into longitudinal folds. Each fold may
appear to have a slightly segmental appearance.
Generally there is one fold positioned on the dorsal
surface of the vagina and a further five or six folds
around the vaginal wall. The vagina of the average
bitch is deceptively long; often the cervix is positioned
level with the third lumbar vertebra (the vagina of a
20 kg dog is often 25 cm in length). The cranial half of
the vagina narrows to approximately half its caudal
diameter. The majority of this narrowing is caused by
an increase in the size of the dorsal vaginal fold (see
Figures 10.2 and 10.12). The region of the noticeable
narrowing is often called the pseudocervix (see Figure
10.14), since to the inexperienced observer this may
be mistaken for the cervix. However, the vagina runs
4/3/08 09:44:15
 Chapter 10
10.2
Dorsal vaginal fold.
(Courtesy of
P Lhermette)
cranially for some significant distance from the
pseudocervix and is dominated by the dorsal
longitudinal fold (often termed the dorsomedian
postcervical fold).
The cervix is a thick-walled structure, generally
seen as a rounded or elliptical feature protruding into
the dorsal wall of the vagina. The cervix is usually
smooth and pink; the small lumen opening on its
ventral aspect is directed dorsally into the uterus.
When viewed endoscopically from the cranial vagina,
it is usually not possible to see the cervical os
because of its ventral position, but its position can be
determined as there are multiple small wrinkles that
diverge away from it.
The uterus of the bitch has a relatively long body
and two equally sized horns that diverge significantly
as they traverse the caudal abdomen to end at the
ovaries immediately caudal to each kidney. A small
oviductal papilla protrudes into the lumen of the uterus
on its dorsomedial aspect.
On entering the urethra, initially the mucosa is
noted to be pink and, particularly in entire females,
folded into a rosette appearance (Figure 10.3). It is
uniform in diameter and runs along the dorsal surface
of the pelvic floor before deviating ventrally to the
bladder. However, if the urethra is distended by
infusion of fluid, the mucosa flattens and the lumen
becomes circular. There is no distinct narrowing of
the urethra at the level of the urethral sphincter;
indeed, it widens abruptly at the bladder neck to
become confluent with the bladder. The smooth
muscle of the urethra is continuous with the detrusor
muscle of the bladder; together these form the
functional internal urethral sphincter. The bladder is a
10.3
Endoscopic
appearance of
normal urethra.
(Courtesy of
P Lhermette)
Ch10 Endo.indd 143
Rigid endoscopy: urethrocystoscopy and vaginoscopy
cavernous and somewhat featureless space. The
epithelium is paler than that of the urethra and smooth,
with prominent mucosal blood vessels visible
throughout (Figure 10.4). The only landmarks within
the bladder are the paired ureteral orifices, which are
located dorsolaterally, just cranial to the bladder neck.
They are recognized as slits in the bladder epithelium
(see Figure 10.6), which become flattened and less
prominent as the bladder is distended by infusion
during examination. In companion animals the ureters
cannot normally be entered with an endoscope, the
exception being in cases of dramatic hydroureter or in
particularly large patients.
10.4
Endoscopic
appearance of a
normal bladder
wall. (Courtesy of
P Lhermette)
Indications
Urethrocystoscopy is indicated for investigation of a
variety of lower urinary tract presentations. These
include dysuria and obstruction, stranguria and
increased frequency of urination, haematuria and
incontinence. In addition, therapeutic interventions
include treatment of urethral sphincter mechanism
incompetence (USMI), ureteral ectopia, urolithiasis
and urethral neoplasia, and the placement of cysto-
stomy tubes. Laparoscopic neutering is dealt with in
Chapter 11.
Clinical history
Cases that are selected for urethrocystoscopy
typically have a chronic history that includes
incontinence, dysuria or stranguria. Less common
signs of lower urinary tract disease include vaginal or
preputial discharge, perineal or preputial irritation, or
pain on urination. Haematuria alone, without other
signs of lower urinary tract disease, is more likely to
result from renal or ureteral conditions, and is less
suitable for endoscopic evaluation. Given the
incidence of uncomplicated urinary tract infection
(UTI), especially in bitches, it is difficult to recommend
urethrocystoscopy as an initial investigation in acute
cases, although it is an appropriate investigation for
recurrent or refractory cases which may have an
underlying pathology such as polypoid cystitis,
urolithiasis or neoplasia.
Clinical examination
In the majority of cases with this type of presentation,
clinical examination is unrewarding. However, partic-
ular attention should be paid to vulvar conformation:
some authors have suggested a link between an
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 Chapter 10 Rigid endoscopy: urethrocystoscopy and vaginoscopy
infantile vulva and USMI. Although this link is dis-
puted, the conformation should be noted. Neoplastic
conditions of the vulva are rare.
Abnormalities of the prepuce are rare but preputial
stenosis is an occasional cause of dysuria.
In males the penis should be extruded from the
sheath as part of the examination, since penile neo-
plasia is an occasional cause of haematuria and penile
trauma (including fracture of the os penis) is a cause
of urinary obstruction. In most dogs the penis can be
extruded in the conscious patient, but in tomcats seda-
tion or general anaesthesia is required to allow a
detailed examination that is safe for the patient.
Digital vaginal examination is possible in larger
dogs. However, in cats and most smaller patients it
should only be attempted after general anaesthesia
or significant sedation. In many cases, vaginoscopy is
a more useful technique for examination.
Rectal examination is essential in males and
females of both species, although sedation or anaes-
thesia is required in cats and smaller dogs. In the
female, rectal palpation is useful to evaluate the
vagina and the urethra. In normal animals the vagina
is barely perceptible as a smooth and soft structure
ventral to the rectum. In animals with vaginal tumours
(most commonly vaginal leiomyoma), these are pal-
pable as firm (in the typical case, globoid) masses.
Although a single larger mass is usually present, in
many cases smaller multiple tumours are also detect-
able. In normal females, the urethra is not palpable,
but in animals with urethral neoplasia, granulomato-
sis urethritis or urethral caruncle, the urethra is detect-
able as a firm tubular structure beneath the vagina. In
male dogs, rectal examination is useful particularly for
initial evaluation of the prostate. In normal adult
males, this is detectable as a firm bilobed mobile
structure that is non-painful on palpation. Prostatic
disease often results in enlargement, together with a
change in consistency (increased heterogeneity and
firmness) and pain. Prostatic carcinoma, however, is
characterized by a small or barely enlarged prostate,
which is extremely painful and fixed to local soft tis-
sues. Prostate disease is rare in cats.
Preoperative diagnostic work-up
In addition to routine haematological and plasma
biochemical evaluation, all animals should have urine
collected for both urinalysis and bacterial culture.
Interventional procedures in the presence of UTI are
likely to be associated with increased rates of
complication. Additionally, many lower urinary tract
diseases are complicated by secondary UTI. Urine
cytology is often unhelpful, even in the presence of
gross neoplasia, but vaginal cytology may be useful
in cases of suspected reproductive disease.
Intraoperative diagnostic work-up
(under general anaesthesia)
Rectal and vaginal palpation should be repeated in
the anaesthetized animal where muscular relaxation
facilitates careful palpation.
144
Ch10 Endo.indd 144
Radiography
Radiography is a vital component of the evaluation of
these cases, even when ultrasonography and endo-
scopy are available. In cases of urinary incontinence,
intravenous urography (IVU) provides additional infor-
mation about renal and ureteral changes. In lower
urinary tract disease, retrograde urethrography (males)
and vaginourethrography are useful to demonstrate
urethral abnormalities due to tissue change and also
to clarify congenital anatomical defects. Cystography,
notably double-contrast cystography, also provides
useful structural information that assists in planning
open surgery. In urolithiasis, cystography may be used
to quantify the number of stones present before
removal and as a postoperative check to ensure that
all have been retrieved.
Thoracic radiographs should be taken when neo-
plasia is suspected, since there is a significant inci-
dence of pulmonary metastasis with urinary and
prostatic carcinoma. In most cases of transitional cell
carcinoma local metastasis is more of a problem, since
urethral blockage and euthanasia will often occur
before pulmonary metastasis can take place. Caudal
abdominal radiographs are valuable for assessing the
size of the sublumbar lymph nodes and, in particular,
for demonstrating the bony proliferation around the
pelvis and ventral to the lumbar vertebrae, which is
commonly a feature of prostatic carcinoma.
Ultrasonography
Ultrasonography is a critically important adjunct to
both radiographic and endoscopic evaluation of the
lower urinary tract. Ultrasonography provides infor-
mation in particular about the structure of solid organs,
notably the prostate and kidneys, and additional infor-
mation about the wall of fluid-filled viscera, such as
the bladder, that may not be detectable on other
investigations. It is also valuable for investigating hol-
low organs or cavities not accessible to endoscopy,
such as the uterus when the cervix is closed and pro-
static cysts. Aspirates or needle biopsy specimens
can be readily obtained from these organs under
ultrasound guidance.
Urethrocystoscopy
Instrumentation
In principle, urethroscopy can be performed with a
rigid endoscope or a flexible (fibreoptic or video-)
endoscope.
Males
In the male dog, because of the long curved urethra,
only the distal penile urethra can be examined with
rigid endoscopy. Flexible endoscopy is the only prac-
tical technique for full urethroscopy. Although rigid
endoscopy through a perineal urethrostomy has been
described, given the morbidity associated with this
surgical approach, it cannot be routinely recom-
mended. Unfortunately, the narrow diameter of the
canine urethra and the presence of the os penis
around the distal portion severely limit endoscope
access and urethroscopy is therefore performed
uncommonly in male dogs.
4/3/08 09:44:15
 Chapter 10
In tomcats, although the urethra can be straight-
ened, the extremely narrow penile urethra limits
access. However, small-diameter semi-flexible endo-
scopes, such as a 1.2 mm cystourethroscope, have
been used successfully in tomcats; some have a
small channel to allow fluid infusion/drainage but
there is no instrument channel or angulation. A 1 mm
semi-rigid endoscope has also been used in tomcats.
Biopsy samples can be taken ‘blind’ or using a pre-
pubic approach with the cystoscope placed trans-
urethrally for guidance.
Females
In bitches and queens, either rigid or flexible
endoscopes can be used; however, given the superior
image quality of rigid endoscopes, these are more
commonly deployed. Flexible video-endoscopes are
generally too large in diameter for this application,
whilst narrow flexible endoscopes have the
disadvantage of being somewhat less robust than
rigid endoscopes. These limitations also prevent
ureteroscopy in dogs and cats.
The most commonly recommended rigid endo-
scopes are 2.7 mm or 4 mm in diameter, used with a
cystoscopic operating sheath. The 2.7 mm endo-
scope is suitable for queens and smaller bitches, but
is usually too short to be used to examine the bladder
in larger bitches, where the 4 mm diameter, 300 mm
long, endoscope is applicable. In either case, an
endoscope with a moderately angled field of view,
typically 30 degrees oblique, is selected to allow
examination of the entire lumen of both urethra and
bladder and examination of the trigone in particular.
The endoscope is generally used with a cystoscopic
sheath, which has two portals (for infusion and out-
flow) together with an operating channel. Ancillary
equipment includes semi-flexible biopsy and grasping
forceps to pass through the operating channel,
together with basket forceps to retrieve uroliths.
Particularly with the narrower endoscope, the operat-
ing channel only permits the passage of fine forceps,
and the operator should recognize both the limitations
on the size of specimen that can be retrieved and the
fragility of these instruments.
General
A standard light guide and light source are required.
Illumination of the urethra is undemanding in terms of
intensity, but the bladder of larger patients requires a
good quality light source. Notably, until the bladder
has been emptied of urine, flushed and filled with
saline, sediment and coloration of the urine markedly
absorb the light and hinder examination.
An endoscopic camera system is highly recom-
mended for urethrocystoscopy because of the bene-
fits of documentation, improved sterility and to avoid
the need to place the operator’s face near the area of
examination, which is contaminated with urine.
Procedures are carried out during distension of
the lower urogenital tract with fluid, commonly sterile
saline. This is infused via a standard giving set through
one of the portals of the sheath, each of which is
equipped with a Luer lock stopcock. Gravity infusion
is adequate and safer than use of a fluid pump. A
Ch10 Endo.indd 145
Rigid endoscopy: urethrocystoscopy and vaginoscopy
second giving set is attached to the other stopcock to
allow drainage of urine and irrigant as required. It is
worth noting that the use of cold irrigants can result in
a significant reduction in the patient’s core body
temperature. Warming the saline irrigant to body
temperature reduces the likelihood of hypothermia,
especially in smaller patients.
A diode laser is suitable for interventional pro-
cedures. This type of laser transmits the energy
through a semi-flexible fibreoptic cable, which can be
passed through the instrument channel of the sheath
and used to resect soft tissue within the urogenital
tract. For transabdominal cystoscopy, standard equip-
ment for laparoscopic procedures is required.
Care of instruments
Care of the rigid cystoscope is identical to that of other
similar instruments. Particular care should be used in
handling the unsheathed endoscope, which is fragile
when unsupported. The semi-flexible forceps are also
fragile and care should be taken both in use and
during cleaning. Additionally, the channels in the
operating sheath are narrow and prone to obstruction
by dried protein if not promptly flushed and cleaned
after use. Most modern endoscopes are suitable for
sterilising by autoclave, although the manufacturer’s
recommendations should be followed (see Chapter
2). In common with other hollow tubular equipment,
the endoscope and sheath can only be reliably
sterilized in a vacuum-assisted, rather than gravity
displacement (typical benchtop model) autoclave.
Patient preparation
Urethrocystoscopy is typically performed under gen-
eral anaesthesia, although it may be possible under
sedation and/or epidural analgesia. It is important that
the patient is relaxed and immobile to allow atrau-
matic inspection and avoid damage to either tissues
or instrumentation. The external genitalia of the
patient should be clipped in long-haired breeds and
the local skin cleaned. To allow detailed inspection of
the bladder lumen, urine must be removed, the blad-
der rinsed and then infused with fresh saline; this can
be carried out by catheterization prior to endoscopy
or with the endoscope during the procedure.
Procedure in the bitch and queen
The animal is positioned in either lateral or sternal
recumbency with the hindlimbs extended caudally.
Lateral recumbency allows greater flexibility in
manipulation of the rigid endoscope. The hindquarters
are positioned at the edge of the table.
Provision should be made to avoid the animal
becoming excessively wet from urine or irrigation
fluid: either a gridded table top or placement of
incontinence bedding under the animal is suitable. A
fluids stand is placed alongside the patient to suspend
the saline for gravity infusion. The monitor is positioned
at the head of the patient.
When the endoscope has been placed within the
operating sheath, the camera is attached and the
sheath flushed with saline from the giving set to
remove air bubbles from the system. The tip of the
endoscope is now placed within the vulvar lips at
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 Chapter 10 Rigid endoscopy: urethrocystoscopy and vaginoscopy

the dorsal commissure to avoid the clitoral fossa, and 10.6

the vulva is pinched closed around the sheath during
examination of the vestibule, vagina and lower (a, b) Normal
ureteral openings
urethra. The ingress stopcock is opened and the in the dog. In (b)
egress stopcock closed until the vestibule becomes urine can be seen
distended with saline, allowing identification of the discharging into
urethral orifice on the floor of the vagina at the the bladder.
vestibulovaginal junction (Figure 10.5) and the vaginal (Courtesy of
lumen running cranially. The vagina is generally P Lhermette)
examined before the urethra is entered.

10.5
(a)
Normal feline
vestibule with
vaginal os above
urethral opening.
(Courtesy of
P Lhermette)

On entering the vagina, a reflection of the anterior

vagina/cervix is often seen in air bubbles on the dor- (b)
sal vaginal wall. It is important not to mistake this
for the true cervix, but to move the tip of the endo-
The endoscope will need to be rotated, so that the
scope ventrally to realign with the more horizontal
obliquity is dorsal, to examine this area. Once the
vaginal lumen. This can then be explored cranially,
ureteral openings have been identified, the remainder
noting the prominent dorsal fold which culminates at
of the bladder lumen is examined, using ingress and
the cervix. The vaginal mucosa of the neutered
egress of irrigant as necessary. In the normal animal,
bitch is relatively smooth in appearance, not unlike
the bladder surface is uniform in appearance, with no
that of deep anoestrus, whereas that of the entire
other landmarks identifiable.
bitch often has prominent longitudinal folds when the
bitch is not in anoestrus.
Biopsy
Once the vaginal examination is complete the
Biopsy samples can be taken from the urethral or
endoscope is withdrawn slightly until the urethral
bladder surface using cup forceps passed through
orifice is identified once more (see Figure 10.5) and
the operating channel. Normal urothelium is relatively
the endoscope advanced into it. With continued saline
tough and may prove difficult to obtain samples from,
infusion the urethra will distend to form a circular tube.
but proliferative areas suspected of inflammatory or
The endoscope is then advanced to the bladder neck
neoplastic change are more readily sampled (Figure
under direct observation, rotating the endoscope to
10.7). Biopsy samples should be submitted for both
allow examination of the entire circumference as
histopathology and bacteriology. If a grab biopsy
required. In the normal animal, the urethra is a single
cannot be performed, suction is a suitable alternative,
lumen with no other orifices.
the samples being retrieved ‘blindly’ using a urethral
At the bladder neck the urethra abruptly opens
catheter. The operator is cautioned that if the bladder
into the bladder, which has a much larger lumen. If
is over-distended, it will be much more difficult to
urine has not previously been drained, the image
retrieve adequate samples.
quality will be lost due to the opacity of normal urine.
The ingress stopcock is closed and the egress
stopcock opened, allowing urine to be evacuated 10.7
under gravity flow to below the height of the patient. Endoscopic
Once the bladder has collapsed, the egress stopcock appearance of
is closed once more and the bladder slowly distended taking a tissue
with saline. Excessive distension is avoided as it may biopsy from a mass
in the proximal
cause artefactual subepithelial haemorrhage, prevent urethra. (Courtesy
examination of the cranial pole in larger bitches, and of P Lhermette)
potentially cause bladder rupture. The bladder is
examined as it distends: the trigone is usually
identified first, at the caudal dorsal surface of the
lumen, and the two ureteral openings are identified as
small slits (Figure 10.6). Jets of coloured urine may
be seen if the bladder is not excessively distended.

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 Chapter 10
Urolith removal
Uroliths that are smaller than the urethral diameter
can be grasped with a stone basket or grasping
forceps and then removed as the endoscope and
sheath are withdrawn together. The stones should be
submitted for stone analysis and culture, even if other
larger stones cannot be removed, since medical
treatment aimed at dissolution should be based on
chemical analysis of the calculus.
Laser techniques
The fibreoptic tip of the laser can be passed into the
operating channel of the sheath and used for tissue
transaction or destruction. Two described applications
are: treatment of ectopic ureter; and palliation of
urethral neoplasia. At the time of writing, both are
considered to be in early clinical evaluation.
The principle of treatment of ureteral ectopia by
this approach is to identify the ureteral orifice in the
urethra and then follow it cranially, ablating the thin
two-layered sheet of epithelium (ureteral and urethra)
that separates it from the urethra, creating a single
lumen. Once the bladder neck is reached, the ablation
is finished and the ureteral orifice is now effectively
translocated from its ectopic position to the trigone.
Results of this treatment have yet to be reported in a
large case series.
Urethral neoplasia (most commonly diagnosed as
transitional cell carcinoma) can be palliated by
destruction of the proliferative epithelium which
obstructs the urethral lumen, using a diode laser
(Figure 10.8). Anecdotally, this can eliminate dysuria
for prolonged periods, but a comparison of the results
of this therapy (which usually is complemented by
piroxicam) with piroxicam alone or with tube cystotomy
is not available.
A further discussion of the use of lasers in tissue
ablation and in lithotripsy is given in Chapter 14.
10.8
Canine urethra
following laser
ablation of
transitional cell
carcinoma. Note
the 8 Fr urinary
catheter in the
lumen. (Courtesy of
P Lhermette)
Transabdominal cystoscopy
In animals where the bladder cannot be entered
through the urethra (most notably males), cystoscopy
can be carried out transabdominally. Full details of
this procedure can be found in Chapter 11.
Similar considerations apply as for urethrocysto-
scopy in terms of intervention, but in addition larger
forceps can be introduced alongside the cannula
Ch10 Endo.indd 147
Rigid endoscopy: urethrocystoscopy and vaginoscopy
through the purse-string suture into the bladder to
collect uroepithelial biopsy samples or retrieve calculi.
Additionally, by opening the valve on the cannula and
slowly withdrawing the endoscope whilst infusing the
bladder, calculi that are smaller than the cannula
diameter can be encouraged to flush up and out
through the cannula. When urolithiasis is being
managed in this way, it is important that the urethra is
flushed actively in a retrograde fashion to ensure no
calculi remain in the urethra.
Once transabdominal cystoscopy is complete,
tying the purse-string suture closes the cystotomy,
and the bladder can then be returned to the abdomen.
The mini-laparotomy is closed routinely after deflation
of the pneumoperitoneum.
Laparoscopic-assisted cystostomy
tube placement
A similar approach to transabdominal cystoscopy can
be used in either sex to place a cystostomy tube. In
this instance, the instrument portal is placed in the
caudal flank so that the lateral aspect of the bladder
can be grasped and brought to the skin in a neutral
position. Again, the portal is enlarged sufficiently to
exteriorize the bladder serosal surface and a purse-
string suture is placed. The cystostomy tube (ideally,
a 16–20 Fr mushroom-tipped or De Pezzer catheter)
is placed through the purse-string suture, which is
then tied. In this instance, two additional cystopexy
sutures are placed to secure the bladder to the mini-
laparotomy site, which is then closed routinely.
Vaginoscopy in the bitch
Instrumentation
Generally, rigid endoscopy equipment with an external
sheath and catheter port is most suitable for
examination of the vagina. Endoscopes that are too
large will be unable to penetrate the pseudocervix of
medium-sized and small bitches, and those that are
too short will be unable to reach the cervix in all but
small breeds.
Rigid endoscopes allow better manipulation within
the vagina than do flexible endoscopes, and more
simple passage of flexible catheters or sampling
brushes. In the authors’ opinion, best results are
achieved using a urethrocystoscope with a 30 degree
viewing angle and an external sheath of 1.9–7.3 mm
diameter, according to the size of the bitch. For the
purpose of cervical catheterization it may be helpful if
there is a built-in catheter deflecting device to help
change the direction of the catheter within the cranial
vagina (Figure 10.9).
Patient positioning and restraint
In general, endoscopic examination of the caudal
reproductive tract is well tolerated by bitches, with the
exception of those that are prepubertal or in anoestrus.
At most other times it is possible to undertake the
examination in a standing bitch restrained on a table.
Lateral movement of the animal can be prevented by
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 Chapter 10 Rigid endoscopy: urethrocystoscopy and vaginoscopy

10.9 Urethrocystoscope with built-in catheter

➚
deflecting device in operation, suitable for
cervical catheterization in the bitch.

arranging the table against a fixed wall or with the use

10.10 Normal anatomy of the vulva of the bitch. The
of a belly-band. Some surgeons prefer to elevate the endoscope should not be inserted into the
hindquarters of the bitch using a belly-band, claiming clitoral fossa (black arrow) but should be directed above
that this restricts movement and encourages the the transverse frenular fold into the vestibular opening
abdominal viscera to move cranially and so increase (white arrow).
space within the pelvic canal; however, some bitches
resent this method of restraint. Where a greater level
of restraint is required, low doses of sedative agents
may be useful.

Procedure
The vulval lips should be cleaned of any discharge
prior to insertion of the endoscope. The use of a dilute
disinfectant solution is not necessary but may be (a)
useful for wetting surrounding hairs and therefore
moving them away from the vulva. Lubricating gel
may be applied to the outer sheath but will not
generally be necessary for bitches that are in oestrus.
When lubricants are used it is important not to place
material close to the tip of the endoscope as this
quickly obscures the field of view. Where endoscopy
is required for the purpose of artificial insemination
with semen it is preferable to use physiological saline
as a lubricant, or if a specific lubricant is required to
use oil-based materials which are less toxic to sperm
compared with water-soluble lubricants.
Prior to insertion of the endoscope the position of
the clitoris within the ventral commissure should be (b)
identified (Figure 10.10). The endoscope should be (a) Schematic representation of the direction of
directed above the clitoris through the dorsal 10.11
endoscope insertion into the caudal
commissure of the vulva, or the bitch may exhibit pain reproductive tract of the bitch. (b) Correct angle of
when the endoscope is introduced. insertion of the endoscope into the vestibule.
The endoscope is normally angled dorsally towards
the base of the tail to facilitate its introduction into mucosal fold and require redirection. This can usually
the vestibule and it can be pushed gently forwards in be achieved by visualizing the lumen of the vagina as
this direction to ensure the tip of the endoscope does the endoscope is advanced. Pushing the endoscope
not penetrate the external urethral orifice. When the into a vaginal fold may result in some discomfort to
endoscope reaches the level of the external urethral the bitch.
orifice the angle is normally changed so that the In some cases insufflation of air through one of the
endoscope is parallel with the pelvis (Figure 10.11). endoscope ports may be useful to push the vaginal
There may be minor resistance to passage of the wall away from the endoscope; this can be achieved
endoscope from the vestibule into the vagina. In most either using a low-pressure pump or by the sporadic
cases the endoscope will pass along the length of the injection of air from a 60 ml syringe. If the purpose of
vagina quite easily, although in some cases as the the examination is to assess the appearance of the
endoscope is advanced it may become lodged on a vaginal wall to evaluate the stage of the oestrous

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 Chapter 10
cycle, however, it is best not to use insufflation. In
some bitches that are in oestrus there may be a
significant volume of haemorrhagic fluid within the
vaginal lumen. This can obscure the view and can be
overcome either by insufflation, by aspiration of the
fluid, or by lavage of the vaginal cavity with a large
volume of sterile saline. Obstruction of the field of
view for other reasons such as debris, mucus or
moisture can be dealt with by removal of the
endoscope, rinsing of the tip in warm sterile saline
and then reinsertion.
When the endoscope reaches the area of the
pseudocervix there is an obvious reduction in the
diameter of the vagina (caused predominantly by the
large dorsal vaginal fold), which may result in some
difficulty in advancing the endoscope. In many cases
it is easiest to advance the endoscope lateral to,
rather than ventral to, this fold.
As the endoscope reaches the level of the cervix
it may be difficult to identify the position of the
cervical os, the opening of which is usually present
on the ventral aspect of the cervix; significant mani-
pulation of the endoscope may be necessary to
move the position of the cervix to facilitate identifica-
tion of the os.
Hysteroscopy can only be performed in the
immediate post-partum period. At this stage the uterus
has a larger size than normal, usually the endometrium
is folded and a lochial discharge is present upon the
endometrial surface. A slightly protuberant oviductal
papilla may be identified, usually on the dorsomedial
aspect of the uterine wall.
Normal findings
Non-oestrous bitch
The vestibule has a relatively flat and pink mucosa.
After passage of the endoscope over the external ure-
thral orifice, the longitudinal vaginal folds become very
apparent. When the bitch is not cycling (either anoe-
strus or mid to late met/dioestrus) these folds have a
low height and a relatively thin appearance. This
means that the underlying vasculature can be seen,
and overall the folds appear red or pink–red (Figure
10.12). The mucosa is dry or relatively tacky in appear-
ance, and lubrication is warranted in most cases.
When the vaginal folds are examined in profile
they have a round and flaccid appearance. If there is
significant insufflation of the vagina with air the folds
may be compressed and become difficult to see.
10.12
Endoscopic
appearance of the
caudal vagina of a
bitch in anoestrus.
The mucosa is
relatively dry and
red, with small
folds.
Ch10 Endo.indd 149
Rigid endoscopy: urethrocystoscopy and vaginoscopy
As the endoscope is advanced, multiple larger
folds can be identified; there may be up to six or seven
larger folds protruding inwards. It may be helpful to
have a catheter within one of the endoscope ports to
push the vaginal wall away from the tip of the
endoscope and facilitate identification of the vaginal
lumen. Approximately midway along the vagina the
pseudocervix is reached, evidenced by the large
dorsal median fold – a large and consistent landmark.
In small or maiden bitches it may be necessary to use
a smaller endoscope than normal to pass beyond this
region. The dorsal fold continues cranially to the level
of the cervix. In the non-oestrous bitch the fold
appears as a continuous structure, although during
pro-oestrus and oestrus it appears divided along its
length into three equal-sized zones called tubercles
(Figure 10.13).
Cranial tubercle Caudal tubercle
Middle tubercle (pseudocervix)
10.13 Schematic representation of the differentiation
of the dorsal median fold into three distinct
tubercles. This is normally evident when examinations are
conducted during oestrus.
In the cranial vagina the cervix can be readily
identified as a rounded structure originating from the
dorsal wall of the vagina and projecting in a ventral
direction. Normally the cervical os faces downwards
and is not immediately in view; it is the dorsal surface
of the cervix that is initially seen. The endoscope may
be manipulated under the cervix, enabling the cervi-
cal os to be visualized. The endoscope may be
pushed beyond the cervix into the blind-ending
cranial vaginal pouch.
Cyclical changes
The hormonal changes that occur during the onset of
pro-oestrus, oestrus and the early luteal phase have
a direct effect upon the vaginal epithelium, resulting in
an initial proliferation and oedema of the mucosa, a
subsequent reduction in oedema, and finally sloughing
of the epithelium. These changes can be readily
detected with vaginoscopic examination.
During pro-oestrus, increased plasma oestrogen
concentrations cause thickening of the vaginal
mucosa, which becomes a keratinized squamous
epithelium. This is essentially a mechanism to protect
the normally thin vaginal mucosa from potential
trauma at the time of mating. Under the influence of
oestrogen there is also significant oedema of the
vaginal wall. A subsequent decline in oestrogen and
slight increase in plasma progesterone initiates
oestrus, at which time the bitch will allow mating. The
reduction in oestrogen is associated with a reduction
in oedema. The rise in plasma progesterone
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 Chapter 10 Rigid endoscopy: urethrocystoscopy and vaginoscopy
concentration (a result of preovulatory luteinization)
and the low oestrogen-to-progesterone ratio causes a
surge in luteinizing hormone (LH) from the pituitary
gland. Most ovulations commence 48 hours after
peak LH concentrations are reached. High concen-
trations of progesterone occur approximately 7 days
after ovulation, after which time the proliferated
epithelium starts to slough.
Endoscopically, at the onset of pro-oestrus the
mucosa becomes thickened and oedematous due to
the increase in plasma concentrations of oestrogen.
The mucosal folds therefore appear greatly enlarged,
thickened and oedematous (Figure 10.14). Serosan-
guineous fluid can be observed within the lumen and
may be seen to exit from the cervix. This is a stark
change in appearance from the relatively thin, flat and
dry mucosa noted during anoestrus. Furthermore,
there is a considerable change in colour of the
epithelium, which changes from being red with clearly
visible vessels to pink or pink/white.
10.14 Endoscopic appearance of the mid-vagina of a
bitch in late pro-oestrus/early oestrus. The
mucosa is oedematous and relatively thickened and has
an obvious white colour. The mucosa is arranged in larger
rounded folds than in the non-oestrous bitch.
As pro-oestrus progresses, the mucosal surface
become progressively less pink and typically appears
white, because the thickened mucosa prevents the
underlying capillaries (that were visible during anoe-
strus) from being seen. In late pro-oestrus or early
oestrus, at approximately the same time as the LH
surge, there is a progressive shrinking of the folds that
is accompanied by further pallor. These effects are the
result of an abrupt withdrawal of oestrogen. Oestrogen
concentrations decline rapidly during and following
the LH surge. Subsequently, over the next several
days, mucosal shrinkage is accompanied by gross
wrinkling of the mucosal folds and they now develop
a distinctly angulated appearance but remain a dense
cream to white colour. The epithelial peaks become
sharp-tipped and irregular in appearance (Figure
10.15). The mucosa also starts to look drier, and in
many bitches there is a change to a clear/creamy col-
our to any discharge originating from the cervix.
150
Ch10 Endo.indd 150
10.15
Endoscopic
appearance of the
mid-vagina of a
bitch on days
(a) 3 and (b) 5
after ovulation. The
mucosa remains
thick but there is
extensive wrinkling
and angulation of
the mucosal fold
(a) profiles compared
with early oestrus.
(b)
There is progressive flattening of the epithelium,
which develops a concertina-like appearance. At the
end of the fertile period there is rapid shedding of
the epithelial surface. Sometimes passage of the
endoscope lifts large sheets of cells from the vaginal
wall. Complete shedding of the epithelium is usually
completed within 48 hours. The mucosal folds
become less distinct and are clearly softer and
flaccid. The surface of the mucosa at this time
becomes variegated in colour with white patches
mixed with areas of red thin epithelium. Finally, as
the luteal phase progresses (whether pregnant or
non-pregnant), there is a reduction in the diameter of
the lumen, similar to that seen in the anoestrus bitch.
Initially there is apparent contraction of the folds,
producing a rosette appearance. Thereafter the flat,
dry and red epithelium is similar to that observed
during anoestrus. The progressive changes from
pro-oestrus through oestrus to the luteal phase can
be used to assess the optimal time for breeding, as
discussed later.
Pathological conditions
The presence of a coloured discharge from the
external urethral orifice may be a useful finding, since
it confirms that pathology is associated with the
urinary tract rather than the genital system.
Urethra
Disorders of the urethra can be generally classified as
functional or structural. The important functional
disorders result in urinary incontinence or dysuria.
Urinary incontinence can also be due to structural
disorders but often is a result of overall loss of the
sphincter mechanism of the urethra.
4/3/08 09:44:21
 Chapter 10
Urethral sphincter mechanism incompetence
USMI is a multifactorial disorder, more commonly
encountered in bitches than in male dogs or in cats. It
is typically seen as an acquired disease of adult
neutered bitches but does occur less commonly in
young animals, where it may be considered congenital,
and in entire adults. Although USMI is often associated
with a short urethra and intrapelvic bladder neck, this
is not invariably the case, and in some cases there is
no detectable anatomical abnormality. In these
animals, urethrocystoscopy will be unremarkable and,
although a judgement of urethral length may be made
endoscopically, a more consistent and comparable
judgement of both urethral length and bladder neck
position is obtained with retrograde vagino-
urethrography. Since USMI is often a disease of
neutered bitches, and thought to be related to absence
of endogenous oestrogens, endoscopy may reveal a
relative lack of folding of the urethral mucosa, although
this finding is not invariably present and can be difficult
to appreciate. Other animals with USMI may have
urethral structural abnormalities, such as cystic
urethral dilatation (more commonly encountered in
males than females), or urovagina (a form of
anatomical intersex resulting in a continuity of the
vestibule with the urethra and absence or dorsal
deviation of the vagina). USMI is also recognized to
be exacerbated by UTI and by obesity. In general,
however, most affected animals show no abnormalities
on physical or endoscopic examination.
Urethral dys-synergia
Inappropriate contraction of the urethra (urethro-
spasm) during micturition is an occasional cause of
dysuria in males and females. Generally classified as
urethral dys-synergia, it is a poorly characterized dis-
order and is typically a diagnosis of exclusion: since
many cases are idiopathic, by definition there are no
detectable structural abnormalities. In these cases
the prognosis is guarded because of the tendency for
the disease to be recurrent, even though each epi-
sode is usually self-limiting. Urethral spasm also
occurs in animals with other urethral conditions (e.g.
irritation after use of an indwelling catheter) and in
males with prostatic disease.
Urethral obstruction
Physical obstruction of the urethra is more common
than dys-synergia. The most frequent cause in males
is the presence of calculi (dogs) or accretions of
calculus and mucus (cats). The feline male urethra is
not amenable to endoscopy (except with endoscopes
of very small diameter), but in dogs it may be possible
to identify the calculi using urethroscopy. In most
instances, radiographic evaluation may be more
appropriate for diagnosis, since the bladder and
urethra are readily examined concurrently. Retrograde
urethrography and double-contrast cystography are
recommended. In the bitch, urethral obstruction is
more commonly associated with mucosal lesions of
the urethra, in particular neoplasia (Figure 10.16).
Grossly similar lesions include granulomatous
urethritis and urethral caruncle. In each case,
endoscopic or radiographic examination will reveal
Ch10 Endo.indd 151
Rigid endoscopy: urethrocystoscopy and vaginoscopy
10.16
(a) Early and
(b) severe
transitional cell
carcinoma in the
canine urethra.
(Courtesy of
P Lhermette)
(a)
(b)
proliferative mucosal lesions obscuring the urethral
lumen, usually circumferentially and along variable
lengths of the urethra. In most cases, biopsy is
required to distinguish these pathologies, although
radiographs of the thorax may identify metastatic
disease, as may ultrasonography of the caudal
abdomen (sublumbar lymphadenopathy).
Prostate
Prostatic diseases are common in older male dogs,
particularly entire animals, but may not be readily
diagnosed on urethroscopy. However, prostatic
carcinoma is often advanced at the time of examination
and may be recognized by the presence of proliferative
tissue protruding into the lumen of the prostatic
urethra. Diagnosis of prostatic disease is more readily
achieved in most cases by a combination of retrograde
urethrography, ultrasonography and biopsy.
Ureters
Ureteral ectopia
Ureteral ectopia is the second commonest cause of
urinary incontinence in dogs, especially in bitches,
and although it is most frequently diagnosed in juve-
niles, it accounts for a significant proportion of animals
with an adult onset of incontinence. In normal animals,
the ureters enter the bladder at the trigone. When
ectopic, the ureteral opening is distal to this, typically
in the urethra. In most male dogs, the ureter enters the
prostatic urethra; in bitches it is variable in position,
positioned anywhere from the bladder neck to the ure-
thral papilla. Entrance into the vagina away from this
site or the uterus is reported but appears to be rare.
The situation in the cat is similar, although the disease
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 Chapter 10 Rigid endoscopy: urethrocystoscopy and vaginoscopy

is much rarer in this species. In dogs the course of the acute UTI is unlikely to be helpful but in chronic cases
ectopic ureter is usually intramural, whereas in cats it significant abnormalities may be encountered. In
is typically extramural. Intramural ureters enter the established cases it is important to rule out the
serosal surface of the bladder at the trigone, in the possibility of complicating factors, including polypoid
normal position, but do not perforate the bladder wall cystitis (Figure 10.19), neoplasia of the bladder
fully; rather, they run within the thickness of the blad- (Figure 10.20) or urethra, and urolithiasis (see below).
der and urethral wall. Extramural ectopic ureters do Polypoid cystitis and most cases of bladder neoplasia
not enter the bladder at all but run within the abdomen
and pelvic canal to enter the urethra directly.
10.18
Urethroscopy is recognized as a very sensitive tool in
the diagnosis of ureteral ectopia, since the ectopic (a) Endoscopic
openings can be readily identified (Figure 10.17) and appearance of
in addition the trigone can be examined to confirm the feline idiopathic
interstitial cystitis.
absence of the normal orifice.
(Courtesy of
T McCarthy)
10.17 (b) Endoscopic
appearance of
Endoscopic moderate to severe
appearance of an cystitis. (Courtesy
ectopic ureter. (a) of P Lhermette)
(Courtesy of
P Lhermette)

In addition to the simple situation of ectopia, ure-

throscopy is likely to be of value in the confirmation of
ectopic ureters with more than one orifice and ure- (b)
teral troughs. The latter situation is when the ureter
opens at the trigone but the orifice is elongated into
an extreme slit, passing beyond the bladder neck and 10.19
into the urethra; this rare condition is a diagnostic Polypoid cystitis in
challenge except by cystotomy, unless urethroscopy the dog. (Courtesy
is available. Although urethroscopy is a very useful of P Lhermette)
tool for the diagnosis of ureteral ectopia it gives no
information about the more proximal ureter or the kid-
ney; given the significant incidence of concurrent
hydroureter, hydronephrosis and pyelonephritis, ultra-
sonography and/or excretory urography are required
in addition to endoscopy for a complete evaluation
and surgical planning.

Ureteroceles
Ureteroceles are cystic dilatations of the terminal
ureter, usually occurring concurrently with ureteral
ectopia. They are also reported to accompany blind-
ending ureters and possibly normal ureters with ter-
minal strictures. Their significance is not always clear
but they have been associated with both incontinence
and dysuria. Urethroscopy would be expected to be a
useful method of diagnosis, although this has not
been reported.

Bladder

Urinary tract infection

Cases in the bladder are commoner than those in the
urethra, although uncomplicated UTI accounts for
many of these cases (Figure 10.18). Cystoscopy of

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 Chapter 10
10.20
Endoscopic
appearance of
(a) transitional cell
carcinoma in the
trigone and
proximal urethra
and (b) transitional
cell carcinoma in
the bladder wall.
(Courtesy of
P Lhermette)
(a)
(b)
both produce proliferative lesions of the bladder
epithelium that can be detected on cystoscopy. The
site of predilection for each condition varies (although
this cannot be relied upon diagnostically): polypoid
cystitis often affects the ventral pole of the bladder but
transitional cell carcinoma (the most frequent
neoplasm) is typically centred on the trigone.
Urolithiasis
Urolithiasis (Figure 10.21) is encountered in cats and
dogs of both sexes, although males tend to present
with urethral obstruction and females with signs of
cystitis or haematuria. There are several types of
stone reported (see BSAVA Manual of Canine and
Feline Nephrology and Urology), but the commonest
in both species is struvite. Diagnosis of urolithiasis
can be established by various imaging modalities but
Endoscopic appearance of uroliths. The round
10.21
structure at the top left of the image is the
inflated bulb of a Foley catheter. (Courtesy of P Lhermette)
Ch10 Endo.indd 153
Rigid endoscopy: urethrocystoscopy and vaginoscopy
cystoscopy has the advantage of offering the chance
of both diagnosis and treatment by retrieval of the
stones (see above), in selected cases.
Reproductive tract
Lymphoid follicles
A common finding in the bitch is the presence of
multiple lymphoid follicles on the vestibular or vaginal
wall (see Figure 10.22). These lesions are usually
multiple, small (1–3 mm in diameter) and pale or white
in appearance. Some bitches have a concurrent UTI.
The follicles appear to be a normal response to
vaginal bacteria and do not require treatment. These
lesions need to be differentiated from herpesvirus
vesicles, which may initially be vesicular in nature
(2–3 mm in diameter) and if ruptured may develop
into smaller focal red raised lesions. Herpesvirus
lesions are most commonly observed in previously
infected bitches that are in pro-oestrus or oestrus, as
there is viral recrudescence at these times.
Remnant hymen/persistent hymen/
paramesonephric septum
In some bitches that experience pain during coitus,
the presence of remnant tissue immediately cranial to
the external urethral orifice may be detected using
vaginoscopy.
The normal hymen is a thin membrane separating
the vagina from the vestibule and failure of this to
break down completely may result in thin ‘strings’ of
tissue obstructing the vaginal cavity. A complete
hymen (imperforate) with bulging of the membrane
because of trapped fluid is occasionally seen.
In some bitches, where there has been inaccurate
development of the paramesonephric duct system, a
ventrodorsal band of tissue or partial vaginal septum
may be present (Figure 10.22) Vaginoscopy may be
used to place ligatures around hymenal remnants to
allow their sectioning. Alternatively, the remnant may
be sectioned with a diode laser or even with scissors
under endoscopic control. Rarely, an episiotomy may
be required.
10.22
Endoscopic
appearance of a
paramesonephric
remnant. Note
multiple nodules
due to lymphoid
hyperplasia.
(Courtesy of
P Lhermette)
Vestibulovaginal stenosis
In some cases there may be an appreciable narrowing
of the vestibulovaginal junction, although this is often
better appreciated using digital palpation or contrast
radiography. It is normal for this area to be approx-
imately one half the diameter of the vagina. In cases
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 Chapter 10 Rigid endoscopy: urethrocystoscopy and vaginoscopy

of vestibulovaginal stenosis, there may be evidence Assessment of breeding time in

of fluid pooling cranial to the stenosis, and signs of the bitch
vaginitis. The clinical importance of this condition is
often minimal; although it has been reported to be The most common cause of infertility in the bitch is
associated with urinary incontinence, the epidemio- associated with a normal female that is simply mated
logical evidence for this is poor. at an inappropriate time. Bitches ovulate approx-
imately 12 days after the onset of pro-oestrus, but
Vaginal hyperplasia some normal bitches may ovulate as early as day 5
Thickening of the vaginal wall during oestrus is normal; whilst others ovulate as late as day 30. Many dog
however, in a small number of bitches there is exces- breeders try to impose standard mating regimes, for
sive tissue proliferation. Often this originates immedi- example, days 10 and 12. For many bitches this is not
ately cranial to the external urethral orifice, and a appropriate and, although both the male and female
tongue-shaped mass of hyperplastic vaginal tissue are normal, there is no resultant pregnancy. Careful
may be identified. The tissue is only present during monitoring of oestrus is important to establish the time
oestrus and regresses in the luteal phase. These cases of ovulation and therefore the most appropriate time
are normally presented because of pain at attempted for mating (Figure 10.23). Observation of the behav-
coitus. It is often difficult to advance the endoscope iour of the bitch has limited value, and whilst the gold
into the vagina because it persistently abuts the ventral standard for evaluation is measurement of plasma
margin of the hyperplastic tissue. In some bitches the progesterone, the use of vaginoscopy provides a
first signs may be when the tissue becomes so large rapid, simple and cost-effective method of assessing
that it protrudes from the vulval lips. the underlying hormonal changes. Examination is nor-
mally performed with the bitch standing. In most cases
Vaginal polyps it can take as little as 2 minutes to make an evaluation
Vaginal polyps are relatively common, particularly in of the stage of the cycle. One specific advantage of
older intact bitches. They are most commonly vaginoscopy is the ability to detect the end of the fer-
asymptomatic, although they may be associated with tile period; something that is difficult to achieve by
vaginitis. Polyps usually have a thin stalk-like measurement of plasma hormone concentration.
attachment to the vaginal wall, whilst the polyp itself is
usually rounded, smooth and pink/white in colour.
Period Days from Days from
Vaginal neoplasia LH surge ovulation
Vaginal tumours are not uncommon. The most
frequently seen are leiomyomas, or in some countries Period of potential fertility – the –3 to +7 (or –5 to +5 (or
in Europe, Africa and the United States a transmissible ‘fertile period’ later) later)
venereal tumour (TVT) may be identified. Tumours Period of potential fertilization +4 to +6 (or +2 to +4 (or
may be intraluminal or extraluminal. The intraluminal of mature oocytes – the later) later)
leiomyomas usually have a wide-based attachment, ‘fertilization period’
whilst extraluminal tumours often press on, and
distort, the normal outline of the vagina. Both have a Time of oocyte maturation +4 to +5 +2 to +3
(estimated)
thick fibrous white capsule, although there may be
prominent vessels visible. TVTs are often irregular, Period of peak fertility in 0 to +6 –2 to +4
red and have ulcerated areas. bitches of high fertility at
natural mating
Abnormalities of the cervix
Observation of the cervix may document abnormalities Preferred time for managed +2 to +6 0 to +4
that interfere with the establishment of normal preg- breeding of natural service or
fresh semen insemination
nancy. Non-patency of the cervix or severe adhesions
or fibrosis may cause such problems. Examination of Time for critical managed +4 to +6 +2 to +4
the cervix may also be useful for investigation of bitches breeding or frozen semen
with a vulval discharge. During pregnancy this may be artificial insemination.
associated with resorption or abortion, or bleeding from
Period of reduced fertility with +7 to +9 +5 to +7
the marginal haematoma of the placenta. Documentation matings or inseminations late
of the site and the nature of the discharge may influ- in oestrus
ence the management of these cases.
In the non-pregnant bitch the nature of the dis- The timing of peak fertility in relationship to the
10.23
charge can be assessed and it may be possible to day of the LH surge and day of ovulation.
collect material for cytological and bacteriological
screening. Vaginoscopic evaluation is based upon assessment
of the appearance of the vaginal wall (the mucosal
Endometrial disease fold contours and profiles, the colour of the mucosa
For a more accurate assessment of endometrial and of any fluid present), and the changes in this
disease it is necessary to catheterize the cervix, either appearance at specific times of the oestrous cycle. A
to allow direct endoscopic visualization of the endo- specific scoring system was devised by Lindsay et al.
metrial surface, or to enable collection of material for (1988) and has been modified by the author [GE] as
cytological and bacteriological investigation. below (Figure 10.24):

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Ch10 Endo.indd 154 4/3/08 09:44:22

 Chapter 10 Rigid endoscopy: urethrocystoscopy and vaginoscopy

Phase I Phase O Phase O Phase S1

Phase S2 Phase A1 Phase A2 Phase A3

Phase D1 Phase D2 Phase D3 Phase D4

10.24 Vaginoscopic appearance from late anoestrus through pro-oestrus and oestrus
and into the early luteal phase. See text for explanation.

Phase I

• nacti e phase characteri ed by a thin red and • An lated phase characteri ed by a thic ened
dry mucosa with low and flattened mucosal folds. mucosa that is normally white but where there is
This appearance is designated I significant reduced turgidity such that in profile
• edemato s phase characteri ed by a the mucosal folds have progressive shrinkage
thickened and oedematous mucosa that appears and angulation such that the peaks are sharp-
turgidly swollen, rounded and grey/white in tipped and irregular in appearance. The mucosa
colour. Folds with this appearance are is wrinkled and shrunken in appearance. The
designated O progressive nature of this phase means that the
• hrin a e phase characteri ed by a thic ened early changes are designated A1 and the later
mucosa that is normally white but where there is changes A2 and A3
reduced turgidity with progressive furrowing, • Declining phase: characterized by a progressive
wrinkling and indentations. The mucosal fold decline in the size of the mucosal fold profile.
profile is, however, still rounded rather than Early in the phase (designated D1) there is a
angular. The progressive nature of this phase flaccid appearance to the mucosal fold profile.
means that the early changes are designated S1 Subsequently, the folds become more rounded
and the later changes S2 (D2) and there is sloughing of the cornified layers

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 Chapter 10 Rigid endoscopy: urethrocystoscopy and vaginoscopy
of the epithelium (D2 and D3), resulting in a thin
mucosa of variegated colour with flattened folds
and a rosette appearance to the mucosa (D4)
• nacti e phase the decline phase is followed catheter through the cervix. In most cases a 2.5 mm
by a return to a phase characterized by a thin,
red and dry mucosa with low and flattened
mucosal folds. This appearance is also
designated I. There may be more debris present
at this stage than found in phase I prior to the
onset of pro-oestrus.
Studies that have related the appearance of the
vaginal wall to the underlying endocrinology have
demonstrated a progression as described above in all
bitches. The specific timing of some events is variable
but a good correlation has been demonstrated
between the onset of ovulation and phase A1, and a
good relation between the fertilization period and
phases A1 to A3 (Figure 10.25). Generally, the onset
of the fertile period can be detected by observing the
onset of mucosal shrinkage without excessive
angulations, whilst gross shrinkage of entire mucosal
folds with obvious angulation (phase A2 and A3) is
characteristic of the fertilization period.
Breeding is best planned approximately 4 days
after the first detected mucosal shrinkage, or at the
onset of the period of obvious angulation of mucosal
folds. The end of the fertilization period can be
detected by observing sloughing of the vaginal
epithelium and development of a variegated
appearance to the colour of the mucosal surface.
Cervical catheterization
It is difficult to place a catheter through the cervix of a
bitch because the vagina is long and narrow, and the
cervical opening is small and at an angle to the vagina.
The procedure is not possible in queens.
Fertile period
I I O O O S1 S2 A1 A2
Ovulation
–12 –10 –8 –6 –4 –2 0 2
156
Ch10 Endo.indd 156
For cervical catheterization it is normal to use a
semi-flexible urinary catheter with terminal rather than
side holes. A guide wire will help with introducing the
diameter catheter is suitable, although in small breeds
or previously non-pregnant bitches a 2 mm diameter
catheter may be necessary.
Using a rigid endoscope the cervix can be visual-
ized and the endoscope then manipulated under the
cervix until the os can be identified. The os is usually
located in the centre of a rosette of wrinkles/furrows
but sometimes its location can only be identified by
the presence of fluid originating from it. A fine catheter
may then be placed through the endoscope towards
the cervical os. In many cases it is necessary to place
a guide wire inside the catheter to increase rigidity.
Once the catheter tip is placed into the os, the guide
wire may be withdrawn slightly, and the catheter
pushed forward (using a rotating action). The catheter
can normally be introduced the full length of the uter-
ine body. The technique requires training and practice
before catheterization can be achieved reliably.
Catheterization is simplest in medium-sized dogs,
and most difficult in giant breeds (with a very long
vagina) and toy breeds (where the size of the catheter
may be too large). Some bitches need to be sedated,
otherwise movement of the bitch makes placement of
the catheter very difficult. The cervix is most simple to
catheterize during oestrus; however, the cervix is also
relaxed during anoestrus and pro-oestrus; catheteri-
zation during the luteal phase can be difficult in some
bitches. Catheterization during oestrus is most com-
monly performed for the purpose of artificial insemi-
nation. However, material for microbiological and
cytological investigation may be collected from the
endometrial surface by aspiration, or the use of small
brushes passed through the catheter.
In the post-partum bitch the endoscope may be
passed directly through the cervical os to enable
visualization of the endometrial surface.
10.25 Relation between
vaginoscopic score,
Fertilization period time of ovulation, fertile and
fertilization periods, and plasma
progesterone concentrations in
bitches.
A3 D1 D2 D3 D4 I I I
Plasma progesterone
4 6 8 10 12 14
4/3/08 09:44:24
 Chapter 10
Postoperative care
Postoperative care in uncomplicated cases requires
no special precautions: routine analgesia is ade-
quate. Antibacterial therapy is used at the surgeon’s
discretion: it is recommended that urine is collected
at the time of endoscopy and submitted for bacterio-
logical examination. If UTI is suspected, then a short
course of broad-spectrum antibiotics can be pre-
scribed whilst culture is pending. Perioperative anti-
biotics should be used during transabdominal
procedures if UTI is suspected.
Urination patterns should be monitored carefully
for the first 24 hours after surgery: dysuria may sug-
gest that urethral obstruction is present (perhaps due
to urethrospasm, incomplete removal of uroliths or
urethral trauma) or that urethritis or cystitis is present.
In the former instance, the bladder is likely to be tense
and full; in the latter cases, it will be small and empty.
Obstructed animals require further investigation but
may benefit from urethral muscle relaxants (e.g.
diazepam or phenoxybenzamine) if urethrospasm is
suspected; they should have an indwelling urethral
catheter placed if the problem is persistent.
If urination is not observed, the possibility of blad-
der or urethral rupture should be considered and evi-
dence sought for accumulation of fluid in the peritoneum
or within the pelvic canal (e.g. by ultrasonography). If
uncertainty remains, retrograde urethrography is likely
to be more sensitive than repeated urethroscopy to
identify a urinary tract perforation.
Complications
Complications relate primarily to iatrogenic trauma to
the vagina, urethra or bladder. Unnecessarily forceful
technique or excessive infusion pressure, particularly
in patients with diseased tissue, may result in tears or
perforations of these organs. This may become
apparent during the procedure, e.g. distension may
not be maintained or extraluminal tissue may be seen
during endoscopy, or only become apparent after
some hours. Although there is little published
information on the management of this type of
complication, experience of other types of urinary
tract trauma suggests that many cases would be
amenable to conservative management, using an
indwelling urethral catheter to maintain bladder
decompression for 2–5 days. If a more aggressive
Ch10 Endo.indd 157
Rigid endoscopy: urethrocystoscopy and vaginoscopy
approach to management (direct repair) is considered,
retrograde urethrocystography should be used to
confirm the site of rupture (intrapelvic or intra-
abdominal) before exploratory surgery. This is also
the technique of choice to confirm that the tear has
healed after management.
Similar to other urinary tract interventions, post-
operative UTI may occur. The value of perioperative
antibacterial therapy for uncomplicated urethroscopy
is not known, but it is a reasonable precaution,
particularly if preoperative UTI is suspected or trauma
occurs during the procedure.
A mild and transient haemorrhagic vulval discharge
or, rarely, vaginitis may occur following diagnostic
vaginoscopy of non-oestrous bitches. This is extremely
uncommon for bitches examined during oestrus.
Perforation of the uterus has been reported
occasionally following hysteroscopy.
References and further reading
Barth A, Reichler IM, Hubler M, Hassig M and Arnold S (2005) Evaluation
of long-term effects of endoscopic injection of collagen into the urethral
submucosa for treatment of urethral sphincter incompetence in female
dogs: 40 cases (1993-2000). Journal of the American Veterinary
Medical Association 226, 73–76
Cannizzo KL, McLoughlin MA, Mattoon JS, et al. (2003) Evaluation of
transurethral cystoscopy and excretory urography for diagnosis of
ectopic ureters in female dogs: 25 cases (1992–2000). Journal of the
American Veterinary Medical Association 223, 475–481
Davidson EB, Ritchey JW, Higbee RD, Lucroy MD and Bartels KE (2004)
Laser lithotripsy for treatment of canine uroliths. Veterinary Surgery
33, 56–61
Jeffcoate IA and England GCW (1997) Urinary LH, plasma LH and
progesterone and their clinical correlates in the periovulatory period
of domestic bitches. Journal of Reproduction and Fertility Suppl. 51,
267–275
Lindsay FEF (1983) The normal endoscopic appearance of the caudal
reproductive tract of the cyclic and non-cyclic bitch: post uterine
endoscopy. Journal of Small Animal Practice 24, 1–5
Lindsay FEF, Jeffcoate IA and Concannon PW (1988) Vaginoscopy and
the fertile period in the bitch. Proceedings of the 11th International
Conference on Animal Reproduction and Artificial Insemination,
Dublin, abstract 565
Messer JS, Chew DJ and McLoughlin MA (2005) Cystoscopy: techniques
and clinical applications. Clinical Techniques in Small Animal Practice
20, 52–64
Samii VF, McLoughlin MA, Mattoon JS, et al. (2004) Digital fluoroscopic
excretory urography, digital fluoroscopic urethrography, helical
computed tomography, and cystoscopy in 24 dogs with suspected
ureteral ectopia. Journal of Veterinary Internal Medicine 18, 271–
281
Simpson GM, England G and Harvey M (1998) BSAVA Manual of Small
Animal Reproduction and Neonatalogy. BSAVA Publications,
Cheltenham
Wang KY, Samii VF, Chew DJ, et al. (2006) Vestibular, vaginal, and urethral
relations in spayed dogs with and without lower urinary tract signs.
Journal of Veterinary Internal Medicine 20, 1065–1073
157
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 Chapter 11 Rigid endoscopy: laparoscopy
11
Rigid endoscopy: laparoscopy
Eric Monnet, Philip Lhermette and David Sobel
Introduction
Exploratory laparotomy is a major invasive procedure,
often carried out on a sick or debilitated patient.
Clinicians may hesitate to put their patient through
such a procedure, and may therefore rely on incom-
plete information from indirect observations such as
blood tests and other imaging studies to form their
diagnosis. Owners may also be reluctant to subject
their pet to major surgery ‘just to get a sample’.
Laparoscopy is a minimally invasive surgical tech-
nique used in veterinary practice for diagnostic proce-
dures and surgical treatment of a variety of conditions.
It is a very safe technique if the basic rules are fol-
lowed. Laparoscopy enables surgeons to carry out a
thorough visual inspection of the abdominal cavity
and obtain tissue samples quickly, with minimal
trauma to the patient. This in turn allows more accu-
rate diagnosis, treatment of abdominal disease or
staging of tumours. Soft tissue trauma is minimized,
biopsy samples are larger and more diagnostic than
percutaneous Tru-cut needle biopsy samples, and
haemorrhage can be controlled directly. Patient recov-
ery is quicker than following conventional surgery,
and smaller incisions result in a reduced incidence of
postoperative wound interference and infection.
Laparoscopy requires a basic set of specialized
equipment. This is equipment that can be used for dif-
ferent rigid endoscopic applications such as thoraco-
scopy, urethrocystoscopy, rhinoscopy and otoscopy.
Laparoscopy also requires the induction of a pneumo-
periteoneum to allow distension of the abdominal cav-
ity with an inert gas to obtain a working space sufficient
to perform diagnostic and surgical procedures. After
the basic technique of diagnostic laparoscopy is mas-
tered and the appropriate indications learned, these
procedures become an easy and rewarding addition
to any small animal veterinary practice.
Instrumentation
The basic equipment required for diagnostic
laparoscopy is listed in Figure 11.1. Much of this
equipment is also used for other minimally invasive
procedures such as otoscopy, rhinoscopy, cystoscopy
and thoracoscopy. The telescope most commonly
used by the authors for laparoscopy is a 5 mm
diameter forward-viewing telescope. This can be
used on all sizes of dogs and even cats, although the
158
Ch11 Endo.indd 158
2.7 mm 30 degree telescope is often used in cats and
small dogs. If used through a 3.9 mm cannula, it is
essential to place the telescope in an examination
sheath first as any leverage on the bare insertion tube
is very likely to damage the endoscope irreparably. A
2.7 mm telescope can also be used on medium-sized
dogs; however, the smaller field of view and decreased
light transmission limits its usefulness. Telescopes
with a 5 mm diameter do not require a protective
sheath and can be used directly through the operating
Essential equipment
Endoscopic camera and monitor
Sterile camera drape
Xenon (or metal halide/halogen) light source
Light guide cable
Electrosurgery unit (monopolar/bipolar)
Carbon dioxide insufflator
Veress needle
Sterile insufflation tubing
2.7 mm 18 cm HOPKINS 30 degree endoscope
(14.5 Fr cystoscopy sheath with 5 Fr instrument channel)
(7 Fr 40 cm biopsy forceps)
(7 Fr 40 cm grasping forceps)
3 mm examination sheath
3.9 mm Ternamian EndoTIP® cannula or 3 mm operating cannula and
sharp trocar
5.0 mm 29 cm HOPKINS 0 degree endoscope
(5.0 mm 29 cm HOPKINS 30 degree endoscope)
6 mm laparoscopic cannula with sharp trocar (x3) or 6 mm Ternamian
EndoTIP® cannulae (x3)
11 mm laparoscopic cannula with sharp trocar
11/6 mm reducing valve
5 mm endoscopic biopsy forceps (cup and/or punch type)
5 mm endoscopic grasping forceps
5 mm endoscopic Babcocks forceps
5 mm endoscopic scissors
5 mm palpation probe with cm markings
Normal saline or sterile deionized water ( 1 litre)
Standard laparotomy surgical kit
Useful additions
Image capture device (still and video)
5 mm bipolar cutting devices (e.g. Hotblade®, LigaSure®)
5 mm suction/irrigation cannula
Monopolar hook dissector
5 mm bowel handling forceps
5 mm endoscopic clip appliers
10 mm endoscopic gastrointestinal anastomosis (GIA) stapler
5mm needleholders
11.1 Equipment required for laparoscopy.
5/3/08 11:41:49

cannula. Operating telescopes with a working channel
to pass instruments into the abdominal cavity are
available but are not generally recommended for
surgical intervention as tissue handling becomes a
limiting factor. Laparoscopes as large as 10 mm are
beneficial in examining large- and giant-breed dogs.
A high-intensity xenon light source is considered
to give the brightest, whitest light and truest colours of
the abdominal viscera and is highly recommended
(Magne and Tams, 1999). However, if a halogen or
metal halide light source is already available for
flexible endoscopy, this can be used instead.
Utilization of a camera and a video monitor allows for
much better visualization of the abdominal cavity by
the operator and the assistant, and is essential for the
maintenance of a sterile field.
The most common method of inducing initial
insufflation of the abdominal cavity requires a Veress
needle (see Figure 2.32). This contains a spring-
loaded hollow blunt obturator, which normally
protrudes past the sharp point of the needle. As the
needle is pressed against the abdominal wall the
obturator is pushed back into the body of the needle
and the sharp point passes through the muscle and
fascia into the peritoneum. As soon as the point of the
needle enters the peritoneal space the obturator
springs back, revealing the blunt point and reducing
the chance of iatrogenic trauma to internal organs.
Automatic insufflators are designed to deliver gas
at a prescribed rate while maintaining a predeter-
mined intra-abdominal pressure (see Chapter 2).
Carbon dioxide is considered to be the gas of choice
for insufflation because of the safety factors in pre-
venting air emboli and spark ignition when using
electrocautery or lasers.
Trocar–cannula units (see Chapter 2) are used
to gain access to the abdominal cavity. The carbon
dioxide insufflation tubing can be connected to the
cannula to maintain insufflation of the abdominal
cavity during the procedure. Diagnostic procedures
usually require two cannulae, while surgical proce-
dures might require two, three or more, depending on
the specific procedure to be performed.
During laparoscopy a number of accessory
instruments are essential. A palpation probe is
required to move and palpate the abdominal organs.
Almost all palpation probes have centimetre
graduations so that the relative size of organs or
lesions can be estimated. Biopsy forceps are used for
liver, spleen, abdominal mass, lymph node and
pancreatic biopsy. For surgical intervention, common
instruments include grasping forceps, scissors,
aspiration tubes and clip applicators. Many of the
biopsy and surgical instruments also have capabilities
for monopolar electrosurgery at their distal tip.
There are a number of minimally invasive surgical
procedures that the authors are currently performing
using laparoscopy. Most of these require multiple
trocar–cannula portals, specific laparoscopic sur-
gical instruments, loop ligatures, clip applicators,
and/or monopolar or bipolar electrosurgery. Ultrasonic
dissectors and radiofrequency units are now avail-
able to establish safe and reliable haemostasis dur-
ing laparoscopy.
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Chapter 11 Rigid endoscopy: laparoscopy
Anaesthetic considerations
Laparoscopy is usually performed using general
inhalation anaesthesia. Most patients tolerate general
anaesthesia well during laparoscopy but it is to be
expected that the pneumoperitoneum from carbon
dioxide insufflation will increase intra-abdominal
pressure and may interfere with ventilation (Duke et
al., 1996; Bufalari et al., 1997). The increase in intra-
abdominal pressure associated with laparoscopy can
also potentially cause compression of the caudal
vena cava and liver, decreasing venous return to the
heart. Diaphragmatic movement is also reduced.
These effects are not usually significant at the
recommended intra-abdominal insufflation pressures
and are easily counteracted by normal homeostatic
mechanisms, but may be more significant in patients
with severe respiratory compromise or pulmonary
disease. For these reasons the patient’s respiratory
status should be carefully evaluated prior to
laparoscopy. Initial insufflation should be at the lowest
rate to allow the patient to compensate for increased
intra-abdominal pressure. Once insufflation is
complete, flow rates can be increased to maintain a
near uniform pressure in the event of gas leakage
during insertion of instruments. The intra-abdominal
insufflation pressures should always be maintained
below 15 mmHg. Usually a pressure of 8–10 mmHg is
sufficient for excellent visualization. It may be
necessary to use a higher pressure during placement
of the initial port to reduce the indentation of the
abdominal wall during insertion, thereby reducing the
risk of iatrogenic damage by the sharp trocar. Once
the ports are in place the intra-abdominal pressure
can be reduced. In cases in which ventilation becomes
compromised it will be necessary to use either manual
or mechanically assisted ventilation. Before starting a
laparoscopy, the urinary bladder should be evacuated
to prevent inadvertent puncture with trocar–cannulae.
A local block with bupivacaine is recommended at
each cannula site at the beginning of the procedure to
aid in analgesia and balanced anaesthesia.
Procedure
Surgical approaches
The two most common approaches include the right
lateral and ventral midline. The right lateral approach
is recommended for diagnostic evaluation of the liver,
gallbladder, right limb of the pancreas, duodenum,
right kidney and right adrenal gland.
A ventral approach is often useful for surgical pro-
cedures, and offers good visualization of the liver, gall-
bladder, pancreas, stomach, intestines, reproductive
system, urinary bladder and spleen. In the ventral
approach, the primary portal is placed on the midline
caudal to the umbilicus. A disadvantage of the ventral
approach is that the falciform ligament may hinder
visualization of the anterior abdomen, especially in
obese animals. Placement of the telescope port cau-
dal to the umbilicus will usually allow the surgeon to
withdraw the telescope sufficiently to manoeuvre
around the caudal boundary of the falciform ligament.
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A left lateral approach may be used, but because
the spleen lies directly under the normal entry sites
there is the potential for splenic trauma by a trocar.
The left lateral approach is required for visualization
of the left kidney and left adrenal gland.
In all cases careful preoperative planning of port
positions is essential, and will vary according to the
size of the patient and the procedure to be undertaken.
It is essential to imagine the operative site in three
dimensions and plan the procedure such that the
ports are sufficiently distant to the site of interest that
the instruments are not crowded together and can be
introduced at a comfortable angle for the surgeon.
Insufflation
A working space has to be created by introducing
carbon dioxide into the abdominal cavity. The most
common method of inducing the initial insufflation
of the abdominal cavity requires a Veress needle
(see below). Alternatively, the surgeon may choose
to use a Hasson or ‘modified Hasson’ technique,
which avoids the blind insertion of the sharp Veress
needle into the peritoneal space (see below).
Cannulae used for the Hasson technique have a
blunt trocar. This technique should minimize the risk
of trauma to abdominal organs, which can occur with
a Veress needle.
After connecting the carbon dioxide line to the
Veress needle or the first cannula (Hasson technique),
the abdomen is adequately distended with the gas.
The abdomen will become softly tympanic upon
palpation. The abdominal pressure should be no
higher than 15 mmHg (see Chapter 7).
Veress needle technique
If a Veress needle is used, it is usually placed in the
same site to be used by the first telescope portal, or
the instrument portal. It is beneficial to introduce a
small bleb of local anaesthetic (bupivacaine) at this
puncture site and at all the port sites, prior to their
introduction, as this greatly reduces any postoperative
discomfort.
A small 1 mm stab incision using either a number
11 or number 15 scalpel blade is made at the chosen
site, either in the ventral midline or in the paralumbar
fossa of the side corresponding the side of the sur-
gical approach.
It is very important to palpate the abdominal cav-
ity to localize the spleen before placing the Veress
needle. The spleen can sometimes be manipulated
out of the way but in any case must be avoided. The
skin of the abdominal wall is grasped with forceps
and tented up, and the Veress needle is grasped by
the barrel, allowing the central blunt trocar to move
freely. It is then introduced at an angle to the skin
surface by pointing it caudally towards the pelvis
(Figure 11.2). In this way iatrogenic damage to the
spleen is less likely and the fatty falciform ligament is
avoided. It may be helpful to allow the heel of the
hand to rest gently on the abdominal wall to allow a
more controlled entry into the abdomen. The bladder
should also have been voided either naturally before
anaesthesia or through preoperative catheterization
to prevent inadvertent puncture.
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Ch11 Endo.indd 160
11.2 Introducing the Veress needle.
With experience, the tip of the needle is felt
entering the peritoneal space with a slight ‘pop’. The
tap on the top of the Veress needle is then opened
and a syringe of saline attached to the Luer fitting.
Gentle suction is applied to check for fluid or blood,
and the needle repositioned if this is found. If all is
well, 1–2 ml of sterile saline is injected into the
abdomen. It should flow freely and easily. The syringe
is then removed and, with the tap still open, the
abdominal wall is tented up with the distal end of the
Veress needle to ensure that the drop of saline sinks
in the needle hub with the negative pressure so
created (hanging drop method). This should ensure
correct placement of the needle. Penetration of the
spleen will result in haemorrhage which can obscure
visualization and interfere with surgery, but is rarely
dangerous and will usually cease unaided. However,
insufflation of gas into a mass, organ or vessel can
result in fatal gas embolism so it is essential to ensure
that the Veress needle is correctly placed before
commencing insufflation.
Problems that may be encountered include:
• lacin the needle s bc taneo sly or
retroperitoneally
• lacin the needle into the oment m or falciform
ligament
• enetratin a isc s
Subcutaneous placement of the Veress needle
can be very frustrating and is fairly easily avoided.
With practice it is possible to appreciate the feel of the
Veress needle penetrating the peritoneum, but
inexperienced endoscopists are understandably
cautious and may fail to penetrate the abdominal wall
completely before starting insufflation. This results in
subcutaneous emphysema. Although not dangerous,
this can impede technique and make subsequent
proper placement of the Veress needle more difficult.
The emphysema will resolve over 48 hours or so.
Once the Veress needle has been placed, sterile
tubing is attached to the hub and connected to the
insufflator. Abdominal pressure should be low initially
(2 mmHg). If it rises rapidly, this usually indicates that
4/3/08 09:44:47

needle placement is wrong (i.e. subcutaneous) or the
needle is blocked. Manipulation of the tip of the needle
or replacement may be required. The abdomen is
slowly insufflated to a pressure of about 10–14 mmHg
(8–12 mmHg in cats). Once the initial ports have been
placed it is often possible to drop the intra-abdominal
pressure to 5 or 6 mmHg just to maintain a sufficient
operating space.
If the Veress needle is inadvertently inserted into
the omental bursa, mesentery or falciform ligament,
these structures can insufflate and obscure the view
when the endoscope is inserted via the primary port.
If this occurs, and it is not possible to negotiate the tip
of the endoscope around the obstruction, it may be
necessary to desufflate the abdomen, reposition the
Veress needle and try again.
Hasson technique
This technique requires a small surgical incision
through the skin and the abdominal wall: essentially a
mini-laparotomy is performed. A blunt obturator and
cannula can then be placed into the abdominal cavity.
A suture is required to maintain the cannula in place
and provide a good seal around it for insufflation.
The disadvantage of this technique is that it cre-
ates a bigger incision than needed for the placement
of the first cannula and the risk of subcutaneous
emphysema is increased from carbon dioxide leaking
around the cannula. Hasson cannulae are commer-
cially available, although standard laparoscopic can-
nulae can also be used with this approach.
Cannula placement
It is very important to avoid the spleen when placing
the first cannula, especially if using a sharp trocar.
Abdominal palpation to locate the spleen before
insufflation, together with careful insertion technique,
will help prevent iatrogenic damage. A trocar–cannula
unit or an EndoTIP® cannula, which receives the
telescope, is then placed through the abdominal wall.
Selection of the site for the endoscope is determined
by the relative importance of visualization of different
abdominal structures. The entry site is determined
and, following local analgesia, an incision is made
through the skin large enough to accommodate the
diameter of the cannula.
It is important to ensure that the initial incision is
the correct size. If a smooth cannula is used, an overly
large incision will allow the cannula to move in and
out of the incision as instruments are inserted and
withdrawn, due to friction between the instrument and
the rubber grommet. A practical way to assess the
correct incision size is to make an impression of the
open cannula end on the skin (with trocar removed).
If the trocar end is cut at an angle, the impression will
be oval. The incision should be made just smaller
than the narrowest diameter to ensure a tight fit. If a
Ternamian EndoTIP® cannula is used the technique is
slightly different. The incision size should be just very
slightly larger than the diameter of the cannula as a
small incision will result in skin being caught up in the
thread and rotated as the cannula is screwed in.
Once the skin incision has been made the trocar–
cannula unit is passed through the abdominal wall.
Ch11 Endo.indd 161
Chapter 11 Rigid endoscopy: laparoscopy
Holding the upper end of the cannula in the palm of
the hand, pressure is exerted in a twisting motion until
the tip of the cannula enters the peritoneal space
(Figure 11.3). Depth of penetration of the cannula is
limited by a finger placed along the shaft. Immediately
after abdominal entry, the sharp trocar is removed
from the cannula to prevent organ trauma and the
cannula can be pushed gently into the abdomen a
little further. The valve in the cannula closes as soon
as the trocar is removed to prevent escape of gas.
The telescope with camera attached is introduced
through the rubber seal on the cannula and the
‘trapdoor’ valve in the cannula is opened manually to
reduce trauma to the lens of the telescope.
11.3 Inserting the primary trocar and cannula.
Alternatively, a Ternamian EndoTIP® cannula may
be used. This has no sharp trocar and is introduced
with a clockwise screw motion to allow blunt dissection
through the abdominal wall. The initial incision must
penetrate the fascial sheath below the skin to facilitate
blunt dissection through deeper tissues without the
need for a sharp cannula. The telescope is already in
place and allows entry into the peritoneal cavity to be
seen. The threaded barrel also helps prevent
displacement during surgery.
The insufflation tubing can now be transferred from
the Veress needle to the inlet port of the cannula. This
allows removal of the Veress needle, if it is still in place,
and gas flow is directed away from the endoscope
lens, helping keep it clear. However, cold gas can
sometimes increase fogging of the endoscope lens. If
this is a problem, moving the gas inflow to the opera-
tive port may help. The telescope is then connected
to the light source and the camera, and advanced
through the cannula and into the abdomen (Figure
11.4). Upon entry into the abdominal cavity the image
may be blurry due to fogging of the telescope lens. To
prevent fogging it is recommended to use a commer-
cially available anti-fogging solution or alternatively a
povidine–iodine solution. It is helpful to immerse the
telescope in warm saline for a minute or two before its
introduction into the abdomen (see also Chapter 7).
Alternatively, if fogging becomes a problem during a
procedure, gently touching the lens of the telescope on
a serosal surface will usually clear the lens.
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 Chapter 11 Rigid endoscopy: laparoscopy
(a)
(b)
11.4 (a) Following insertion of the telescope, the
area immediately underlying the primary port
and Veress needle is examined for iatrogenic damage.
(b) A secondary port has been inserted for the
introduction of the biopsy forceps.
Examination technique
Once the telescope is in the abdominal cavity, careful
examination of the viscera is performed. The region
directly below the cannula site is evaluated first for
any evidence of haemorrhage or other iatrogenic
damage. The site of entry for the second (accessory)
portal is then selected under direct visualization and
percutaneous palpation of the body wall. This location
depends upon the procedures that are to be performed.
Transillumination of the abdominal wall using the
telescope will enable any large vessels to be avoided
when making the incision for the second portal. The
second cannula is then placed through the abdominal
wall in the manner previously described, and is
observed directly through the telescope as it enters
the abdomen to avoid damage to underlying viscera.
Exploration of the abdominal cavity is assisted by
using the palpation probe to ‘feel’ and move the
organs as needed. Instruments should never be
passed blindly into the abdomen but rather viewed
internally as they pass through the cannula, and
directed to the area of interest. Using this technique
will help prevent serious tissue trauma by the probe
or other accessory instruments. It may sometimes be
helpful to tilt the patient from side-to-side or up/down,
to allow gravity to move viscera out of the field of view
and facilitate examination.
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Ch11 Endo.indd 162
Ending the procedure
At the conclusion of the laparoscopic procedure the
instruments and telescope are removed. The pneumo-
peritoneum is relieved by discontinuing carbon dioxide
insufflation and opening the two-way stopcocks on
the cannulae. The cannulae are then removed. Gentle
pressure on the abdominal wall will help remove any
gas not removed via the cannulae. The puncture sites
are sutured in two layers in a routine manner.
Additional considerations
If appreciable ascites is present, this is best partially
drained prior to laparoscopy. Gas-filled loops of
intestine floating on top of ascitic fluid are more prone
to damage by the Veress needle or introduction of
cannulae, and will make visualization difficult during
surgery. Drainage by syringe and three-way tap, with
a large bore intravenous catheter placed in the midline
will usually suffice. If ascites is present all abdominal
incisions should be closed in at least two layers to
prevent seepage of fluid postoperatively.
With any laparoscopic procedure, the surgeon
should always be prepared to convert to conventional
open surgery should it be required. For example,
persistent haemorrhage, unforeseen complications or
removal of a large mass may all require conversion to
open laparotomy. A full laparotomy kit should be
available in theatre at all times.
Biopsy
Liver
Liver biopsy is one of the most common indications
for laparoscopy and with practice can be completed
very rapidly and with minimal trauma to the patient.
Most diseases of the liver will be managed medically,
but often a definitive diagnosis can only be obtained
histologically. Tissue samples can be taken under
direct visualization from lesions in the liver, and
graphic images of the entire organ or specific lesions
can be sent to the laboratory along with the samples
to aid diagnosis. Any haemorrhage can be seen and
dealt with directly. Excellent work has been under-
taken by Dr Sharon Center and her colleagues at
Cornell demonstrating the superior histopathological
results from wedge-style biopsy samples compared
with those obtained using a Tru-cut-style needle.
Furthermore, there is less risk of iatrogenic damage
than with percutaneous needle biopsy and, as an
added bonus, the entire abdomen can be examined
in detail during the same procedure.
Before undertaking a liver biopsy a coagulation
profile should be obtained. This should include
prothrombin time (PT), partial prothromboplastin time
(PPT) and an accurate platelet count. Determination
of buccal mucosal bleeding time is also advised.
Although coagulopathies are a relative contraindication
to liver biopsy, the coagulation status does not
necessarily predict whether the animal will bleed from
a liver biopsy.
Liver biopsy is most commonly performed in left
lateral recumbency, with a right lateral approach. A
ventral approach may also be used and gives access
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to more of the ventral liver surface, but access may
be partially obstructed by the falciform ligament in
obese patients. The first cannula for the telescope is
placed in the caudodorsal abdominal wall in the region
of the paralumbar fossa. A second cannula is then
placed at the same level as the first, but more towards
the midline (Figure 11.5). (A left-handed surgeon may
do the opposite so as to have the biopsy instrument in
the dominant hand.) Eighty-five percent of the liver,
extrahepatic biliary system and right limb of the
pancreas can be visualized with this approach. The
telescope and palpation probe are moved cranially,
with the tip of the probe in view. The diaphragm and
the diaphragmatic surface of the liver can then be
examined. The telescope is withdrawn slightly and
the gallbladder can be seen between the right lateral
and right medial lobes of the liver, which are elevated
to expose the visceral surface and the proximal biliary
tree. The gallbladder can be palpated with the probe
and the patency of the biliary tree assessed. The
cystic duct can be traced down to the common bile
duct where it enters the duodenum. The other lobes
of the liver are then elevated in turn to visualize the
visceral surfaces and hilus (Figure 11.6).
11.5 Portal positions for liver biopsy (O) and
pancreatic biopsy (X) in left lateral recumbency.
11.6
Inspecting the liver with a palpation probe.
Cup biopsy forceps (5 mm) are recommended.
The quality of sample collected with this technique is
considered superior to that from any other technique
as the sample is taken from the region of interest and
Ch11 Endo.indd 163
Chapter 11 Rigid endoscopy: laparoscopy
a significant amount of tissue is available for histo-
pathological analysis. The normal liver should be of
uniform, deep red colour and should not be friable or
bleed easily on palpation. The gallbladder should be
thin walled and easily compressible. Any swellings or
areas of discoloration or obvious pathology are noted
and the gallbladder is also palpated. The biopsy for-
ceps are directed to the area of the liver to be sam-
pled – either an edge or the surface of the liver can be
sampled with forceps (Figure 11.7). It is always impor-
tant to take samples from three or four areas, includ-
ing some that appear grossly normal, if the liver
pathology is diffuse, and generalized biopsy samples
are taken from the edge of the liver lobes. Biopsy for-
ceps are passed down to a position just below the
border of the lobe to be biopsied. The jaws of the for-
ceps are opened and the forceps are slowly with-
drawn with slight upward pressure, such that the edge
of the liver lobe naturally falls within the jaws as the
forceps come to the edge of the lobe. The authors
generally hold the cups tightly closed for approx-
imately 15–30 seconds before pulling the sample
away from the liver. Normal liver capsule is quite
tough and a reasonable tug is often needed. This
does not cause damage to the liver or sample and
there is rarely much haemorrhage.
11.7 Biopsy of the liver using cup biopsy forceps.
The biopsy area is then closely monitored for
excessive bleeding. Generally, most biopsy sites
bleed very little (Figure 11.8), although the magnified
image observed on the monitor can often make a
slight seepage of blood seem like a lot; usually it is a
maximum of 5 ml and bleeding stops within two or
three minutes. If bleeding is considered to be
excessive, pressure can be applied with the palpation
probe, or a small piece of saline-soaked haemostatic
gauze, such as Gel-Foam™, can be placed into the
biopsy site. These options are sufficient to control
excessive bleeding. On occasion the judicious use of
electrocautery is of benefit. Cautery can be applied to
the biopsy forceps while performing the biopsy, but
this has the potential for thermal injury to the sample
and is not recommended.
Endoscopic needles or long spinal needles can be
used to drain and flush cysts and abscesses, or take
samples from cysts or the gallbladder under direct
visual guidance.
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11.8 Liver biopsy site immediately after a sample has

been taken, showing minimal haemorrhage.
Pancreas
The right lobe of the pancreas lies adjacent to the
duodenum, between two layers of the mesoduodenum.
The body of the pancreas, adjacent to the pylorus,
unites the left and right lobes, and the left lobe is in
the deep leaf of the greater omentum.
Pancreatic biopsy is performed via a right lateral
approach. This approach gives an excellent view of
the duodenum, the right limb of the pancreas, the
extrahepatic biliary system and the liver. A ventral
midline approach enables examination of the whole
pancreas but requires considerably more dissection
to access the left lobe and is rarely necessary. Access
to the left lobe in the omental bursa is gained by blunt
dissection through the avascular part of the greater
omentum just caudal to the gastro-epiploic vessels.
The greater curvature of the stomach may need to be
elevated first and cranial traction applied to the omen-
tum in order to see the left lobe of the pancreas.
As for liver biopsy (see above), two cannulae are
required. These are placed in the caudal part of the
abdomen in sites similar to those for liver biopsy, but
it is often beneficial to place each cannula 3–5 cm
caudal to those used for liver biopsy. The endoscope
is introduced to the level of the pylorus, and the
mesentery moved cranially and to the left with a gentle
raking movement of the blunt probe. The duodenum
is identified and elevated, revealing the right limb of
the pancreas for inspection.
The normal pancreas is pale pink and uniformly
nodular in texture. Swelling and oedema may indicate
pancreatitis, whereas extensive nodularity or calcifi-
cation may indicate chronic pancreatitis. Tumours
may also be seen, although islet tumours are often
too small to be seen macroscopically. Punch-type
biopsy forceps are preferred (Figure 11.9), although
cup biopsy forceps can also be used. The biopsy site
selected should be at the edge of the pancreas, away
from the location of the pancreatic ducts that traverse
the centre of the gland and subsequently enter the
duodenum with the common bile duct. As with all pan-
creatic surgery, minimal manipulation minimizes the
risk of iatrogenic mechanically induced pancreatitis.
In practice, this is rarely a problem. Haemorrhage
from biopsy sites is minimal and can be controlled as
for liver biopsies (Figure 11.10).
11.9 Biopsy of a normal pancreas using punch-type
biopsy forceps.
11.10 Pancreatic biopsy site immediately after a
sample has been taken, showing minimal
haemorrhage.
Kidney
Laparoscopy is well suited for evaluation and biopsy
of the kidney. An automatic core-type biopsy needle
is recommended for biopsy. Direct visualization of
the kidney allows the operator to navigate the biopsy
needle to the desired site to be sampled and also to
monitor and control excessive postoperative bleeding.
Prior to renal biopsy, adequate renal evaluation is
necessary, including such techniques as contrast
excretory urography and ultrasonography. This is vital
to determine the functional integrity of the kidney in
question and to determine whether specific pathology
is present in one or both kidneys. Unless there is a
specific indication to sample the left kidney, the right
kidney is preferred because it is less mobile. A left
kidney biopsy through a left lateral approach is more
difficult because of the location of the spleen
underlying the usual cannula entry site.
The ventral abdomen and right abdominal wall to
just below the lateral processes of the lumbar
vertebrae are clipped and prepared for surgery. The
patient is positioned in partial or complete left lateral
recumbency. Using a right lateral mid-abdominal
telescope placement the right kidney is easily
visualized (Figure 11.11). The authors then always

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 Chapter 11 Rigid endoscopy: laparoscopy

biopsy site. Haemorrhage can appear alarming due

to the magnification, and is generally greater than that
seen with liver or pancreatic biopsy samples taken
with biopsy forceps. The palpation probe is quickly
moved over the bleeding area and pressure applied
for several minutes. Additional samples are taken if
the first is not considered suitable. Once the
haemorrhage has been controlled, the palpation
probe is removed and the abdomen deflated. Finally
the camera and primary port are removed and
cannulae withdrawn. Port closure is routine.

Intestine
Full-thickness small intestinal biopsy samples can
be obtained at laparoscopy using the technique of
Laparoscopic view of the right kidney of a cat grasping and then exteriorizing a portion of intestine
11.11 through the abdominal wall. The intestinal biopsy
with renal lymphosarcoma.
sample is then obtained from the exteriorized bowel,
as would be done for a standard full-thickness surgi-
place a second cannula so that a palpation probe is
cal biopsy.
available to provide tamponade at the biopsy site.
Intestinal biopsy requires three cannulae. One is
The palpation probe is placed in the abdomen above
used for the telescope and the two others are used to
the kidney. The entry site for the needle is determined
introduce two pairs of grasping forceps. Generally,
by percutaneous palpation on the abdominal wall
this procedure is performed in dorsal recumbency
whilst viewing with the telescope internally. When
from a standard ventral midline approach. The camera
kidney biopsy samples are taken, the needle entry
portal is placed just cranial to the umbilicus along the
site through the abdominal wall should be caudal to
ventral midline and the two operative portals are
the diaphragm. If the needle penetrates the diaphragm
placed 4–6 cm lateral to the midline on either side
an iatrogenic pneumothorax may result from leakage
(Figure 11.13). The technique involves using 5 mm
of the pneumoperitoneum into the thorax.
atraumatic grasping forceps with multiple teeth to
A 1 mm stab incision is made in the skin at the
grasp the intestine at the site to be sampled. It is often
desired entry site and the needle directed into the
necessary to ‘run’ the bowel, using two pairs of
abdominal cavity and to the kidney. The usual location
grasping forceps. This is done in much the same way
for sample collection is the cranial or caudal pole of
as when performing the same operation in an open
the kidney, being careful to obtain predominantly
laparotomy. An assistant manipulates the telescope
cortex with little medulla. The needle should not
penetrate deep into the kidney because the arcuate
arteries are located in the corticomedullary junction.
The biopsy needle is seated through the renal capsule
and the needle ‘fired’ (Figure 11.12). The needle is
then removed from the abdominal cavity. There are
generally several millilitres of blood flowing from the

X X

11.12 Taking a biopsy sample from the right kidney 11.13 Portal positions for full-thickness intestinal
with an automatic core-type biopsy needle. biopsy.

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 Chapter 11 Rigid endoscopy: laparoscopy
and camera, while the surgeon uses atraumatic
grasping forceps in the other two ports to run the
bowel until a suitable area is found for biopsy.
The antimesenteric border of an intestinal loop is
firmly grasped with the forceps and pulled to the
cannula. The cannula incision is carefully enlarged
with a scalpel blade or cautery, sufficient to exteriorize
the loop of bowel. It is helpful to place an 11 mm port
at the site selected for exteriorization as this requires
less enlargement, and may even be of sufficient size
in cats and small dogs. Four to five centimetres of the
loop of intestine are exteriorized and stay sutures are
used in the intestine to prevent it from falling back into
the abdominal cavity (Figure 11.14). It is important not
to exteriorize too much bowel as this can make
replacement into the abdomen difficult through a
small incision. A small full-thickness biopsy sample is
then obtained in the same manner as during open
abdominal surgical biopsy.
11.14 Exteriorized loop of small intestine.
The small bowel is generally closed in the standard
manner in two or three layers. If there is any question
of contamination of the peritoneal space with bowel
contents during the procedure, warm saline lavage
can be performed using a laparoscopic suction
cannula with portals for inflow and egress. The
intestine is then returned to the abdominal cavity. This
technique results in loss of pneumoperitoneum and it
is therefore difficult to take multiple intestinal biopsy
samples. However, if multiple biopsy samples are
required it is possible to re-insert the 11 mm cannula
and place a temporary purse-string suture in the
abdominal wall around it to form a seal. The abdomen
can then be re-insufflated and the procedure repeated
to obtain further samples. Following the final sample,
the abdomen is re-insufflated and all operative sites
inspected for haemorrhage. The abdomen can then
be deflated and the telescope and ports removed.
Closure of the abdominal wall is performed in the
standard manner.
166
Ch11 Endo.indd 166
Feeding tube placement
Duodenal and/or jejunal feeding tube placement has
been described as a modification of percutaneous
endoscopic gastrostomy (PEG) tube placement
techniques. Following routine PEG tube placement,
a duodenal feeding tube is inserted through the PEG
tube into the gastric lumen and grasped by a pair of
forceps placed through the flexible endoscope. The
end of the feeding tube can then be guided through
the pylorus and into the duodenum and/or jejunum
as required.
An alternative method of laparoscopic jejun-
ostomy tube placement does not require the use of
a flexible endoscope or PEG tube. The patient is
positioned in dorsal recumbency and the abdomen
shaved, prepared and draped for surgery. The abdo-
men is insufflated (see above) with a Veress needle
placed at the site of the proposed feeding tube place-
ment, just caudal and lateral to the umbilicus on the
right side. A primary camera port is then introduced
cranial to the umbilicus in the midline a comfortable
distance away. The insufflation tubing is transferred
to the camera port and the Veress needle removed
from the abdomen. A secondary port, preferably
10 mm with a 5 mm reducer to accommodate the
instruments, is introduced under direct visualization,
on the right side at the position of insertion of the
Veress needle. A third port may be required to
‘run’ the bowel and select a suitable site for the jejun-
ostomy tube. This also allows easier identification
of the direction of the bowel to allow the duoden-
ostomy and/or jejunostomy tube to be placed cor-
rectly in an aboral direction. This tertiary port is
placed at the same level as the secondary port on
the other side of the midline.
Duodenostomy or jejunostomy feeding tubes can
be placed using the laparoscope simply by
exteriorizing the respective piece of intestine through
the abdominal wall and inserting the tube externally.
The technique of bowel exteriorization is similar to
that described above for intestinal biopsy. A purse-
string suture is placed on the antimesenteric border
of the jejunum. The tube is inserted in the centre of
the purse-string suture, which is then tightened. Then
the intestine is pexied to the abdominal wall. The
pexy is performed with four sutures placed around
the insertion site of the feeding tube. The sutures are
placed between the antimesenteric border of the
jejunum and the abdominal wall. The skin is closed
around the feeding tube in a routine fashion. The
tube itself is sutured to the skin with a Chinese
finger-trap pattern of suture material placed around
the tube itself. The jejunostomy site is visualized
through the endoscope before desufflating the
abdomen and removing the endoscope and cannula.
Port closure is routine.
A gastrostomy feeding tube can also be placed
using laparoscopy by exteriorizing the body of the
stomach through the left abdominal wall and inserting
the tube externally following a gastropexy (see below
and Chapter 4). A purse-string suture and pexy are
performed as for the jejunostomy tube.
4/3/08 09:44:52

Gastropexy
A prophylactic gastropexy is recommended for ani-
mals at high-risk of developing gastric dilatation-
volvulus (GDV). Laparoscopic gastropexy is
performed by exteriorizing the pyloric antrum through
the right abdominal wall. The animal is placed in dor-
sal recumbency and the abdomen shaved, prepared
and draped for surgery. The abdomen is insufflated
(see above) with a Veress needle placed on the mid-
line at the level of the umbilicus, and a primary tele-
scope portal is then introduced at this site. The
instrument portal for the grasping forceps is placed
2 cm behind the last rib on the right side, at the
junction of distal and proximal third of the last rib. It
may be helpful to use an 11 mm port with a 6 mm
reducer at this site. Fine-tooth grasping forceps or
Babcock forceps are used to grasp the pyloric antrum
between the greater and smaller curvatures. The
abdominal cavity is then deflated to minimize tension
on the wall of the stomach. The portal for the grasp-
ing forceps is then enlarged parallel to the last rib. A
5–6 cm incision is adequate. A portion of the pyloric
antrum is exteriorized and stay sutures are placed in
the gastric wall. A 3 cm incision is made into the mus-
cularis of the gastric wall to develop a serosomuscu-
laris flap, without penetrating into the gastric lumen.
The edges of this incision are then sutured to the
transverse abdominal muscle with a simple continu-
ous pattern of 3 metric (2/0) monofilament absorba-
ble suture. The internal and external oblique muscles
are then closed. Subcutaneous tissue and skin are
closed in a routine fashion.
Ovariohysterectomy
The peritoneum is very sensitive to painful stimuli,
and tearing the ovarian ligament from its peritoneal
insertion during a routine open bitch spay results in
considerable postoperative discomfort. This is
completely eliminated using a laparoscopic technique
and postoperative pain is therefore greatly reduced,
partly due to less intraoperative trauma and partly
due to a reduction in wound size.
Ovariohysterectomy can be performed using lapar-
oscopy in most medium-sized and large dogs.
Limitations of laparoscopic-assisted ovariohyster-
ectomy relate to the size of the patient, as the space in
the abdominal cavity of small animals can make the
procedure technically more difficult. The advantage of
laparoscopic ovariohysterectomy is the perceived
rapid recovery of the patient following the procedure.
Ovariohysterectomy is performed with the patient
in dorsal recumbency and in a Trendelenburg position
to move the abdominal viscera to the cranial part of
the abdomen. It is also necessary to tilt the patient on
the right side to work on the left ovary, and then tilt the
patient on the left side to work on the right ovary. The
procedure requires three cannulae. The authors’ pref-
erence is to place the cannulae along the midline
(Figure 11.15). It is also possible to perform the pro-
cedure with only two cannulae; in that case a large
curved needle with a weighted handle (commercially
Ch11 Endo.indd 167
Chapter 11 Rigid endoscopy: laparoscopy
X
X
X
Portal positions for laparoscopic
11.15
ovariohysterectomy.
available) is used to maintain the position of the ova-
ries percutaneously during the ligation of the pedicle.
The abdomen is insufflated using a Veress needle
placed 3–4 cm cranial to the umbilicus in the midline.
A primary telescope portal is then established in the
midline 1–2 cm caudal to the umbilicus. The area
under the point of insertion is examined as usual for
any iatrogenic damage and the insufflation tubing is
transferred to the telescope portal. The Veress needle
is removed. A second 5 mm portal is established
under direct visualization at the site of the Veress
needle. Entry here may be through the falciform
ligament and it is helpful to introduce the cannula at a
slight angle towards the right side. The final port is
established in the midline 2–3 cm cranial to the pubis,
under direct visualization, being careful not to damage
the bladder which lies just underneath the point of
entry. In medium-sized to large bitches, an 11 mm
port with reducer is used here to facilitate the removal
of the ovaries and uterus.
The surgeon (and assistant if required) stands to
one side of the patient, and the patient is rotated
towards them approximately 45 degrees. The uterine
horns are visualized (Figure 11.16) and traced forward
to the ovary.
The ovary is grasped with Babcock forceps passed
through the caudal portal. Gentle caudal traction and
elevation are applied and the ovarian suspensory
ligament and associated ovarian blood vessels are
identified. If preferred, the handle of the Babcock
forceps can be laid down, maintaining the position of
the ovary unaided and allowing the surgeon to operate
the camera and hand instrumentation through the
other ports. This enables a surgeon to carry out the
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 Chapter 11 Rigid endoscopy: laparoscopy

Caudal abdomen of a bitch at laparoscopy (a)

11.16
showing the uterine body and horns emerging
from beneath the urinary bladder.

procedure without a surgical assistant. Monopolar or

bipolar grasping forceps passed through the cranial
port are used to bluntly dissect the blood vessels from
the surrounding fat and seal them in two places. The
forceps are then replaced by scissors and the ovary is
freed by cutting between the cauterized points on the
blood vessels.
Alternatively, a monopolar dissection hook can be
used to cauterize and dissect the ovarian ligament
and pedicle. This reduces the need to change
instrumentation, although in larger bitches, it may still
be necessary to transect the ovarian ligament with
scissors as it can be quite tough.
If preferred, the vessels can be ligated using
endoscopic vascular clips (Figure 11.17) or sutures.
Alternatively, a bipolar cutting device such as a Patton
Hotblade® (Figure 11.18) or LigaSure® device can be
(b)
used if available; this makes surgery a lot simpler as
it does not require a change of instruments in order to 11.17 (a) Ovarian pedicle exposed with caudal
dissect the ovary free. However, these instruments retraction of the uterus. (b) Vascular clips have
are expensive and require gas sterilization. been placed.
Once the ovary is free, the area is checked for any
bleeding and any small vessels are grasped with the
monopolar grasping forceps and cauterized. Gentle
traction is applied to the ovary, and the broad ligament
and associated mesentery are gradually stripped
down, applying cautery as necessary, until the ovary
lies just under the point of entry of the caudal port,
where it can be released.
The patient is then rotated on to her other side, the
surgeon swaps sides, and the process is repeated for
the other ovary. However, this time the ovary is not
released. The patient is rotated back into dorsal
recumbency and, whilst maintaining a firm hold on the
ovary, the forceps, cannula and ovary are all with-
drawn from the abdomen in one go. If the ovary is
very large or surrounded by a lot of fat, it may be
necessary to enlarge the port slightly before the ovary 11.18 Transecting the ovarian pedicle with the
can be withdrawn from the abdomen. This is achieved Hotblade® bipolar device.
by passing a no. 11 scalpel blade cranial to and
alongside the port in the midline, with the sharp edge The ovary can be grasped with a pair of Allis tissue
facing away from the port. Entry of the blade into the forceps or haemostats at this point to enable removal
abdomen can be monitored through the telescope. In of the cannula, ensure a firm grip and facilitate traction.
this way the caudal port is enlarged just enough to Once the ovary and one uterine horn are exteriorized,
exteriorize the ovary. gentle traction is applied to exteriorize the uterine

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body and cervix (Figure 11.19). The uterine body is
then clamped and ligated, using a transfixing suture,
before transection and removal in the usual fashion.
The uterine stump is replaced into the abdomen, and
the remaining uterine horn and ovary are exteriorized
to complete the procedure. The caudal port is held
closed manually in order to insufflate the abdomen
sufficiently for a final inspection for haemorrhage, and
to ensure the uterine stump has been fully returned to
the abdomen. The abdomen is then deflated and the
cannulae are removed. All the incisions are closed
using 3 or 2 metric (2/0 or 3/0) absorbable suture
material; usually only one suture is necessary. The
skin is closed using tissue adhesive (Figure 11.20).
11.19 Exteriorizing the uterus through the caudal
portal position.
11.20 Wound closure following laparoscopic
ovariohysterectomy in a 2-year-old Retriever.
An alternative technique is to dissect the ovaries
as above and then place a pre-tied loop of suture
(Endoloop Suture™ or Loop Ligature™) in the
abdominal cavity through one cannula. Both ovaries
and uterine horns are passed through the loop (Figure
Ch11 Endo.indd 169
Chapter 11 Rigid endoscopy: laparoscopy
11.21), which is then tightened down at the level of
the cervix. The uterus is transected and both the
uterus and ovaries are removed through one of the
cannula holes, which is enlarged if necessary.
11.21 Both uterine horns have been passed through
an Endoloop™.
Ovariectomy
Ovariectomy can also be performed via laparoscopy.
This is a simpler and faster procedure than ovario-
hysterectomy. Ovariectomy has been the standard
practice in many European countries for over 20
years and is becoming more common in the USA
and elsewhere. A recent report by Goethem et al.
(2006) concluded that ‘ovariohysterectomy is techni-
cally more complicated, time-consuming, and is
probably associated with greater morbidity (larger
incision, more intraoperative trauma, increased dis-
comfort) compared with ovariectomy, making ovari-
ectomy the preferred method of gonadectomy in the
healthy bitch.’
Experience has shown that removal of the uterus
is unnecessary and does not result in pyometritis in
the absence of ovarian tissue. Conversely, there are
no published data to show any benefit from removal
of the uterus.
Instrumentation required for ovariectomy is
essentially the same as for ovariohysterectomy, with
the addition of an ovariectomy hook (commercially
available). This is a sharp curved needle attached to
a heavy handle. This is passed percutaneously and is
used to fix the ovary in place against the body wall to
facilitate dissection. A wider than normal surgical clip
is required to give access to the body wall in the mid-
lateral abdomen.
The procedure and port placements are similar to
those used for laparoscopic ovariohysterectomy, but
the caudal portal is not required. In larger bitches
(over 25 kg) an 11 mm cranial portal, located midway
between the umbilicus and the xiphoid process, is
used for removal of the ovaries. A 6 mm portal just
caudal to the umbilicus is used for the camera/
telescope. In small bitches, a 6 mm cranial portal and
3.5 mm caudal portal are used.
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Following insufflation of the abdomen and place-

ment of the portals, the patient is rotated towards the Ovarian cyst
surgeon and the contralateral ovary is grasped with
Babcock forceps introduced through the cranial portal.
The ovary is held up against the abdominal wall and
the site of contact is determined by palpation on the
external abdominal wall whilst observing the perito-
neum through the endoscope. Once the exact site is
determined, an ovariectomy hook is placed through
the abdominal wall to transfix the ovarian pedicle and
hold the ovary in place. The weight of the handle on
this device means that it can maintain the position of
the ovary unaided when the handle is laid down on the
patient. The Babcock forceps can then be removed
and replaced with a bipolar cutting device, such as a Ovarian remnant
Hotblade® or LigaSure®. The ovarian ligament, pedicle
and uterine attachments are transacted and cauterized
to free the ovary. The bipolar device is replaced by the
Babcock forceps and the ovary is grasped. The
ovariectomy hook is then removed, and the patient is
rotated back into dorsal recumbency. The ovary is
removed from the abdomen, either through the lumen
of the cannula or, if it is too large, by removal of the
cannula and direct traction through the body wall. The
cannula can then be replaced and the procedure
repeated on the other ovary.
Following desufflation, closure is routine, with a
single 2 metric (3/0) absorbable suture and skin
adhesive at each portal site.

Removal of the ovarian remnant with monopolar

Ovarian remnant removal
Location of ovarian remnants in open surgery can
be difficult and time-consuming. The magnification
and illumination provided by laparoscopy greatly facil-
itates this procedure and results in considerably less
trauma for the patient. Location of the remnant is eas-
ier if the patient is in oestrus at the time of surgery.
Only two portals are required and the technique is
the same as for laparoscopic ovariectomy. The portals
are placed as before and the patient is rolled to each
side in turn to visualize the contralateral kidney. The
area around and behind the kidney is inspected with
the aid of a palpation probe. Location of the ovarian
remnant is usually quite straightforward. The pedicle
can be grasped directly in a bipolar cutting instrument
(e.g. Hotblade® or LigaSure®) or, if necessary, it can
be transfixed with an ovariectomy hook prior to
transection. In many cases, especially in cats,
laparoscopic scissors attached to a monopolar
electrosurgery unit are all that is required for
transection (Figure 11.22). Following isolation of the
remnant, the scissors or bipolar cutting device is
replaced with grasping forceps, and the remnant
removed via the cannula. The abdomen is then
desufflated and the ports closed routinely.
Cryptorchid surgery
A testicle that is located in the abdominal cavity can
be removed easily using laparoscopy. This technique
is simpler, quicker and less traumatic than open
11.22
scissors in a cat.
surgery. Laparoscopic vasectomy can also be
performed. The dog is placed in dorsal recumbency,
in the Trendelenberg position, and the abdomen
shaved, prepared and draped for surgery. Gravity will
then displace the abdominal organs into the cranial
abdomen, which will facilitate visualization of the
internal inguinal canal. Two cannulae are adequate to
perform the surgery. The abdomen is insufflated (see
above) with a Veress needle placed just caudal to the
umbilicus. The Veress needle is then removed from
the abdomen and a primary telescope port is
introduced at the same site. Care should be exercised
to palpate the abdomen and direct the Veress needle
and primary cannula well away from the spleen. The
insufflation tubing is then transferred to the camera
port. A secondary port, preferably 11 mm with a
6 mm reducer to accommodate the instruments, is
introduced under direct visualization just lateral to the
rectus abdominis muscle, about half-way between
the umbilicus and the pubis on the affected side.
In unilateral cases, the normal side (usually the
left) is examined first and the vas deferens and
testicular vessels are traced down to the inguinal ring,
which is inspected for herniation. The inguinal ring on
the affected side is located and checked (Figure
11.23). If the vas deferens and testicular vessels are
seen entering the inguinal ring, then the testicle is in
the inguinal canal.

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Inguinal canal
Testicular vessels
Vas deferens
Urinary bladder
11.23 Normal inguinal canal showing the vas deferens
and testicular vessels.
In bilateral cases, both inguinal rings are inspected
to determine the presence of the vas deferens and
testicular arteries. If these structures are present,
either the dog has already been castrated or the tes-
ticles are beyond the inguinal ring. An absence of the
vas deferens and testicular artery in the inguinal canal
means that the testicle is ectopic. The ectopic testicle
is usually readily visible upon entering the abdominal
cavity. If not visualized immediately, it may be located
by gently moving the bladder laterally with closed
grasping forceps to locate the vas deferens, and trac-
ing this back to the testicle. The testicle is grasped
and pulled up to the mouth of the operating cannula.
The cannula, forceps and testicle are then drawn out
of the abdomen together (Figure 11.24). In small dogs
this does not require any further enlargement of the
abdominal wound. The vas deferens and spermatic
vessels are then ligated and the testicle removed in
routine fashion. The ligated stump of the vas and
pampiniform plexus is returned to the abdomen.
11.24 Removal of an ectopic testicle.
Alternatively, the ectopic testicle can be brought
against the abdominal wall towards the midline and
stabilized with a suture passed percutaneously
through the abdomen wall. The vascular pedicle and
the vas deferens are then ligated with a pre-tied
suture (Figure 11.25), staples or electrocautery. The
Ch11 Endo.indd 171
Chapter 11 Rigid endoscopy: laparoscopy
11.25 Right cryptorchid testicle cranial to the bladder.
An Endoloop™ has been placed around the
pampiniform plexus.
ectopic testicle is transected and removed through
one of the cannula holes. The abdomen is desufflated
and ports closed routinely.
Laparoscopic-assisted cystoscopy
Laparoscopic-assisted cystoscopy is the procedure
of choice for male dogs and cats where large stones
are to be removed. This procedure does require more
instrumentation than urethrocystoscopy, in particular
insufflation equipment, but it gives greater access to
the bladder in these patients.
The patient is clipped and prepared for routine
abdominal surgery. A catheter is placed in the bladder
and the urine evacuated. The bladder is flushed with
warmed sterile saline and drained. A Veress needle is
placed at or just caudal to the umbilicus, and the
abdomen is insufflated with carbon dioxide in the
usual way. The primary telescope portal is placed at
the site of the Veress needle and the insufflation tube
is attached to the cannula. A 5 mm 0 degree telescope
is introduced to visualize the bladder (Figure 11.26). A
second portal is placed in the midline, directly over
the cranial extremity of the bladder under direct visual
guidance. A 6 mm port will suffice as the incision can
be enlarged, but an 11 mm port with 6 mm reducer
will make the procedure easier, especially in large
Laparoscopic-assisted cystoscopy. The primary
11.26
telescope portal is in place and a small skin
incision has been made for insertion of the instrument
portal.
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 Chapter 11 Rigid endoscopy: laparoscopy

dogs. Babcock forceps (5 mm) or atraumatic graspers

are introduced through this second port (Figure 11.27)
and the bladder wall is grasped and bought up to the
mouth of the cannula.

11.29 Telescope and laser fibre inserted into the

bladder.

11.27 Babcock forceps are placed in the secondary

portal to grasp the apex of the bladder.

The abdomen is deflated to reduce tension on the

bladder and the cannula is then removed from the
animal whilst maintaining hold of the bladder wall,
thus exteriorizing a small portion of the bladder wall
through the abdominal incision. If necessary, this
incision may be extended a little (1–1.5 cm is usually
sufficient) using a scalpel blade placed with the sharp
edge away from the bladder wall. Stay sutures are
placed in the bladder wall and a continuous suture is
placed between the bladder wall and the periphery of
the abdominal wound (Figure 11.28). An incision is Small bladder polyp seen at laparoscopic
then made in the centre of the exposed bladder wall 11.30
cystoscopy.
to enter the lumen of the bladder. The telescope is
transferred into this incision (Figure 11.29) to inspect
the interior of the bladder and instruments can be
passed alongside to retrieve stones, remove polyps
or take biopsy samples. Diode laser fibres can be
introduced to debulk transitional cell carcinomas or
remove polyps (Figure 11.30; see Chapter 14). The
urinary catheter can be withdrawn and, in most male
dogs, the urethra can be examined to the prostatic
urethra and even as far as the pelvic flexure (Figure
11.31). The urinary catheter is withdrawn to near the
tip of the penis and flushed with sterile saline to push
any urethral stones into the bladder for removal.

11.31 View of urethra looking caudally towards the

pelvic flexure.

At the end of the procedure, the bladder wall is

sutured in the normal fashion, the sutures to the
abdominal wall are removed and the bladder is
returned to the abdomen. All ports and catheters are
removed and skin closure is routine (Figure 11.32). It
should be noted that whilst laparoscopic cystoscopy
does provide access to the bladder of patients that
otherwise would not be able to be examined
endoscopically, visualization of the more distal
11.28 Bladder wall sutured to the abdominal incision.
portions of the mid-urethra is still limited.

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Postoperative view following wound closure
11.32
after cystoscopy.
Cholecystectomy
Laparoscopic cholecystectomy has become the
modality of choice in human surgery for treatment of
a variety of pathologies requiring removal of the
gallbladder. This procedure can be used in small
animal surgery, although it does require a more
experienced operator as well as additional equipment
and personnel. Cholecystectomy is indicated in cases
of chronic cholelithiasis/mucolithiasis, obstruction of
the cystic duct, gallbladder neoplasia and chronic
cholecystitis.
The surgical approach is generally identical to that
of the ventral midline approach for exploration of the
liver. Once the gallbladder is visualized, the right
middle liver lobe must be retracted ventrally and
cranially to provide separation between the gallbladder
and the hepatic bed. This is usually achieved with a
specialized liver retractor or a 10 mm fan-fold retractor.
The retractor is introduced into the peritoneal space
via a 10 mm portal placed just to the left of midline,
approximately 4–5 cm caudal to the xiphoid process.
An additional assistant is often needed to manipulate
this instrument.
Once the liver has been adequately retracted,
dissection of the gallbladder and vascular supply is
undertaken. The gallbladder is gently grasped with
atraumatic forceps and retracted cranioventrally.
Curved 5 mm Metzenbaum scissors attached to
cautery are then used to separate the serosal surface
of the gallbladder from the liver. Often chronically
diseased gallbladders are thickened and friable with
significant adhesions to the surrounding hepatic bed.
Some degree of oozing haemorrhage is expected,
which can be controlled with cautery, and visualization
can be maintained by occasional irrigation and suction
using a 5 mm suction/irrigation cannula. The curved
blade of the Metzenbaum scissors should be pointed
away from the gallbladder and towards the liver, to
avoid iatrogenic puncture of the gallbladder lumen.
This dissection can also be performed using a
harmonic scalpel if available. The left side of the
gallbladder is generally dissected first and then a
similar dissection is performed on the right side.
Dissection should be carried out to the neck of the
gallbladder at the origin of the cystic duct.
Ch11 Endo.indd 173
Chapter 11 Rigid endoscopy: laparoscopy
Following dissection of the gallbladder, the cystic
artery and vein should be exposed and isolated with
care. Clips (5 mm) are then triple applied and the
vascular supply transected. The 5 mm clips are
applied in similar fashion to the neck of the gallbladder
and the proximal portion of the cystic duct, which are
also transected. In larger patients this can be
performed using a endoscopic linear cutter and a
vascular cartridge. Babcock forceps are used hold
the gallbladder, which is now free of any attachments.
The gallbladder can then be removed directly via an
enlarged incision in one of the portal sites or, if the
gallbladder is friable, an endoscopic retrieval bag
should be considered to minimize the risk of spillage
of gallbladder contents and subsequent bile peritonitis.
The retrieved gallbladder should be submitted for
histopathology and culture.
With the gallbladder removed, the surgical site is
examined for haemorrhage and bile leakage. Any
bile or blood leakage can often be easily controlled
with judicious use of cautery. Irrigation of the area is
performed to make sure that the surgical sites are
clean. The liver retractor is removed and the
mechanical pressure from the right middle liver lobe
provides compression of the surgical site. Closure of
the portal sites is performed in a routine manner.
Other potential surgical procedures
Other surgical procedures that can be performed
using laparoscopy are:
• Adrenalectomy
• Correction of portosystemic sh nts
• ephrectomy (hand-assisted)
• emo al of abdominal masses
• emo al of intestinal masses
• ernia repair
Complications
Potential laparoscopic complications may be related
to various aspects of the procedure.
• Anaesthesia
• Veress needle trocar insertion
– Injury to abdominal wall
– Penetration of organs
– Perforation of hollow viscus
• ns fflation s bc taneo s emphysema
• eritoneal tentin
• nappropriate ins fflation
• ne mothora
• as embolism
• perati e complications
– Bleeding
– Tissue injury
• echnical problems
– Lack of experience
– Equipment-related.
Complications are rare and generally relate to
the surgeon’s inexperience, the underlying disease
process or anaesthetic risk.
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 Chapter 11 Rigid endoscopy: laparoscopy
Iatrogenic damage can be induced by entry of the
Veress needle or trocars, and can lead to haemorrhage
or perforation of underlying viscera. Penetration of
the bowel by the Veress needle is seldom a cause for
major concern and the small perforation will heal
without surgical intervention. Larger lacerations may
require surgical repair. Fatal air embolism can be
induced if the Veress needle is inserted into the
spleen. If air embolism is suspected, the patient
should be placed in left lateral recumbency with the
head down and ventilated with oxygen. This moves
the gas bubbles away from the right ventricular outflow
tract to help alleviate the obstruction. Carbon dioxide
is readily soluble and if the embolism is minor the gas
should dissolve rapidly.
Proper technique and positioning of the Veress
needle should reduce the risk of complications con-
siderably. Alternatively, EndoTIP® cannulae or an
open (Hasson) technique may be used as described
above. Penetration of major blood vessels with instru-
ments, such as biopsy needles, can lead to haemor-
rhage which may require open surgery to control.
Penetration of the diaphragm by an instrument
or biopsy needle can lead to pneumothorax, as can
pre-existing diaphragmatic hernia. Positive pressure
ventilation must be commenced immediately, and the
procedure can usually proceed with appropriate
monitoring as for an open chest surgery. A thoracic
drain should be inserted at the end of the procedure
as normal.
Haemorrhage from biopsy sites is rarely a prob-
lem, even in patients with laboratory evidence of
minor clotting defects. Biopsy of tumours could lead
to seeding of tumour cells to other parts of the abdo-
men or abdominal wall. If this is of concern, biopsy
specimens can be placed into a retrieval bag, fash-
ioned out of a finger of a sterile surgical glove or a
sterile zip-lock bag, before removal from the abdo-
men. Specialized endoscopy retrieval bags are avail-
able and are easier to use, but are expensive.
References and further reading
falari A hort C iannoni C edric ardie and landers A ed.
(1997) Evaluation of selected cardiopulmonary and cerebral
174
Ch11 Endo.indd 174
responses during medetomidine, propofol, and halothane anesthesia
for laparoscopy in dogs. American Journal of Veterinary Research
12 , 1443–1450
Cole C Center A lood owland et al. (2002) Diagnostic
comparison of needle and wedge biopsy specimens of the liver in
dogs and cats. Journal of the American Animal Hospital Association
220, 1483–1490
D e teinacher and emedios A ( ) Cardiop lmonary effects
of using carbon dioxide for laparoscopic surgery in dogs. Veterinary
Surgery 1, 77–82
Gilroy BA and Anson LW (1987) Fatal air embolism during anesthesia for
laparoscopy in a dog. Journal of the American Veterinary Medical
Association 5, 552–554
oethem V chaefers- ens A and irpenstei n (2 ) a in a
rational choice between ovariectomy and ovariohysterectomy in the
dog: A discussion on the benefits of either technique. Veterinary
Surgery 35, 136–143
Grauer G (1999) Laparoscopy of the urinary tract. In: Small Animal
Endoscopy, 2nd edn, ed ams pp 2 osby t o is
Grauer GF, Twedt DC and Morrow KN (1983) Evaluation of laparoscopy
for obtaining renal biopsy specimens from dogs and cats. Journal of
the American Veterinary Medical Association 183, 677–679
armoinen aari in inen and estermarc (2 2) al ation
of pancreatic forceps biopsy by laparoscopy in healthy beagles.
Veterinary Therapy 3, 31–36
ohnson and wedt DC ( ) ndoscopy and laparoscopy in the
diagnosis and management of neoplasia in small animals. Veterinary
Clinics of North America 7, 77–92
olata and reeman ( ) Access portal placement and basic
endosurgical skills. In: Veterinary Endosurgery, ed reeman pp
44–60. Mosby, St Louis
a ne and ams ( ) aparoscopy instr mentation and
technique. In: Small Animal Endoscopy, 2nd edn, ed ams pp
397–408. Mosby, St Louis
Minami S, Okamoto Y, Eguchi H and Kato K (1997) Successful laparoscopy
assisted ovariohysterectomy in two dogs with pyometra. Journal of
Veterinary Medical Science 9, 845–847
ena Anel Domin e C Ale re Al are Celorrio and Anel
E (1998) Laparoscopic surgery in a clinical case of seminoma in a
cryptorchid dog. Veterinary Record 142, 671–672
awlin s CA (2 2) aparoscopic-assisted astrope y Journal of the
American Animal Hospital Association 38, 15–19
awlin s CA o t ahaffey owerth ement and
Canalis C (2001) A rapid and strong laparoscopic-assisted
gastropexy in dogs. American Journal of Veterinary Research 6,
871–875
awlin s CA owerth ement and Canalis C (2 2) aparoscopic-
assisted enterostomy tube placement and full-thickness biopsy of the
jejunum with serosal patching in dogs. American Journal of Veterinary
Research 63, 1313–1319
ichter (2 ) aparoscopy in do s and cats Veterinary Clinics of
North America: Small Animal Practice 4, 707–727
oth i en ( ) aparoscopy in small animal medicine Veterinary
Quarterly 3, 225–228
Twedt DC (1999) Laparoscopy of the liver and pancreas. In: Small Animal
Endoscopy, 2nd edn, ed ams pp osby t o is
wedt DC and ohnson ( ) aparoscopy in the e al ation of li er
disease in small animals. American Journal of Digestive Disease 22,
571–580
Wildt DE (1980) Laparoscopy in the dog and cat. In: Animal Laparoscopy,
arrison and D ildt pp 2 illiams il ins
Baltimore
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Rigid endoscopy: thoracoscopy
Introduction
Thoracoscopy allows for exploratory and interven-
tional procedures within the chest to be performed
through multiple 5 mm or 10 mm thoracic portals.
Significant spreading of the ribs or sternum is avoided,
decreasing the perioperative morbidity associated
with intrathoracic procedures. Use of a rigid endo-
scope allows for significant visual magnification of
normal structures while allowing access to the organs
and areas normally approached by standard inter-
costal thoracotomy or median sternotomy. Complete
evaluation of the parietal pleura, mediastinum, lungs,
lymph nodes, diaphragm and pericardium can be
accompanied by biopsy of any of the listed structures.
Samples may also be obtained for aerobic, anaerobic
and fungal culture.
The use of video-assisted thoracoscopic surgery
(VATS) was initially limited to diagnostic exploration of
the structures listed above. However, with more
advanced instrumentation, experimentation and expe-
rience, many more surgical procedures have become
feasible. These include: lung biopsy; partial or com-
plete pneumolobectomy; pericardectomy; thoracic
duct ligation; ligation and division of the ligamentum
arteriosum; and closure of a patent ductus arteriosus.
Indications
Thoracoscopic exploration is indicated for most intra-
thoracic conditions in which a diagnosis or treatment
is necessary. Conditions include: pleural effusion;
pericardial effusion; pulmonary disease; mediastinal
mass lesions; lymphadenopathy; chylothorax; regur-
gitation; persistent right aortic arch; pulmonary mass
lesions; and spontaneous pneumothorax.
The benefits of thoracoscopy over thoracotomy
include the visualization of all areas accessible by the
approach normally taken for the disease process
being evaluated. Not only can all areas of the thorax
normally evaluated be seen, but magnification greatly
enhances the chance of identifying small lesions
(Figure 12.1). Multiple biopsy samples can be obtained,
and small or early lesions may be easily identified.
Instrumentation
The equipment required for thoracoscopy differs little
from that required for laparoscopy (see Chapters 7
and 11). The thorax is supported by a rigid wall, the
Ch12 Endo.indd 175
Chapter 12 Rigid endoscopy: thoracoscopy
12
MaryAnn Radlinsky
Excellent illumination and magnification during
12.1
thoracoscopy provide detail beyond that
normally seen with open thoracotomy.
lungs collapse upon establishment of an iatrogenic
pneumothorax, and further collapse is possible with
selective bronchial intubation or bronchial blockage,
all of which may make insufflation unnecessary.
Any rigid telescope may be used for thoracoscopy.
Most surgeons prefer to have both a 0 degree and a
30 degree telescope available. The 0 degree telescope
is best suited for early exploration, as the view is
easiest to understand, being straight on and simple to
process. The 0 degree telescope, however, causes
the surgeon to lever the telescope against the ribs in
order to see as much of the thoracic cavity as possible.
This problem can be alleviated by use of the 30
degree telescope. A 30 degree telescope has a field
of view that is angled 30 degrees from the long axis of
the telescope. By using an offset angle, more of the
thoracic cavity can be evaluated. The surgeon can
‘look around corners’ with the angled endoscope and
cause less pressure on, and place less torque on, the
ribs adjacent to the port site, as well as on the
endoscope itself. By turning the 30 degree telescope,
the surgeon gets a much wider view of the area than
is possible with the 0 degree telescope.
The size of the telescope used is determined by
the size of the patient. A 5 mm 30 cm telescope has
the widest range of use. A 5 mm telescope can be
used in cats and dogs of all sizes. The length of the
5 mm telescope is appropriate for nearly all sizes of
dog but may be slightly longer than needed for small
dogs and cats. The light transmitted by the 5 mm
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 Chapter 12 Rigid endoscopy: thoracoscopy
telescope is appropriate for viewing the thoracic
structures of most sizes of patients. Small dogs and
cats may be well served by a 2.7 mm telescope (often
used for rhinoscopy and cystoscopy), even though it
transmits less light. Due to the small size of those
patients, the decreased illumination and diminished
field of view are less of a problem, and the ability to
manoeuvre a smaller telescope in the small intercostal
spaces is also a benefit. The shorter length (e.g.
18 cm) of the 2.7 mm telescope is also appropriate
for use in small patients. A 10 mm telescope is useful
in large- to giant-breed dogs, but is not essential.
The telescope and operating instruments are
introduced into the thoracic cavity via cannulae that
are inserted into the pleural space using a trocar.
Sharp trocars are not necessary for thoracoscopy if
insufflation is not being used. Blunt trocars can be
placed through mini-thoracotomies in an open fashion.
Performing a mini-thoracotomy allows for the
establishment of a pneumothorax prior to trocar–
cannula insertion, thereby decreasing the risk of
pulmonary trauma.
Cannulae used for thoracoscopic surgery are
often open rather than valved. Open cannulae allow
for rapid exchange of instruments into and out of the
thoracic cavity and decrease the trauma to the
thoracic wall. If insufflation of the thorax is desired for
further pulmonary atelectasis, valved cannulae may
be used. Cannulae that are soft and flexible (Figure
12.2) decrease the pressure on the adjacent soft
tissue structures and may decrease the perioperative
pain associated with nerve compression by rigid
cannulae. They are recommended for intercostal
ports and can be sutured in place to decrease the risk
of dislodgement upon changing instruments.
Flexible endoscopic ports and the blunt
12.2
obterator used for placement. Ports have been
cut to different lengths for different sized patients.
Some flexible cannulae may also be cut to size to
fit the patient better and may be resterilized for
repeated use. Occasionally the flexible cannulae may
have friction problems that inhibit movement of the
instruments, or more commonly the telescope.
Application of a small amount of water-soluble lubri-
cant dramatically decreases friction, but application to
the end of the telescope should be avoided so as not
to interfere with visualization.
176
Ch12 Endo.indd 176
Laparoscopic cannulae may be used for
thoracoscopy but are often longer than required. As
described above, flexible cannulae are useful for
intercostal space applications and can be cut to fit
each patient. Longer cannulae or threaded cannulae
may be useful for thoracoscopic evaluation of the
patient in dorsal recumbency. A paraxiphoid approach
(see below) requires a longer cannula, and the
threaded cannula may be useful for slow controlled
placement in the paraxiphoid position. Threaded
cannulae may also be used intercostally and are more
secure than regular laparoscopic ports. Traditional
laparoscopic cannulae are, however, supplied with
valves (which may be removed for thoracoscopy) and
sharp trocars. Extreme care must be taken when
using a sharp trocar for thoracic insertion of a cannula
as it is more likely to damage pulmonary parenchyma.
Open placement, establishment of a pneumothorax,
and placement under direct visualization may not be
enough to decrease the risk of trauma. Replacement
of the sharp trocar with a blunt trocar is recommended
if laparoscopic cannulae are used for thoracoscopy.
Xenon light sources provide the best lighting,
superior to that of halogen light sources. The rigid
thoracic wall provides a stable cavity to explore, and
the far reaches of the thoracic inlet and diaphragmatic
recesses are easily illuminated and evaluated with a
xenon light source. Flexible fibreoptic cables attach
the light source to the telescope, causing minimal
interference with manipulation of the telescope and
adjacent instrumentation.
The video camera must be of high quality and is
usually designed to fit the associated telescope so
that the thoracoscopic procedure can be viewed on a
video monitor. Either a single- or three-chip camera
(see Chapter 2) may be used for evaluation of the
thoracic cavity; the three-chip camera provides the
best quality for video and image capture.
Diagnostic procedures
Operative instruments for diagnostic thoracoscopy
are no different from those used in laparoscopy. As
with the telescope and cannulae, the size of the
patient should be considered: 5 mm instruments are
the most versatile; smaller patients may benefit from
2.7 mm shorter instruments; and large patients will
tolerate 10 mm instruments. As thoracoscopic
techniques become more advanced, more instruments
may be required.
Basic instrumentation for diagnostic thoracoscopy
includes: a palpation probe for palpation, manipu-
lation and measurement of structures; biopsy forceps
(cup or punch); straight or curved grasping forceps;
and scissors. With these instruments, samples of
pleura, mediastinum, pericardium and lymph node
may be obtained. An aspiration–irrigation cannula
can be purchased. Alternatively, a small Poole suction
tip or a feeding tube may be inserted through a
cannula to obtain fluid samples. Spinal needles may
be inserted through the thoracic wall to obtain
pericardial fluid samples under direct visualization.
Sampling for cytological evaluation, bacterial and
fungal culture, and histopathological evaluation
should be considered.
4/3/08 09:45:23

Therapeutic procedures
As therapeutic intervention is considered, more
instrumentation may be necessary. Straight and
curved dissectors are useful for dissection of fine
structures within the thorax. Lymph node removal,
mass removal, ligation of the ligamentum arteriosum,
ligation of the thoracic duct, and pericardectomy are
all best performed when the surgeon has several
different types of dissecting forceps and scissors at
their disposal. More aggressive grasping forceps are
useful for manipulation of the pericardium and other
connective tissues within the mediastinum. A fan
retractor is useful for holding pulmonary parenchyma
out of the surgical field for many procedures and may
be vital to dissection of the pulmonary hilus,
ligamentum arteriosum and patent ductus arteriosus.
Lung biopsy is greatly facilitated with the application
of pre-tied suture loops. Clip appliers are very useful
for haemostasis and ligation of the thoracic duct.
More advanced procedures, such as partial or
complete pneumolobectomy, may utilize endoscopic
gastrointestinal anastomosis (GIA) or thoraco-
abdominal (TA) stapling devices.
Much of the instrumentation used, e.g. grasping
forceps, scissors, dissectors, can be connected to
electrocautery or radiosurgical devices. The insulated
shaft allows for monopolar use. Specially designed
bipolar forceps and cutting devices are also available.
More specialized devices for incision and sealing of
vascular structures include harmonic scissors and
vessel sealing devices. The more advanced the
procedure, the more advanced instrumentation is
usually used.
Patient preparation and positioning
All patient preparation and draping, plus equipment
that may be required for immediate conversion to an
open thoracotomy should be in the operating suite.
The patient should not require re-draping, and
equipment must be immediately available for use.
The patient’s position may be changed during the
procedure to gain from gravity’s pull on the internal
organs, primarily the heart. Lungs will also gravitate
ventrally as they become atelectic. The surgeon
should be aware, however, that fluid within the pleural
space will buoy the lungs dorsally, laterally or ventrally,
depending on the positioning of the patient. Removal
of as much fluid as possible will improve visualization
of thoracic structures.
Patient positioning on the operative table should
be secure and appropriate for the procedure. The
patient may be positioned in dorsal, lateral or sternal
recumbency, as required for the procedure. In each
case, the ability to change position of the patient
intraoperatively should be considered. Simple angling
of the patient may allow gravity to provide improved
exposure of the desired site. The need to convert
rapidly to an open approach should also be considered
when securing the patient to the operating table.
Many types of table are available for laparoscopy and
thoracoscopy that allow for tilting of the patient in
multiple directions.
Ch12 Endo.indd 177
Chapter 12 Rigid endoscopy: thoracoscopy
Specific patient preparation depends on the
approach used. Thoracoscopy may be performed
from an intercostal approach, which approximates lat-
eral thoracotomy. From this approach, the entire
hemithorax can be examined. All dorsal, middle and
ventral structures should be able to be viewed, includ-
ing the diaphragm, lungs, mediastinal structures (e.g.
vessels, nerves, lymphatics, lymph nodes), pulmo-
nary hilus and lymph nodes, great vessels, pericar-
dium and the thoracic inlet. The patient preparation
for such an approach is similar to that for a standard
lateral thoracotomy. The entire hemithorax should be
clipped and aseptically prepared for port and thoraco-
stomy tube placement. Draping of the chest should
be wide enough to allow palpation of intercostal
spaces and placement of multiple ports; draping is
often wider than that for an open thoracotomy.
A dorsally recumbent patient undergoing thoraco-
scopy approximates the exploration obtained by a
median sternotomy. With this approach, both sides of
the chest may be explored, but access to the very
dorsal structures is limited. This approach is often
used for general exploration in cases of unknown
diagnoses, such as chronic pleural effusion of
unknown origin. The patient should be clipped and
aseptically prepared from 5 cm caudal to the xiphoid
process to the thoracic inlet and dorsal enough for
placement of thoracostomy tube(s), giving access to
the whole of the ventral two-thirds of the thoracic wall
on both sides of the chest. Draping is again some-
what wide to allow ventral intercostal portal placement
and thoracostomy tube placement.
Preoperative diagnostic work-up
Most patients undergoing thoracoscopic evaluation
will have already had non-invasive diagnostic pro-
cedures such as complete blood count, biochemical
profile, urinalysis, thoracic and abdominal radiogra-
phy, abdominal ultrasonography and echocardiogra-
phy completed. Fine-needle aspiration of any mass
lesions and analysis of pleural fluid, if present, should
be performed. Pleural fluid should be evaluated for
protein level, nucleated cell count, cytological exami-
nation, aerobic and anaerobic cultures, and trigly-
ceride and cholesterol evaluation if necessary. Systemic
alterations in the patient, as well as cardiopulmonary
status, should be considered prior to thoracoscopy,
just as they would be prior to open thoracotomy.
Anaesthetic considerations
Diagnostic thoracoscopy under heavy sedation and
oxygen supplementation has been reported, but is
usually not practical in veterinary medicine. Such a
practice requires valved cannulae and a controlled
pneumothorax, with rapid examination and biopsy of
appropriate structures.
General anaesthesia and mechanical ventilation
are the standard practice for thoracoscopy in
veterinary medicine. The physical status, systemic
compromise and ventilatory capability of each patient
should be considered, and the anaesthetic technique
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 Chapter 12 Rigid endoscopy: thoracoscopy
should be tailored to the patient’s needs. Establishing
pneumothorax during thoracoscopy, in which both
lungs were mechanically ventilated, has been shown
to decrease partial pressure of oxygen (PaO2) and
increase partial pressure of carbon dioxide (PaCO2).
These changes were probably due to ventilation–
perfusion mismatch but were not severe enough to
result in clinical compromise (Kudnig et al., 2004). A
decrease in total peripheral vascular resistance did
result secondary to the hypercapnia, but again was
not severe enough to lead to complications. Clinical
cases undergo changes in tidal volume, inspiratory
pressure and ventilatory rate based on changes in the
patient. Adequate monitoring equipment must be
used to detect changes and adjust ventilation as
required by the patient.
Thoracoscopy usually requires alteration in the
ventilation settings to obtain adequate pulmonary
atelectasis for visualization within the pleural space.
These changes may result in further ventilatory alter-
ations within the patient. If the pulmonary atelectasis
gained by the open pneumothorax provided by port
placement is not sufficient for the procedure, selec-
tive single lung ventilation may be desired.
One-lung ventilation is often used to increase the
working space within the chest for more advanced
procedures. The effect of one-lung ventilation on
closed-chest dogs in one study (Kudnig et al., 2006)
consisted of minimal, clinically controllable alterations
similar to those identified in open chest bilaterally
ventilated dogs. The atelectic lung presumably
undergoes hypoxaemic vasoconstriction, shunting
pulmonary blood flow to ventilated areas of the lung,
and minimizes intrapulmonary shunting or ventilation–
perfusion mismatch. The use of one-lung ventilation
in abnormal patients may be more demanding and
difficult. Monitoring pulse oximetry, end-tidal carbon
dioxide, blood pressure, electrocardiography and
blood gases is recommended for patients undergoing
thoracoscopy. The addition of 5 cmH2O positive end-
expiratory pressure (PEEP) has been recommended
in patients undergoing thoracoscopy with one-lung
ventilation to decrease the negative effects. Using
PEEP recruits more alveoli from the ventilated lung,
minimizing ventilation–perfusion mismatch, and does
not affect cardiac output or delivery of oxygen to the
tissues (Kudnig et al., 2006).
One-lung ventilation can be achieved by selective
bronchial intubation or by establishing bronchial
blockade of the operated side. Establishment of one-
lung ventilation should be done in the operating suite
just prior to thoracoscopy to avoid dislodgement
during patient transport or positioning. Endoscopic
guidance is required and there is something of a
learning curve, especially for establishing bronchial
blockade. The blocker must be properly located and
inflation of the balloon must block the flow of gas
without causing inadvertent displacement into the
carina or distal trachea. Endotracheal tubes may be
altered or specialized tubes purchased for bronchial
intubation or blockade. Selective intubation or
bronchial blockade also usually requires use of a
flexible bronchoscope to facilitate and confirm
appropriateness of the tube or blocker.
178
Ch12 Endo.indd 178
Procedure
Any time that thoracoscopy is performed the surgeon
must be prepared to convert to an open thoracotomy
should the need arise, either due to unexpected com-
plications or to resect a large mass. The approach
chosen should be appropriate for the site to be evalu-
ated, for the intended surgical intervention, and take
account of the possible need for open surgery. All
instrumentation for open thoracotomy should be avail-
able to the surgeon. If a lesion is to be excised, the
size of the thoracotomies for portal placement should
be assessed. For biopsy, small lesions or compres-
sible tissue (e.g. the pericardium), 5 mm or 10 mm
portals may allow for extraction of the tissue through
those sites. Larger lesions may be dissected thoraco-
scopically, with enlargement of a port site for extrac-
tion of the tissue. Very large lesions that would require
a large thoracotomy for extraction may be best
approached by standard open thoracotomy. These
decisions can be made by the surgeon using thoraco-
scopy as a diagnostic tool prior to open surgery.
If possible, it is always prudent to use other non-
invasive modalities to make this determination.
Diagnostic techniques
The chest should first be completely explored and all
abnormalities evaluated. Biopsy of the pleura, lung,
lymph nodes (sternal, hilar), mediastinum, mass
lesions and pericardium may be performed if no abnor-
malities are noted. Primary diffuse pulmonary disease
can be further assessed by pulmonary biopsy. Mass
lesions of the lung, pleura, mediastinum and lymph
nodes may be sampled or removed. Pericardectomy
can be performed for cases of pericardial effusion,
and the right atrium may be assessed upon opening
the pericardial sac.
Evaluation of spontaneous pneumothorax and the
right atrium may be more challenging. All lung lobes
must be evaluated visually, and saline infusion into
the thorax may provide a diagnosis of the currently
leaking site. If a leak is not identified, thoracoscopy
should at least provide information as to the presence
of emphysematous lung, pleural blebs or atelectic
lung. Thoracoscopy in those cases can aid in
identification of the abnormal lung and allow for
surgical planning should an open thoracotomy
become necessary. Localizing the pulmonary lesion
via thoracoscopy will allow a single thoracotomy to be
performed if necessary to remove abnormal pulmonary
parenchyma. In cases of spontaneous pneumothorax,
abnormal lung may be removed.
Once the side of the lesion is identified, a lateral
open approach may be used, thereby avoiding a
median sternotomy for pneumolobectomy. A median
sternotomy is less desirable for pneumolobectomy,
as the pulmonary hilus is displaced dorsally, away
from the surgeon. The right atrium may be evaluated
following pericardial incision, but the use of an angled
endoscope and careful manipulation of the pericardium
are required for such an endeavour.
Therapeutic procedures
The use of a video camera and video monitor is vital
in therapeutic procedures. An assistant may direct the
4/3/08 09:45:23

telescope while the surgeon performs the procedure.
Without a video camera and monitor, this would not
be possible. Concurrent viewing by all members of
the operating and anaesthetic team allows correlation
of the patient’s progress with the progress of the
procedure, linking the entire team together, maximizing
the quality of patient care.
Establishing a pneumothorax
A pneumothorax may be established in different
ways:
• A Veress needle (see Chapter 2) may be
inserted via a stab incision through the skin and
the stopcock opened to allow air to enter the
pleural space
• Dissection of the thoracic wall and placement of paraxiphoid cannula must be opened to explore
a blunt trocar and port will also allow air to more
rapidly enter the pleural space
• A simple method is to perform a mini-thoracotomy often adhere to the contralateral lungs until bilateral
and then place a cannula over a blunt trocar.
Port placement
The initial port site on the chest wall should be chosen
to allow examination of the majority of the pleural
space and to allow for triangulation of subsequent
ports for biopsy or therapeutic intervention.
In a lateral approach, a skin incision is made that
is slightly larger than the diameter of the port. Blunt
dissection of the musculature of the thoracic wall is
carried out until the parietal pleura is penetrated. The
size of the thoracotomy should be large enough to
allow easy placement of a blunt trocar and cannula.
The entire hemithorax should be examined prior to
placement of subsequent ports, which should be done
under direct visualization with the telescope.
The paraxiphiod port is often placed first in patients
undergoing thoracoscopy in a dorsal position. The
port should be placed with concurrent visualization
through a 0 degree telescope placed inside the port.
A threaded cannula is ideal for such placement. An
initial incision is made in the skin to one side of the
base of the xiphoid process between it and the costal
arch. Port placement is easiest if it is introduced into
the ipsilateral hemithorax. It is important to make the
incision larger than the diameter of the threaded
cannula to avoid gathering of the skin and subcutis
upon port advancement. The port should be placed in
the site and slowly advanced, using a clockwise
motion, directed toward the ipsilateral thoracic wall
and somewhat dorsally, to ensure entry into the
pleural space. A 0 degree telescope is introduced into
the cannula as soon as it engages the musculature.
The cannula is advanced under endoscopic guidance
until the diaphragm and diaphragmatic pleura are
penetrated. It is then advanced slightly beyond the
pleura to allow uninhibited insertion and removal of
the telescope and other instruments through the
cannula. The initial evaluation of the chest through
the paraxiphoid cannula is limited to the hemithorax
entered (Figure 12.3).
Fenestration of the mediastinum through other
cannulae placed in the ipsilateral intercostal spaces
will allow bilateral exploration. The mediastinum will
Ch12 Endo.indd 179
Chapter 12 Rigid endoscopy: thoracoscopy
12.3 The normal mediastinum seen upon entry via a
the contralateral hemithorax.
pneumothorax has been established. The mediastinum
may be fenestrated using two pairs of grasping
forceps placed in a poorly vascular section; a fatty
mediastinum may require stabilization with grasping
forceps and incision with scissors. Use of electro-
cautery, radiosurgery or vascular sealers is
recommended to avoid haemorrhage that would
obscure further visualization.
Other portals should be placed after exploration of
the chest. Their placement depends on the expected
procedures to be done. Triangulation is required for
accurate and easy operation, and should be planned
for. Subsequent portal placement should be done
under thoracoscopic visualization. The area to be
entered may be identified by placing pressure on the
intercostal space and identifying it internally. Mini-
thoracotomies and placement of cannulae with blunt
obturators have been described. Each cannula can
be used for examination or passage of operating
instruments. Portals placed for lateral thoracic
procedures may be placed anywhere from dorsal to
ventral, as long as the site is visualized with the
telescope. Interference with the movement of the
pulmonary parenchyma should be considered, along
with the intended surgical site. Cannulae placed
during thoracoscopy of the dorsally recumbent patient
should be placed ventrally enough to avoid the
pulmonary parenchyma during instrument entry and
manipulation. Care should be taken to avoid the
internal thoracic arteries, which should be easily
visualized. Operating portals should also be spaced
widely enough to avoid interference between
instruments being used and the telescope. Use of a
30 degree telescope offers the widest variety of fields
of view and the least risk of instrument interference.
Biopsy
Pleural
Pleural biopsy is a simple procedure that can be done
during any thoracoscopic exploratory surgery. The
intercostal vessels (Figure 12.4) and nerves lying
primarily at the caudal aspect of the ribs should be
avoided to minimize the risk of life-threatening
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 Chapter 12 Rigid endoscopy: thoracoscopy
Intercostal vessels (arrowed) seen coursing
12.4
along the caudal border of the ribs should be
avoided during cannula insertion and pleural biopsy.
haemorrhage. Cup biopsy forceps are inserted under
thoracoscopic visualization. The rib should be
palpated cranial and caudal to the intended site of
pleural biopsy to avoid the neurovascular structures.
This method should avoid the nerves and vessels in
cases in which the thickened parietal pleura obscures
their view. The forceps are opened and samples taken
from the parietal pleura; significant force is not
routinely required. Should significant haemorrhage
occur, electrocautery, radiofrequency, vascular clip
application or open thoracotomy may be required.
Multiple samples of the parietal pleura should be
taken, including multiple abnormal sites, as reactive
mesothelium is difficult to distinguish from meso-
thelioma or metastatic neoplasia.
Mediastinum
Cup biopsy forceps can be used to sample the
mediastinal pleura. Alternatively, dissecting forceps,
scissors or sealing devices can be used in cases in
which the mediastinum is fatty or well vascularized.
Mass lesions should be evaluated for vascularity prior
to sampling, and large vessels should be avoided.
Haemostatic foam may be inserted into the biopsy
site left by cup forceps. Mass lesions may be dissected
with curved forceps and graspers, followed by
Metzenbaum scissors. Haemostasis may be achieved
with electrocautery, radiofrequency or vessel sealing
devices.
Sternal lymph nodes may also be sampled. The
lymph node may be partially dissected and sampled
with cup biopsy forceps, or completely excised.
Complete mass or lymph node excision requires
haemostasis with any of the listed devices. Hilar
lymph nodes require superficial dissection for biopsy
and careful dissection for complete excision.
Lung
Pulmonary biopsy can be achieved using three
methods: Tru-cut biopsy; pre-tied loop ligature; or
endoscopic stapling. Tru-cut biopsy needles may be
used to sample lung masses of large enough size as
to not result in trauma to the normal surrounding
pulmonary parenchyma. The needle is directed and
fired into the mass under thoracoscopic guidance.
180
Ch12 Endo.indd 180
Pre-tied loop ligatures can be used to sample the
distal 2 cm of lung lobes. The pre-tied loop ligature
and grasping forceps are introduced into the thoracic
cavity. The edge of the lung is grasped through the
loop ligature and elevated while the ligature is
tightened. The lung and ligature are stabilized and the
portion of lung excised with Metzenbaum scissors,
cutting off excess suture with hook scissors.
Endoscopic stapling devices can be used to obtain
larger lung biopsy samples and may be fired twice to
perform wedge excisions of lung.
Ending the procedure
The port site should be closed to achieve an airtight
seal. Closure is usually in two layers, one in the
muscle and fascia, the second in the skin. The
subcutis may also be closed. Evacuation of the pleural
space via the thoracostomy tube should immediately
follow port closure to assist ventilation of the patient.
Intermittent pleural drainage via the tube allows for
early identification of haemorrhage or air accumulation
in the pleural space.
Normal findings
The normal thorax is easily explored and many
structures are readily visible (Figure 12.5). The
thoracic wall is easily viewed through the pleura,
which is normally incredibly thin. Ribs, costochondral
junctions, intercostals vessels and nerves should be
easy to identify. Depending on the position of the
patient, other structures may be seen. With the patient
in dorsal recumbency, the following can be seen:
sternebrae, internal thoracic vessels, pericardium,
sternal lymph nodes, the lungs and the diaphragm.
The ventral mediastinum is thin and interlaced with
fat. Upon initial examination it may be readily visible
in the central portion of the ventral thorax. Alternatively,
it may be adhered to the contralateral lungs.
12.5 A view of the caudodorsal thorax at the dorsal
pleural reflection demonstrates the detail visible
during thoracoscopy.
Once the mediastinum is opened, the lungs on
both sides of the chest may be examined; they should
be pink and retract easily (Figure 12.6). The
pericardium can easily be seen, and the phrenic
4/3/08 09:45:25

12.6
Endoscopic appearance of normal lung.
nerves should be visible at the base of the heart in the
fat on the pericardium as the heart is moved by
rotating the patient or upon grasping the pericardium.
The heart should be visible through the translucent
pericardium. The pulmonary vasculature is easily
identified upon retraction of the lung away from the
heart. Thymic tissue is readily apparent in the
mediastinum of young patients. Hilar and dorsal
structures may be more readily viewed via a lateral
approach. Dorsal structures such as the sympathetic
trunk, thoracic duct(s), azygous vein, mainstem
bronchi and hilar lymph nodes should be identified.
Pathological conditions
Thickening of the pleura, obscuring the ribs, intercostal
vessels, intercostal nerves or contralateral pulmonary
parenchyma is an abnormal finding. In addition, the
sternebrae and internal thoracic vasculature may be
difficult to identify in a severe case of pleural
thickening. Small thickened areas on the pleura are
also abnormal. Thickening of the pleura and
mediastinum may be associated with any condition,
resulting in pleural effusion. Thickening may be
generalized with or without concurrent plaque or
nodular pleural lesions. The thickened pleura and
nodules should be sampled to increase the chance of
obtaining a diagnosis.
The pleura is usually dramatically thickened with
or without adhesions between the visceral pleura and
surrounding structures in cases of pyothorax.
Significant pleural thickening and disease may make
division of the ventral mediastinum more difficult;
haemostasis with electrosurgery or sealing devices
may be necessary. Significant thickening of the pleura
may also hinder the placement of the paraxiphoid port
if adequate dorsal angling is not utilized.
It is important to consider thoracocentesis or
passing a Poole suction tip into the chest to drain as
much pleural fluid as possible in cases of pleural
effusion (Figure 12.7). Thoracic drainage will allow
the lungs to crop ventrally, thereby increasing
visualization of intrathoracic structures, and will allow
more appropriate ventilation of the patient.
Ch12 Endo.indd 181
Chapter 12 Rigid endoscopy: thoracoscopy
12.7 Telescopic view of the middle chest toward the
thoracic inlet (arrowed) in a dog with chronic
pleural effusion.
Pneumothorax
Cases of spontaneous pneumothorax may be asso-
ciated with an obvious pulmonary lesion, such as
subpleural blebs, bullae or emphysematous lung.
The chest should be filled with saline under direct
visualization in an attempt to identify a source of air
leakage. Similar evaluation may be done for cases of
pulmonary trauma in which persistent air leakage
has occurred.
Pericardial disease
The pericardium may be thickened in cases of
pericardial effusion, constrictive pericarditis, cardiac
or heart base tumours, or pyothorax. Opening of the
pericardium is difficult if fluid is present, and
pericardiocentesis under thoracoscopic visualization
may be used to allow grasping of, sampling of, and
removal of the pericardium. The heart should be
examined for tumours with the pericardium at least
partially intact, as the pericardium is grasped and
manipulated to move the heart for complete inspection.
Neoplasms may be readily visible on the right auricular
appendage or heart base.
Lung disease
Abnormalities of the lung include fibrosing pleuritis, a
condition in which the visceral pleura thickens and
limits expansion of the pulmonary parenchyma.
Severe fibrosing pleuritis results in small, rounded
lung tissue adjacent to the hilus. Lung may also
appear and feel thick, and may not deflate normally.
Lung tumours (Figure 12.8) should be readily visible if
they are superficially located, and will become more
visible when atelectasis occurs. A palpation probe
easily compresses normal lung tissue, making lung
tumours readily palpable. The appearance of multiple
masses may represent metastasis, and multiple
biopsy samples may be necessary to obtain a
diagnosis. The pulmonary hilus and hilar lymph nodes
must be examined and sampled, or removed in the
case of pulmonary neoplasia. Lung lobe torsion
presents as a dark, consolidated lung lobe with a
twisted hilus. The condition is usually associated with
a haemorrhagic pleural effusion. Tumours of the
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 Chapter 12 Rigid endoscopy: thoracoscopy
12.8 Caudal mediastinal mass in a patient with
chronic pleural effusion. The diagnosis was
lymphosarcoma.
cranial mediastinum, such as thymoma, should be
readily visible. Care should be taken to evaluate
adjacent anatomy (e.g. phrenic nerves, internal
thoracic vessels, cranial vena cava) associated with
the cranial mediastinum prior to attempting removal.
Diaphragmatic hernias
Diaphragmatic hernias are readily identified in asso-
ciation with abdominal tissues within the thorax.
Extreme caution should be taken if a diaphragmatic
hernia is identified during laparoscopy, as insufflation
of carbon dioxide into the abdomen will enter the tho-
rax. Entry of a significant amount of carbon dioxide
leads to a tension pneumothorax and decreased car-
diac output secondary to decreased venous return.
Pericardiocentesis
Pericardiocentesis may be performed under
thoracoscopic guidance. A needle is introduced
through the thoracic wall and directed into the
pericardium under direct visualization. Upon entry
into the pericardial sac, fluid is aspirated. The needle
is maintained ventral to the heart.
Pericardiocentesis may be necessary prior to
pericardectomy or pericardial window formation, to
allow grasping of the pericardium for incision. The
intact distended pericardium is as difficult to grasp as
a balloon filled with air. Following pericardiocentesis,
the relaxed pericardium is more easily grasped and
stabilized for manipulation and incision.
Mediastinal debridement
The thoracic cavity may be explored and debrided via
thoracoscopy in cases of pyothorax. The patient
should be positioned in dorsal recumbency for
complete exploration and debridement of both
hemithoraces. The initial evaluation should assess
whether the procedure can be done with the
endoscope. Multiple strong fibrous adhesions are an
indication for conversion to a median sternotomy, as
fluid loculation and firm adhesions will require
significant time and give an increased risk of
182
Ch12 Endo.indd 182
parenchymal damage. Debridement of the entire
mediastinum is the goal of the procedure. Grasping
forceps and Metzenbaum scissors should be used to
remove all abnormal tissue from the thoracic cavity.
Use of electrocautery, radiosurgery or vessel sealing
devices are strongly encouraged for the entire
procedure, as bleeding will diminish visualization.
Thoracoscopy allows for excellent visualization of
the entire thoracic cavity from the thoracic inlet to the
diaphragm. All abnormal tissue, including the
pericardium if necessary, should be removed. Tilting
the patient to the right and left may assist in
visualization of the dorsal structures. Samples should
be submitted for histopathological examination and
aerobic, anaerobic and fungal culture.
Pericardectomy
Pericardectomy was the first interventional technique
used clinically in dogs and demonstrated a decrease in
patient pain and stress after surgery when compared
with lateral thoracotomy. The procedure is now wide-
spread and is the standard of care for pericardectomy.
Patients may be placed in either lateral or dorsal
recumbency. If subtotal pericardectomy is desired,
dorsal recumbency provides access to the entire
pericardium ventral to the phrenic nerves. If the
patient is in dorsal recumbency, the first port is usually
the paraxiphoid port. Additional intercostal ports may
be placed at the 6th intercostal spaces bilaterally, or
at the 6th and 10th intercostal spaces on the right
(Figure 12.9). Alternatively, ports may be placed in
the paraxiphoid location, and at the 9th intercostal
Right Left
PX
12.9 Port sites for pericardectomy. Sites may be
adjusted to match the anatomy of each patient.
The paraxiphoid port (PX) can be used for the telescope
with the operative ports placed either bilaterally at the 6th
intercostal space, or at the 6th and 10th intercostal spaces
on the right of the patient.
4/3/08 09:45:27

space on each side of the chest. Additional ports may
be placed as needed, being careful to place all ports
ventral enough to avoid trauma to the pulmonary
parenchyma. It is important to note that one-lung
ventilation is not required in dogs undergoing
pericardectomy in dorsal recumbency, making the
anaesthesia simpler.
The lateral approach has been described for a
right or left approach, with the left approach offering
visualization of the right atrial appendage and aortic
root for tumour evaluation. Ports are placed in the
3rd, 5th and 9th, or 3rd, 4th and 5th, or 4th, 6th and
8th or 4th, 6th and 10th intercostal spaces for the
lateral approach.
The procedure is performed with grasping forceps
and scissors. It is desirable to connect scissors to
electrocautery or radiosurgical equipment; electro-
cautery or vessel sealing instruments with a built-in
cutting device are available and decrease the need to
cauterize and exchange instruments prior to incising
the pericardium. If the pericardial sac is distended
with fluid, pericardiocentesis under thoracoscopic
visualization (see above) will allow for relaxation of
the pericardium and stabilization with grasping
forceps. If pericardiocentesis is not performed, the
distended pericardium can be difficult to grasp.
Creation of a pericardial window allows fluid to
drain continuously from the pericardial sac into the
pleural space, preventing cardiac tamponade in cases
of idiopathic pericardial effusion or neoplasia. First,
the thoracic cavity is explored to identify and sample
abnormalities, which may represent neoplastic
spread. Next, the phrenic nerve is identified so it can
be avoided. The cranial aspect of the pericardium is
identified if performing a pericardial window; the
pericardium is grasped and incised with scissors. A
pericardial window is typically 3–5 cm and can be
made ventral to the mediastinal fat. Once an opening
is made in the pericardium, it may be easier to
manipulate the pericardium if one edge of the grasping
forceps is placed inside the pericardial sac. The
pericardium should be easily removed through one of
the operating portals. If necessary, a port site is
enlarged for extraction of the tissue. The pericardium
should be submitted for histopathological examination
and bacterial culture, and susceptibility testing.
Subtotal pericardectomy for constrictive peri-
carditis, infectious pericarditis or neoplasia is best
done from a ventral approach. Portals may be required
on both sides of the chest for adequate pericardial
excision. The mediastinum is opened with grasping
forceps, or forceps and scissors. Electrocautery,
radiosurgery or vessel sealing devices may be needed
in large dogs or where there is a large amount of fat
in the ventral mediastinum, to decrease blood
contamination of the endoscope. The thorax is
explored and any lesions sampled as dictated by the
findings. The phrenic nerves must be identified
bilaterally prior to pericardectomy (Figure 12.10). The
subtotal pericardectomy is performed as for a
pericardial window but the excision extends more
dorsally, cranially and caudally, taking care to preserve
a cuff of tissue around the phrenic nerves. Rarely is
elevation of the phrenic nerves from the pericardium
Ch12 Endo.indd 183
Chapter 12 Rigid endoscopy: thoracoscopy
Identification of the phrenic nerves (arrowed) is
12.10
paramount to subtotal pericardectomy.
indicated for a more complete pericardectomy.
Electrosurgery, radiosurgery or vessel sealing devices
are highly desirable to decrease haemorrhage, which
would obscure visualization of dorsal structures. The
pericardial sac should be evaluated for haemorrhage,
and haemostasis should be complete prior to thoracic
wall closure.
Partial and complete
pneumolobectomy
Partial lobectomy and complete pneumolobectomy
can be performed with the assistance of endoscopic
stapling devices. Partial or complete lobectomy may
be required for lung tumours, abscess, bullae or
subpleural blebs.
Either a lateral or ventral approach may be used.
The lateral approach for biopsy of the caudal aspect
of the left cranial lung lobe described ports at the 4th,
6th, 7th and 9th intercostal spaces; initial thoracic
exploration and placement of ports triangulated
toward the lobe to be sampled should suffice. A
paraxiphoid port and triangulated ports aimed at the
affected site may also be used if the side of the lesion
cannot be determined preoperatively. A pre-tied loop
ligature may be used for sampling small portions of
the lung periphery.
Partial lobectomy
Partial lobectomy requires use of an endoscopic GIA
or linear stapling device. The lungs should be com-
pletely evaluated and appropriate samples taken
to assess for spread of the disease as necessary. If
the diseased portion of lung is peripheral, partial
lobectomy may be performed with endoscopic assist-
ance. The lungs and lymph nodes should be evalu-
ated prior to increasing the length of a chosen port
site. One port site adjacent to the lesion may be
extended to a size appropriate to allow exteriorization
of the affected lung and a margin of normal paren-
chyma. Standard stapling devices or suture tech-
niques may then be used to resect the portion of lung,
the remainder of which is then replaced into the
thorax. The procedure should be done without retract-
ing the ribs, to decrease postoperative morbidity.
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 Chapter 12 Rigid endoscopy: thoracoscopy

If the procedure is to be done completely endo-

scopically, the affected lung lobe should be stabilized
and elevated as necessary. A long stapling device is
desired to decrease the need for multiple expensive
disposable cartridges. A 65 mm device is the longest
available. The GIA stapling device compresses and
discharges two or three double-staggered rows of
staples, and divides between the four or six rows. Use
of an endoscopic TA stapler has also been described.
The sample is removed through a port site; enlarge-
ment of the port site may be required for mass lesions.
Ideally, the sample is placed in an endoscopic retrieval
bag to avoid contamination of the pleural space, tho-
racic structures and port site, as infection or neoplasia
could be seeded to other structures upon removal.
The biopsy site should be evaluated for haemorrhage
and air leakage prior to closure of the thoracic wall. Lateral view of the oesophagus of a dog with a
12.11
persistent right aortic arch prior to dissection.
Complete pneumolobectomy
Complete pneumolobectomy has been described
for clinical management of lung tumours in dogs in the dorsal aspect of the 5th intercostal space is
(Lansdowne et al., 2005). The dog is placed in lat- also included. An alternative approach is to place
eral recumbency, with the affected lung upwards. An three ports caudally in the thorax, viewing from cau-
endobronchial blocker or selective intubation is dal to cranial and dissecting similarly.
required. For caudal lesions, ports are placed in the A stomach tube in the oesophagus enhances
ventral aspect of the 8th intercostal space and dor- identification of the ligamentum. The lungs are
sally in the 10th and 7th intercostal spaces. Cranial retracted caudally with a fan retractor and the ligament
lobes are approached with ports in the ventral aspect identified with a palpation probe. The ligamentum is
of the 7th intercostal space, the dorsal half of the isolated with sharp and blunt dissection, using curved
8th and middle of the 5th intercostal spaces. dissecting forceps, Metzenbaum scissors and
Dissection includes the dorsal ligaments using grasping forceps (Figure 12.12). Careful dissection is
Metzenbaum scissors with electrocautery. An endo- required, as the ligament may be patent. Vascular
scopic GIA stapling device is used to ligate the lung clips are placed at the dorsal and ventral aspects of
at its hilus. Lansdowne et al. (2005) recommend the dissected ligament, which is transected between
a GIA stapling device that provides three double- them. The oesophagus is debrided of remaining
staggered rows and cuts between the six rows pro- fibrous connective tissue until easy passage of a
vided by the device. A 60 mm cartridge with 3.5 mm stomach tube is possible. Alternatively, a balloon
staples was used in that study. Cranial and caudal catheter may be used to assess the size of the
lung lobes were successfully removed without trac- oesophageal lumen and to balloon the remaining
tion of the ribs. The right middle and accessory lung fibres. Care must be taken to avoid damage to the
lobes present the greatest challenge for removal. muscular layers of the oesophagus while gaining the
Complications of lobectomies are associated with appropriate dissection of any remaining connective
inadvertent loss of one-lung ventilation and haemor- tissue bands (Figure 12.13).
rhage from trocar sites. It is important to assess and
biopsy hilar lymph nodes in every case of possible
pulmonary neoplasia.

Division of the ligamentum

arteriosum
The ligamentum arteriosum causes extraluminal
compression of the cranial oesophagus (Figure
12.11), leading to regurgitation in young animals
with a persistent right aortic arch, which is the
most common form of vascular ring anomaly. The
oesophagus may be evaluated with flexible
endoscopy prior to surgery to ensure compression
of its lumen by a left-sided band. Ligation and divi-
sion of the ligament has been described using
different approaches.
The patient is positioned in right lateral recum-
bency and portals placed at the costochondral junc- The ligamentum arteriosum (arrowed) is visible
12.12
tion of the 3rd, 5th and 7th intercostal spaces. A portal after dissection of the mediastinum.

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 Chapter 12 Rigid endoscopy: thoracoscopy

Portals are placed in the chest with two at the dor-

sal third and one for the telescope in the mid-chest.
Instruments are placed through the cranial and caudal
ports, which are placed in the dorsal third of the tho-
rax, usually in the 8th and 10th intercostal spaces. The
telescope is placed through a port in the 9th intercos-
tal space (Figure 12.14). Initial dissection is done with
Metzenbaum scissors: the mediastinal pleura is
incised longitudinally at the ventral third of the aorta at
the site chosen for ligation. Care should be taken to
avoid the costal arteries cranial and caudal to the dis-
section (Figure 12.15). Dissection is continued ventral
to the thoracic duct with curved dissectors while apply-
ing gentle, ventral traction on the aorta, and through
the mediastinum into the left hemithorax. The same
12.13 Appearance of the oesophagus (arrowed) procedure is done dorsal to the thoracic duct and its
following transection of all fibrous bands. branches, until the left hemithorax is entered. A 10 mm
endoscopic clip applier is introduced into the caudal
port, and clips applied to all visible branches of the
Occlusion of a patent ductus
thoracic duct during ventral retraction of the aorta.
arteriosus
A partially open and thoracoscopic approach for clip
application to occlude a patent ductus arteriosus
(PDA) was described in five dogs (Borenstein et al.,
2004). The dogs ranged from 5 kg to 20 kg and from
4 to 6 months of age. The partially open approach
used a mini-thoracotomy of 2–3 cm at the 4th
intercostal space for instrument passage. A telescope
was placed through a port in the middle of the 5th
intercostal space and a lung retractor was placed
through a port in the ventral aspect of the 4th or 5th
intercostal space. Thoracoscopic clip application was
done with two ports – one dorsal and one ventral – in
the 5th intercostal space, and one port dorsally in the
3rd intercostal space for the telescope.
The duct was palpated, and dissected from lateral
to medial cranially and caudally. Medial wall dissection
was not performed. One of the dogs had residual flow
through the PDA, which was considered clinically 12.14 Port sites for thoracic duct ligation. Ports may
insignificant. It is important to note that 10 mm clips be moved caudally in patients with a deep-
were the largest available, limiting the size of a PDA chested conformation.
that can be occluded using this method. The dogs
were also of a size amenable to the 10 mm and 5 mm
portals and instruments used.

Thoracic duct occlusion

The thoracic duct can be identified in dogs via a right
lateral approach and in cats via a left lateral approach
for the treatment of chronic chylothorax. The light and
magnification provided by thoracoscopy enhance the
visualization of the thoracic duct in most cases.
Visualization is impeded in chronic cases with
thickening of the pleura. The thoracic duct may not be
visible in those cases, and an en bloc ligation of all
12.15 The sympathetic trunk (long arrow) and an
structures dorsal to the aorta and ventral to the
intercostal vessel (short arrow) are visible prior
sympathetic trunk may be necessary. The ligation to dissection of the thoracic duct, which is seen as a grey
should be done in the caudal thorax, caudal to the linear structure crossing the intercostal vessel.
entrance of the azygous vein into the chest. Placement
of the patient in sternal recumbency usually is all that Successful ligation may be evaluated with lymph-
is necessary to avoid pulmonary trauma, as the lungs angiography, via a right paracostal approach to the
will become atelectic, and the procedure can be abdomen or by injection of contrast medium into a
performed dorsal to them. mesenteric lymph node, likewise approached via a

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 Chapter 12 Rigid endoscopy: thoracoscopy
paracostal laparotomy. Clips should be applied until
all lymphatic flow through the chest has ceased.
Concurrent pericardectomy has been recommended
and can be accomplished by placing the patient in
lateral or dorsal recumbency. Pericardectomy should
be subtotal, or a pericardial window may be expanded
by making two or three longitudinal fenestrations
from the apex to just ventral to the phrenic nerves
(Figure 12.16).
12.16 Appearance of the heart through the pericardial
window with longitudinal pericardial
fenestration.
Postoperative care
Any patient undergoing thoracoscopy should be
treated as for thoracotomy. All surgical sites should
be assessed for haemorrhage and treated
appropriately. Inability to control haemorrhage is an
indication for open thoracotomy. The lung should be
placed under saline and observed for air leakage.
Specific lung biopsy, partial lobectomy or complete
lobectomy sites should be placed under saline and
observed for leakage. Air leakage should be treated
appropriately by application of another loop ligature if
that technique was initially used or by placement of
more staples following GIA resection of lung.
Haemorrhage is also possible from the port sites.
Endoscopic evaluation of the sites after removal of
the cannulae will decrease the risk of unseen
haemorrhage following the procedure.
Placement of a thoracostomy tube is recommended
in all cases except those in which solid tissue biopsy
was achieved with minimal haemorrhage. The
thoracostomy tube is placed in a normal fashion under
endoscopic visualization (Figure 12.17); grasping
forceps can be used to adjust tube location within the
pleural space. The tube is secured with a purse-string
and Roman sandal suture pattern, and the thorax
wrapped to avoid tube dislodgement. The thoracic
bandage must not inhibit ventilation.
Hypoxaemia may occur following thoracoscopy.
Nasal oxygen can decrease the risk following sur-
gery and can be discontinued within 12 hours in
most patients without pulmonary compromise. Pain
management will also ensure more normal thoracic
186
Ch12 Endo.indd 186
12.17 Video-assisted thoracostomy tube placement.
wall excursions and ventilation. Local nerve blocks
and systemic opioid analgesics are commonly used
following thoracoscopy. Injection of bupivacaine to
the affected port sites or the adjacent nerves prior
to removing the surgical drapes will usually suffice
to give the local anaesthetic sufficient time for onset
of action.
Recovery following thoracoscopy should be the
same as that for thoracotomy, but hopefully with less
pain and less ventilatory compromise. It is important
to remember that patients with pleural disease of
unknown origin or idiopathic pericardial effusion may
still accumulate fluid within the pleural space, as thora-
coscopy is therapeutic but not curative. Management
of those cases should pay close attention to fluid bal-
ance if fluid is being removed from the pleural space.
Accumulation of significant haemorrhage in the pleu-
ral space is a clear indication for re-exploration. Air
accumulation after thoracoscopy may resolve with
intermittent or continuous suction of the pleural space;
failure to resolve may require re-exploration.
Complications
Tumour seeding of port sites following thoracoscopy
has been reported in human patients and in dogs.
Care should be taken to avoid this complication but
the diagnosis is not always known prior to
thoracoscopy, and widespread neoplasia, such as
mesothelioma, can affect port sites despite proper
handling of tissues. The use of endoscopic retrieval
bags is recommended for removing samples following
biopsy or mass excision.
References and further reading
Borenstein N, Behr L, Chetboul V et al. (2004) Minimally invasive
patent ductus arteriosus occlusion in 5 dogs. Veterinary Surgery
33, 309–313
Brisson BA, Geggiti F and Bienzle D (2006) Portal site metastasis of
invasive mesothelioma after diagnostic thoracoscopy in a dog. Journal
of the American Veterinary Medical Association 229, 980–983
Brisson HN, Dupre GP, Bouvy BM and Paquet L (2003) Thoracoscopic
treatment of bullous emphysema in 3 dogs. Veterinary Surgery 32,
524–529
Cantwell SL, Duke T, Walsh PJ et al. (2000) One-lung versus two-lung
ventilation in the closed-chest anesthetized dog: a comparison of
cardiopulmonary parameters. Veterinary Surgery 29, 365–373
4/3/08 09:45:32

Dupre GP, Corlouer JP and Bouvy B (2001) Thoracoscopic pericardectomy
performed without pulmonary exclusion in 9 dogs. Veterinary Surgery
30, 21–27
Faunt KK, Cohn LA, Jones BD and Dodam JR (1998) Cardiopulmonary
effects of bilateral hemithorax ventilation and diagnostic thoraco-
scopy in dogs. American Journal of Veterinary Research 59,
1494–1498
Faunt KK, Jones BD, Turk JR, Cohn LA and Dodam JR (1998) Evaluation
of biopsy specimens obtained during thoracoscopy from lungs of
clinically normal dogs. American Journal of Veterinary Research 59,
1499–1502
Isakow K, Fowler D and Walsh P (2000) Video-assisted thoracoscopic
division of the ligamentum arteriosum in two dogs with persistent right
aortic arch. Journal of the American Veterinary Medical Association
217, 1333–1336
Jackson J, Richter KP and Launer DP (1999) Thoracoscopic partial
pericardiectomy in 13 dogs. Journal of Veterinary Internal Medicine
13, 529–533
Kovak JR, Ludwig LL, Bergman PJ, Baer KE and Noone KE (2002) Use
of thoracoscopy to determine the etiology of pleural effusion in dogs
and cats: 18 cases (1998-2001). Journal of the American Veterinary
Medical Association 221, 990–994
Kudnig ST, Monnet E, Gaynor JS et al. (2006) Effect of positive end-
expiratory pressure on oxygen delivery during 1-lung ventilation for
thoracoscopy in normal dogs. Veterinary Surgery 35, 534–542
Kudnig ST, Monnet E, Riquelme M et al. (2004) Cardiopulmonary
Ch12 Endo.indd 187
Chapter 12 Rigid endoscopy: thoracoscopy
effects of thoracoscopy in anesthetized normal dogs. Veterinary
Anaesthesia and Analgesia 31, 121–128
Lansdowne JL, Monnet E, Twedt DC and Dernell WS (2005) Thoracoscopic
lung lobectomy for treatment of lung tumors in dogs. Veterinary
Surgery 34, 530–535
MacPhail DM, Monnet E and Twedt DC (2001) Thoracoscopic correction
of persistent right aortic arch in a dog. Journal of the American Animal
Hospital Association 37, 577–581
McCarthy TC (1999) Diagnostic thoracoscopy. Clinical Techniques in Small
Animal Practice 14, 213–219
McCarthy TC and McDermaid SL (1990) Thoracoscopy. Veterinary Clinics
of North America: Small Animal Practice 20, 1341–1352
McCarthy TC and Monnet E (2005) Diagnostic and operative thoracoscopy.
In: Veterinary Endoscopy for the Small Animal Practitioner, ed. TC
McCarthy, pp.229–278. Elsevier Saunders, St Louis
Potter L and Hendrickson DA (1999) Therapeutic video-assisted thoracic
surgery. In: Veterinary Endosurgery, ed. LJ Freeman, pp.170–191.
Mosby, St Louis
Radlinsky MG, Mason DE, Biller DS and Olsen D (2002) Thoracoscopic
visualization and ligation of the thoracic duct in dogs. Veterinary
Surgery 31, 138–146
Walsh PJ, Remedios AM, Ferguson JF et al. (1999) Thoracoscopic versus
open partial pericardectomy in dogs: comparison of postoperative
pain and morbidity. Veterinary Surgery 28, 472–479
Walton RS (2001) Video-assisted thoracoscopy. Veterinary Clinics of North
America: Small Animal Practice 31, 729–759
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 Chapter 13 Rigid endoscopy: arthroscopy
13
Rigid endoscopy: arthroscopy
Rob Pettitt and John F. Innes
Introduction
The use of rigid endoscopy for joint surgery has
been the standard in human and equine orthopaedics
for over three decades. The use of arthroscopy in
small animals for the treatment and diagnosis of
joint disease has increased dramatically in the last
10–15 years due to advances in equipment and
techniques. Numerous benefits of arthroscopy have
been cited, including improved viewing and magni-
fication of lesions, decreased operative time, minimal
joint trauma, and lower patient morbidity. There is,
however, a considerable learning curve, and these
advantages can only be achieved through practice
and an understanding and correct selection of
arthroscopic equipment. This chapter provides an
introduction to small animal arthroscopy through its
indications, ancillary procedures, instrumentation
and current applications.
Indications
Although arthroscopy is a minimally invasive surgical
modality, it allows for a thorough and detailed investi-
gation of a number of joints of the dog and some in the
cat. The ability to perform outstanding joint inspection
and the magnification of intra-articular structures and
pathological lesions, combined with the increased field
of view achieved by moving the arthroscope through
the joint, increases the diagnostic possibilities.
Arthroscopy can reveal early or very discrete lesions
when other modalities, such as radiography, fail to
demonstrate evidence of pathology. Second-look
arthroscopy permits the surgeon to assess the effi-
cacy of previous surgery, the progression of disease,
and determination of necessary further clinical inter-
ventions. However, this increased diagnostic cap-
ability has brought with it an increase in the confusion
surrounding the significance of the lesions noted.
The advantages of arthroscopy significantly out-
weigh the disadvantages. Decreased postoperative
pain with arthroscopically assisted surgery in humans
is well documented and the same appears to be true
for small animals (Hoelzler et al., 2004). Small
instruments passing through inflamed capsular tissue
will transect fewer nerve endings when compared
with a standard arthrotomy. This leads to reduced
postoperative morbidity, increased use of the limb
and, hence, an improved recovery.
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Ch13 Endo.indd 188
However, even though the advantages of arthro-
scopy outweigh the disadvantages, the latter are
worthy of comment. The major disadvantage is the
long learning curve associated with arthroscopically
assisted surgery. Coordination is required to mano-
euvre the arthroscope and instruments through the
joint whilst viewing the instruments on a monitor. This
is compounded by the relatively small size of canine
joints. Skill and training are required to manipulate the
instruments within the joint without causing iatrogenic
damage to the articular surfaces. This skill can be
improved by enrolment on suitable arthroscopy
training courses, especially those that involve cadaver
practical sessions. Continued practice using cadavers
will facilitate learning and should be continued until
the operator can easily establish the required portals
and evaluate the whole joint competently. In the early
stages, it is preferable to restrict arthroscopy to those
joints that are more accessible, and the surgeon
should always be prepared to convert the arthroscopy
to an open arthrotomy if needed. Initially, arthroscopy
may only be used as a diagnostic aid but, as the
operator’s skill improves, then therapeutic arthroscopy
can be performed. Invariably, arthroscopic surgery
initially takes longer to perform than a conventional
arthrotomy but as the surgeon’s proficiency increases
arthroscopic procedures often take less time than
conventional surgery.
Although feasible, arthroscopy of the cat is rarely
performed and little is known about the arthroscopic
management of feline joint disease. The main focus of
this chapter is therefore aimed at canine arthroscopy.
Preoperative diagnostic work-up
Pre-anaesthetic tests
Preoperative laboratory work-up should be based
upon the patient’s physical status and anaesthetic
risk. Dogs (and cats) presenting for arthroscopy are
often in good general health and typically have limited
or low co-morbidity. Additional blood work, radiographs
and urinalysis prior to anaesthesia may be indicated
in older dogs or those with co-morbidity.
Diagnostic imaging
Plain film radiography is the most commonly used
modality in the work-up of a lame dog. It is important
to take good quality orthogonal (usually craniocaudal
and mediolateral) views centred on the joint of interest;
4/3/08 09:46:18
 Chapter 13 Rigid endoscopy: arthroscopy

additional views may be desired in certain joints (see capture system. A suitable heavy duty cart is essential
below). However, radiography is a relatively insensitive for storage and to facilitate operation of the equipment,
diagnostic modality, especially in elbow and shoulder although ceiling-mounted, multi-arm equipment
disease. It is not uncommon for joints that are pendant in a bespoke endoscopic theatre (Figure
radiographically normal to have significant pathology 13.1) is an expensive but desirable option, in that
when viewed arthroscopically. cables are not left trailing on the floor but are routed
Additional imaging techniques can be employed, through pendant arms and ceiling ducts.
such as positive-contrast arthrography, ultrasono-
graphy, computed tomography (CT) and magnetic
resonance imaging (MRI), in order to try and estab-
lish a diagnosis prior to arthroscopy. Diagnostic imag-
ing has advanced dramatically in recent years and
there is much wider access to the more advanced
imaging modalities such as CT and MRI. These
modalities have allowed the identification and report-
ing of previously unrecognized pathology but have
also increased the confusion regarding the signifi-
cance of the lesions noted. In any clinical situation,
the clinician should carefully assess the benefits of
using a particular modality to achieve a diagnosis
rather than obtaining unnecessary images. The
reader is referred to the BSAVA Manual of Canine
and Feline Musculoskeletal Imaging for further infor-
mation on imaging synovial joints. Dedicated arthroscopic suite for minimally
13.1
invasive surgical techniques.
Arthrocentesis
Arthrocentesis is an underused technique in canine
orthopaedics but one that can be invaluable. This is Arthroscopes
especially true in cases of septic arthritis or immune- An arthroscope is made up of a central series of
mediated polyarthritis, or where it might differentiate lenses, to allow transmission of an image to the
likely diagnoses when other modalities are incon- eyepiece, surrounded by optical fibres. These optical
clusive or unavailable. Arthrocentesis is a relatively fibres pass light from the light post adjacent to the
simple and inexpensive procedure to perform and eyepiece along the shaft to the tip of the arthroscope
should be included as a routine part of a lameness for illumination (Figure 13.2). Arthroscopes are
work-up. Aspirates should be submitted for cytological classified based on length, diameter of the shaft, and
examination as well as culture and sensitivity testing angle of the lens.
if sepsis is suspected. The reader is referred to the
BSAVA Manual of Canine and Feline Musculoskeletal
Objective lens
Disorders and BSAVA Manual of Canine and Feline
Clinical Pathology for further information on the role,
technique and interpretation of synovial fluid aspiration
and analysis.
Fibreoptics

Instrumentation
Good arthroscopy is reliant on the correct selection
and understanding of equipment and instrumentation.
The quality of the optical system is paramount in
obtaining high-quality images for diagnosis. Good
accurate inspection of the joint structures is only
possible with appropriate fluid flow through the joint
during the examination. This requires the correct
establishment and maintenance of ingress and egress
portals and the administration of fluids either by
gravity or, preferably, with a fluid pressure system.
Successful therapeutic and exploratory arthroscopy
may also rely on the correct selection and use of
specialized hand, motorized or radiofrequency instru-
ments. A more complete discussion of endoscopic
instrumentation is provided in Chapter 2.
Optical system
The optical system consists of a monitor, light source
and cable, camera, arthroscope and a (optional) data
Sheath
Flow area
Arthroscope
13.2 Arthroscope tip, showing the arrangement of
components.
It should be noted that the diameter measure-
ment is that of the outside diameter of the arthroscope
itself, without the accompanying sleeve. Arthroscope
diameters used in small animals are 4.0 mm, 2.7 mm,
2.4 mm and 1.9 mm (Figure 13.3). The last is very
fragile and should not be used by inexperienced sur-
geons as it is likely to break. The larger the diameter
of the arthroscope, the greater the field of view (Figure
13.4) and the brighter the transmitted light. Typically,

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 Chapter 13 Rigid endoscopy: arthroscopy

light post. On some arthroscopes there is a notch on

the projected image on the monitor to indicate this
direction. With angled lenses, rotating the endoscope
along its long axis allows inspection of a large area of
the joint with minimal movement of the arthroscope,
reducing the risk of damage to the articular surface.
The length of the arthroscope refers to its long
axis and is usually designated ‘long’ or ‘short’. Longer
arthroscopes have an increased depth of field (focus)
compared with similar diameter short arthroscopes
but short ones are easier to handle in small joints and
are less susceptible to damage from bending.
Each arthroscope requires a dedicated sheath or
sleeve for use within the joint to protect it from bending
13.3 1.9 mm, 2.4 mm and 2.7 mm arthroscopes. and to deliver fluid (see also Chapter 2). At the
proximal end of the cannula is an attachment for a
fluid line with a stopcock. High-flow cannulae are now
available for the smaller arthroscopes and these are
80° field preferable. Sleeves and accompanying obturators or
of view trocars are introduced into the joint via a small stab
incision. A blunt obturator (Figure 13.5) is preferable
to a trocar in that it is less likely to cause injury.

30° angle
of view

2.7 mm diameter (a)

13.4 Field of view for a 2.7 mm arthroscope. The

2.4 mm arthroscope has a similar field of view.

a 2.7 mm arthroscope has a field of view of 80

degrees, compared to 65 degrees with a 1.9 mm
arthroscope. The advantage of choosing a narrower
diameter arthroscope is minimization of joint trauma
combined with increased mobility within the joint,
especially the elbow and tarsus. This must be bal-
anced against the fragility of the smaller arthroscopes
and the smaller field of view. The larger arthroscopes
have increased durability due to their resistance to
bending but have an increased risk of causing iatro-
genic trauma. (b)
Lens angle refers to the angle between the long
axis of the shaft and the lens face. Although this can 13.5 (a) A 2.7 mm arthroscope plus protective cover,
cannula and obturators. (b) Sharp and blunt
be 0, 30 or 70 degrees, the 30 degrees angle is most obturator tips.
commonly employed in canine arthroscopy. This is a
compromise between field of view and amount of
image distortion. A 0 degree arthroscope has no Accessory instruments
image distortion but the field of view is small. There are a myriad of instruments available to the
Conversely, a 70 degree arthroscope has a much surgeon for use in arthroscopy, and initial selection of
larger field of view when it is rotated around its long appropriate ones may seem daunting. Hand instru-
axis but the image is distorted. ments for use in small animal arthroscopy must be
With an angled lens, the operator needs to be small in diameter to minimize iatrogenic trauma
aware of the direction in which he/she is looking. The and manufactured to high standards for maximum
direction of viewing is opposite to the position of the reliability. Some basic instruments are essential,

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including probes, grasping forceps, cannulae and
milling drills (see below). It is advisable to have a sep-
arate basic surgical kit that has been modified for use
in arthroscopic procedures. In addition to surgical
instruments, suitably sized sterile hypodermic needles
syringes, scalpel blades, forceps and needle holders
can be added when required. An example of a suitable
basic kit used by the authors is shown in Figure 13.6.
13.6 A basic arthroscopy instrument kit.
Instrument cannulae
Inspection of the intra-articular structures may not be
sufficient to evaluate a joint fully and it is often neces-
sary, and advisable, to palpate the soft tissue struc-
tures and the articular surface. Instruments can be
introduced either through a cannula or directly through
the periarticular soft tissues. Cannulae are generally
used for joints with greater soft tissue coverage and
are optional for more superficial joints. Instrument
cannulae are available in a range of sizes and facili-
tate ease of instrument introduction and switching.
Suitable sizes for use in canine arthroscopy are
between 2.3 mm and 3.5 mm, with lengths of 3–5 cm.
Small joint cannulae systems are commercially avail-
able. These consist of a series of cannulae and a
switching stick to permit serial dilation of portals to
facilitate insertion of larger instruments (Figure 13.7).
After triangulation, using a hypodermic needle, the
switching stick is introduced through a small stab inci-
sion in the periarticular tissues. Once in the field of
Instrument cannulae for elbow and shoulder
13.7
arthroscopy, with switching stick (top).
Ch13 Endo.indd 191
Chapter 13 Rigid endoscopy: arthroscopy
view, a cannula can be introduced over the switching
stick, which is subsequently removed. If a larger can-
nula is needed, the switching stick is reintroduced
and the cannulae swapped.
The disadvantage of using a cannula system is
the relatively restricted diameter of instruments that
can be inserted (or fragments removed) and limited
mobility of the instruments when in the joint. It is also
relatively easy to displace the cannula from the joint,
which may lead to extravasation of fluid and compress
the joint. This problem can be minimized by using
cannulae that can be screwed into the joint capsule
but these are currently more expensive. Although
designed for single use only, they can be used on
multiple occasions if sterilized carefully.
Hand instruments
Hand instruments are required to explore and palpate
intra-articular structures. A minimum of two pairs of
grasping forceps, a probe, a milling drill and a curette
are recommended. Instrument sets are available that
consist of a single handle with interchangeable tips.
Probes (Figure 13.8) are usually right-angled and
approximately 2 mm across at the tip. They are used
to palpate articular surfaces, to move soft tissue
structures to improve the view, or to elevate meniscal
or cartilage defects.
13.8 A 2 mm 90 degree probe.
Grasping forceps (Figure 13.9) come in a range of
sizes; the grasping surfaces are available as locking
or non-locking types. Most have an internal operating
mechanism that avoids any interference with the
surrounding structures. They need to be small enough
to fit into the joint but strong enough to remove
osteochondral lesions. Modern instruments are fitted
with an overload protection device which prevents
breakage of the forceps when an excessive force is
applied. Smaller (e.g. 2 mm) forceps are particularly
prone to breakage. A range of tips are available,
depending on the required purpose of the forceps.
A hand milling drill (Figure 13.10) is a useful tool
for curettage and abrasion of the subchondral surface
following fragment removal. The 2 mm tip is easily
inserted into a joint and a high degree of accuracy
can be achieved with this by using controlled delicate
movements. Large lesions can take a long time to be
milled using a hand drill and in such cases it may be
more suitable to use a motorized shaver.
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 Chapter 13 Rigid endoscopy: arthroscopy

Arthroscopic knives are available in forward or

back cutting designs (Figure 13.11). They may be
straight, curved or hooked, and the selection of a
suitable knife is dependent on the procedure being
performed. They are particularly useful for removal of
meniscal lesions and transsection of soft tissue
attachments to bony structures (e.g. the annular
ligament attachment to a fragmented coronoid
process lesion). Disposable versions are preferable
as the knives blunt very quickly, but they are more
expensive. A range of curettes are available and are
useful for removal of defective articular cartilage and
(a) bony fragments. The tip may be open (eye) or closed
(cup), with the former better for cartilage debridement.
Straight curettes are easier to insert through a cannula
and usually suffice but curved versions may be more
useful for working at awkward angles.

(b)

(a)

(b)

13.11 Arthroscopic knives: (a) hook; (b) forward

(c) cutting.

Awls, used for microfracture of subchondral bone,

are available for canine arthroscopic use. An alterna-
tive is to use a small (1.1 mm) Kirschner wire secured
in a Jacob’s chuck or power drill.

(d)
13.9 Grasping forceps: (a) locking and non-locking
handles; (b) locking forceps with grasping
teeth for large fragment removal; (c) a variety of tips;
(d) close-up of rat tooth tip.
A 2.0 mm hand burr for curettage of cartilage
13.10
and bone.
Power shavers
These are not essential for canine arthroscopy but in
certain situations they may expedite surgeries, espe-
cially in the removal of hyperplastic synovium and fat
pad, treatment of large lesions, or abrasion of ebur-
nated subchondral bone. They are used to debride
cartilage and bone and, in stifles, to facilitate the
removal of the infrapatellar fat pad. A small joint shaver
is required for all canine joints except for the stifle of
medium- and large-breed dogs, where the standard
handpieces are suitable and more efficient. The shav-
ing unit (see Figure 2.41) can be operated in forward,
reverse or oscillating modes, depending upon the pro-
cedure being performed. Speed control is important
because different tissues require varying speeds to
optimize removal. A range of shaving heads is avail-
able, designed for removal of either bone or soft tis-
sue. Tips used for soft tissue removal tend to be larger
and have more aggressive cutting toothed heads.
Most handpieces come with a suction device. This has
the benefit of removing the debrided material from the

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 Chapter 13 Rigid endoscopy: arthroscopy

joint but also draws the soft tissues into the tip to facili- 13.12
tate further removal. Slower, oscillating speeds are
more useful when removing the fat pad, as they allow Hand pressure infusion
cuff.
larger amounts of tissue to be drawn into the blade in
the pause between forward and reverse revolutions.
Foot or handpiece controls are used to control the
direction and speed of the shaver.
The disadvantages of using motorized shavers
are the initial cost and the increased risk of iatrogenic
damage. Extreme care must be taken when using
these instruments to minimize this damage. There
are few situations in canine arthroscopy where it is
essential to have a motorized shaver, which means
that the high cost of purchasing a unit does not need
to be incurred by those starting out in arthroscopy.

Fluid management systems

Good quality arthroscopy is reliant upon well controlled
fluid flow through the joint. This is essential:

• o distend the oint prior to insertion of the

obturator and sleeve, to minimize the risk of
iatrogenic articular damage
• or remo al of debris and blood to increase
clarity of view
• or oint la a e to remo e inflammatory
mediators
• o stop minimi e intraoperati e haemorrha e
through fluid pressure.

Fluid control is reliant on the establishment and

maintenance of ingress and egress portals. Failure to
maintain this control will result in a poor view of the
joint and extravasation of the fluid into the surround-
ing soft tissues. The joint will then collapse and hinder
the procedure.
Lactated Ringer’s solution (Hartmann’s) is the
fluid of choice and can be provided under gravity or
by pressurized systems. Gravity-fed systems supply
fluid via a normal fluid administration set attached to
the arthroscope cannula. The pressure can be
increased by enclosing the fluid bag in an infusion
pressure jacket (Figure 13.12). These systems are
cheap, easy to set up and maintain, and require little Dr Fritz aiming device for triangulation of
13.13
space but they offer poor control of pressure and instruments.
require closer attention than automatic fluid pumps to
prevent excessive pressure drops. Fluid pumps (see and joint capsule until it appears in the viewing win-
Figure 2.34) are able to provide a consistent pressure dow. The aiming device can then be removed and the
over longer periods of time but may be expensive to procedure continued as normal using the Kirschner
purchase and require dedicated tubing. The more wire as a switching stick.
advanced units are able to maintain a constant intra-
articular pressure by controlling flow into and out of
the joint. Again, for the beginner, an infusion pressure Patient preparation and positioning
bag is perfectly satisfactory.
Irrespective of which joint is to be examined arthro-
Aiming device scopically, the patient is clipped and prepared for an
This is a piece of equipment (Figure 13.13) that open arthrotomy. This allows for arthroscopy to be
greatly facilitates the triangulation of instruments into readily converted to arthrotomy if needed; this occurs
the viewing window and may be useful to the inexpe- most commonly when surgeons begin to learn arthro-
rienced arthroscopist, especially for the shoulder joint. scopy. As the competence of the clinician increases,
The device is attached to the arthroscope sleeve conversion is required less often, minimizing anaes-
(there are specific devices designed for the 2.4 mm thetic duration and increasing the aesthetic appear-
and 2.7 mm arthroscope). A Kirschner wire is placed ance postoperatively. Once clipped, the area should
into the device and advanced through the soft tissues be prepared as for a standard surgical procedure.

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 Chapter 13 Rigid endoscopy: arthroscopy
Several ways of draping the surgical field are
available and are at the discretion of the surgeon. The
draping technique employed should allow for suitable
mobility of the limb. For maximum manoeuvrability, a
hanging limb preparation with four quarter draping
(Figure 13.14) is recommended for joints such as the
stifle. A further large drape is then placed over the
dog, leaving only the relevant limb exposed.
Four quarter draping of the right elbow for
13.14
arthroscopy. Hanging limb for routine elbow
arthroscopy used for preparation only. The limb is then
laid parallel to the table for arthroscopic procedure.
This technique is also advised where the surgeon
is inexperienced and an open arthrotomy may be
needed. Where mobility of the joint is less important a
single adherent operating drape with a translucent
window can be used. Whatever technique is employed,
it is important that the uppermost layer of drapes is
impermeable to fluids to prevent strikethrough and
breakdown of asepsis (Figure 13.15).
13.15 Impermeable drape used to prevent
strikethrough.
Careful positioning of the patient, surgeon and
equipment is essential to minimize the technical
difficulty of arthroscopy. The exact position of the
animal depends on the joint being investigated and
the approach required. When draped, it can be
difficult to orientate around a limb, so use should be
made of ties and sandbags to secure the position of
the patient. A sandbag can also be used to act as a
fulcrum, especially in the elbow, to widen the joint
194
Ch13 Endo.indd 194
and minimize iatrogenic damage. Custom braces are
available (Figure 13.16) and may be useful in
supporting the leg in fixed positions. Distraction
devices are used widely in human arthroscopic
surgery but less commonly so in small animal
arthroscopy, probably due to the wide variety in size
of veterinary patients requiring a large number of
distraction devices.
13.16 Multiarm positional aid and stifle brace for
Multiarm attachment. (Courtesy of Veterinary
Instrumentation, Sheffield)
Anaesthetic considerations
Pre-anaesthetic evaluation is based upon the patient’s
clinical and physical assessment. Most animals pre-
senting for arthroscopy are usually systemically
healthy, with minimal or no concomitant medical dis-
ease and so require minimal preoperative laboratory
screening. A standard general anaesthetic protocol
can be used for all dogs in good general health under-
going arthroscopy unless there are any other anaes-
thetic considerations.
Analgesia
Pre-emptive and continuous multimodal analgesia is
essential for all animals undergoing arthroscopy.
Drug groups that can be utilized include: opioids;
non-steroidal anti-inflammatory drugs (NSAIDs);
α2-adrenergic agonists; ketamine; nitrous oxide; and
local anaesthetics.
Particularly useful in arthroscopy is the use of
intra-articular analgesia, in particular using local
anaesthetics. Bupivacaine (1 mg/kg) is commonly
used, as it has a duration of action of 6–8 hours. Mu
(µ) receptors in the synovium are upregulated in
cases of chronic inflammation and therefore intra-
articular morphine (0.1 mg/kg) is beneficial in animals
with more chronic disease.
Other local anaesthesia techniques can be
employed, including brachial plexus blocks in the tho-
racic limb (for elbow and distal limb) and extradural
(epidural) analgesia for pelvic limb procedures. These
are not normally used by the authors for arthroscopic
procedures alone but are employed when arthros-
copy is performed prior to performing more invasive
procedures (e.g. treatment of cranial cruciate liga-
ment disease).
4/3/08 09:46:35

Postoperative care
Postoperatively, analgesia is continued using opioids
and NSAIDs. Cold therapy may also be employed.
Arthroscopy does facilitate day-case surgery but the
authors like to hospitalize patients overnight in cases
where some form of therapeutic arthroscopy has
been performed, in order to continue postoperative
opioid analgesia for up to 24 hours. NSAIDs are
recommended for at least 2 weeks postoperatively.
The shoulder joint
Arthroscopy is providing a new insight into small
animal articular disorders and this is particularly so in
the shoulder. Increasing awareness of the potential
for arthroscopically assisted surgery and the continued
advancement in technology have led to many areas
of progress.
Anatomical considerations
The shoulder is a diarthrodial ball and socket joint
(Figure 13.17), which is capable of a wide range of
motion – primarily flexion and extension, but also
abduction, adduction, and internal and external
rotation. The canine shoulder joint is not an intrinsically
stable socket joint; normal joint motion is limited by
capsular, muscular, ligamentous and bony restraints.
Passive mechanisms contributing to shoulder joint
stability include the medial glenohumeral ligament
(MGHL), the lateral glenohumeral ligament (LGHL),
joint capsule, joint conformity, and finite joint fluid and
adhesion/cohesion mechanisms. Active mechanisms
have been hypothesized to contribute to shoulder
joint stability, through the action of the ‘cuff’ muscles
(supraspinatus, infraspinatus, subscapularis and
teres minor muscles) and biceps brachii. Selective
contraction of these muscles increases glenohumeral
compression and thus resists the displacing forces
acting on the joint. In humans, the active and passive
d Patient positioning
b with a single drape placed laterally; the latter still
c allows manoeuvrability of the limb.
a The traditional portal for shoulder arthroscopy is the
Shoulder joint. a = Humeral head;
13.17
b = Subscapularis tendon; c = Medial
glenohumeral ligament; d = Glenoid cavity.
Ch13 Endo.indd 195
Chapter 13 Rigid endoscopy: arthroscopy
mechanisms are proposed to act in unison, with the
active stabilizers being more important when humeral
head displacement is small and the passive stabilizers
when displacement is large.
Indications
The shoulder is a common site of lameness in dogs
but prior to the advent of arthroscopy it was difficult to
diagnose the cause of the lameness accurately.
Arthroscopy provides an excellent view and permits
palpation of the intra-articular structures of the shoul-
der with minimal trauma (Van Ryssen et al.,1993b).
Osteochondritis dissecans (OCD) is probably the
most common indication for surgical arthroscopy of
the shoulder but diagnostic arthroscopy can be con-
sidered in all cases of lameness attributable to the
shoulder. This is particularly important considering
the number of ligamentous and soft tissue injuries
that can occur around the shoulder. Conditions that
are readily diagnosed by arthroscopy include:
• CD (ca dal h meral head)
• edial sho lder instability (s bscap laris tendon
tears; MGHL tears)
• ateral lenoh meral li ament tears
• ncomplete ossification osteochondral
fragmentation of the caudal glenoid
• iceps brachii tendon of ori in r pt re (partial or
complete)
• yno ial biopsy
• icipital tenosyno itis
Instrumentation
A long 30 degree oblique 2.7 mm arthroscope is most
commonly used in the shoulder, although a 1.9 mm or
2.4 mm arthroscope should be considered in small
dogs and in cats. If diagnostic arthroscopy is all that is
required, two portals can be used. It is advisable to
palpate all the intra-articular structures of the shoulder
and so, ideally, an instrument portal should also be
established. The minimum selection of instruments
required for arthroscopy of the shoulder includes
probes, cannulae (and switching stick), large grasping
forceps (for OCD lesions), milling drill, curette and an
aiming device.
The patient is placed in lateral recumbency with the
affected limb uppermost. The limb should be held
horizontal to the table or slightly adducted. The limb
can be draped either as a hanging limb preparation or
Procedure
Portal placement
lateral portal. Usually the egress cannula is estab-
lished craniolaterally, with the instrument portal
caudolaterally (Figure 13.18). However, when prima-
rily interested in the biceps tendon and sheath, the
authors prefer to use a craniolateral arthroscope por-
tal; and when particularly interested in the lateral
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 Chapter 13 Rigid endoscopy: arthroscopy

13.18 inserted into the sleeve. The camera, fluid line and
light cable can then be attached and the optical
Model equipment turned on.
demonstrating the
position of portals
If required, an instrument portal is established
for shoulder next. For treatment of OCD, this is usually created
arthroscopy. A = approximately 2 cm caudal to and slightly distal to the
Arthroscope portal; acromion. It is created in the same way as for the
E = Egress portal; arthroscope portal. The use of a cannula is
I = Instrument recommended for the instrument portal in the shoulder
portal.
due to the depth of periarticular musculature.
The initial view from the lateral portal is usually
cranial to the dome of the humeral head. It is not
uncommon for the arthroscope to be initially more
medial than required and it may need slow retraction
until the articular surfaces of the humeral head and
glenoid are visible. It is possible to retract too far and
pull the arthroscope out of the joint, so care should be
exercised. Once the articular surfaces are viewed,
spatial awareness becomes easier. The initial view
consists of, from top to bottom of the image (proximal
to distal in the joint), the glenoid, MGHL, subscapularis
muscle tendon of insertion and the humeral head
(Figure 13.19).

13.19
glenohumeral ligament, the authors place the lateral a
portal slightly caudal to the acromion. A craniomedial Normal
arthroscopic
portal is also reported (see later). anatomy of medial
The egress portal is established first, using a 20 b
shoulder joint.
gauge (1.5–2 inch) long needle. This is introduced a = Glenoid;
midway along the craniocaudal border of the superior b = MGHL;
c c = Subscapularis
ridge of the greater tubercle. It is directed caudally
and medially, at 70 degrees to the vertical, in order to tendon;
d = Humeral head.
enter the joint. Aspiration of synovial fluid is usually
possible after correct introduction of the needle; d
10–12 ml of lactated Ringer’s solution (Hartmann’s)
can then be introduced in order to distend the joint. If
synovial fluid is not forthcoming but the surgeon is
confident the needle is in the joint, then fluid can still
be injected. Fluid should be injectable with minimal Examining the joint
pressure initially. As the intra-articular pressure It is important for the surgeon to develop their own
increases, back-pressure will be felt on the syringe. pattern of examining each joint. There are no right or
The syringe is usually left in place initially and pressure wrong ways as long as the examination is thorough
maintained by an assistant. Care should be taken not and methodical. The pattern used by the authors is
to inject fluid extra-articularly as this will collapse the described here. From the initial starting position the
joint making the arthroscopy difficult. camera should be held still and the light post moved
The arthroscope portal is established next. A ventrally to view the articular surface of the medial
second hypodermic needle is introduced approximately glenoid. The light post is then rotated into the 9 o’clock
1 cm distal to the acromion. Correct placement of the position and the camera head moved cranially in
needle will result in fluid flow through the needle due order to view the caudal humeral head (Figure 13.20).
to the pressure on the syringe. A no. 11 scalpel blade
is used to make a small incision through the skin and 13.20
periarticular soft tissues. The blade should not pass
through the synovium as this will lead to extravasation Normal caudal
humeral head.
of fluid. The arthroscope cannula with an attached
blunt obturator is then introduced parallel to the
needle until it is felt to enter the joint. The limb should
be held parallel to the table when introducing the
cannula with the assistant placing a distal distraction
force on the limb to widen the joint space. This
minimizes the risk of iatrogenic trauma. Confirmation
of correct placement is achieved by opening the fluid
stopcock on the cannula and observing fluid egress.
The obturator is then removed and the arthroscope

196

Ch13 Endo.indd 196 4/3/08 09:46:37


With minor alterations to the position of the light post
and camera it is possible to examine the medial gutter
(consisting of the caudomedial joint capsule and the
medial humeral head; Figure 13.21). Advancement of
the arthroscope in a caudomedial direction will
facilitate the viewing of the gutter.
13.21
Normal
caudomedial
gutter.
From here the camera is returned to the neutral
position and the light post is rotated to the 3 o’clock
position to view the cranial compartment. From this
position, the craniomedial joint capsule and biceps
tendon are visible (Figure 13.22). The tendon can be
seen coursing distally through the bicipital groove.
Flexion of the elbow at this point increases the length
of the tendon that is visible. The light post is then
moved clockwise, to the 4 o’clock position, to view the
origin of the biceps tendon and the supraglenoid
tuberosity. By advancing the arthroscope at this point
the cranial aspect of the joint capsule can be examined
lying cranial to the biceps tendon.
The final part of the joint to be inspected is the
lateral compartment (Figure 13.23). Care has to be
taken when examining this region as it is easy for the
arthroscope to ‘pop’ out of the joint, causing
extravasation of fluid; for this reason this compartment
is inspected last. The camera is moved further
caudally and the light source rotated to view the
craniolateral compartment (4–5 o’clock position). The
camera is then moved cranially, and the light post
clockwise to the 7–8 o’clock position, to view the
caudolateral joint capsule.
(a) (b)
13.22 Cranial compartment. (a) Normal origin of biceps tendon and cranial joint capsule. (b) Normal variant of biceps
tendon. (c) Bipartite biceps tendon.
Ch13 Endo.indd 197
Chapter 13 Rigid endoscopy: arthroscopy
13.23
Lateral
compartment.
(a) Origin of lateral
glenohumeral
ligament.
(b) Normal variant.
(a)
(b)
Suspended limb arthroscopy
In contrast to the human shoulder, that of the dog
does not have a histologically distinct labrum and,
therefore, although reported in the literature, tears of
the labrum (so-called Bankart tears in humans) cannot
exist. One possible reason for the confusion lies in
the fact that it is difficult to view the medial and lateral
restraints or the rotator cuff muscles accurately from
a standard lateral portal. A craniomedial portal is
preferred and is best established with the limb in a
suspended position (Figure 13.24). A standard lateral
portal is established with the limb suspended (slight
adduction should be placed on the limb and the table
lowered until the weight of the dog is suspended
through the shoulder; this will help to distract the
limb). The joint should be examined thoroughly from
(c)
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 Chapter 13 Rigid endoscopy: arthroscopy
13.24
Positioning of
the patient for
suspended limb
shoulder
arthroscopy.
Note the position
of the head to
facilitate easy
access to the
craniomedial
aspect of the
shoulder.
(Courtesy of
C Deintt)
this portal before establishment of the craniomedial
portal. This can be achieved directly (from the outside
in) or indirectly (from the inside out).
Direct examination: With the arthroscope view
being the craniomedial joint capsule, a 20 gauge
needle is inserted into the joint between the biceps
tendon and the subscapularis tendon. The light
source can usually be seen through the skin at this
point which will help with triangulation. With the aid
of a switching stick, a craniomedial portal is estab-
lished in the normal manner.
Indirect (push-through) technique: The arthro-
scope is advanced until it rests in the desired position
against the craniomedial compartment of the shoul-
der. The arthroscope is then removed from its can-
nula and replaced with a switching stick which is
pushed through the joint capsule and soft tissues until
the skin tents. A small stab incision is made through
the skin and the switching stick exited through this.
The arthroscope cannula is then removed from the
lateral portal and replaced craniomedially.
Once the arthroscope is in position the medial
glenoid recess and lateral compartment can be
assessed.
Pathological conditions
Osteochondritis dissecans
Osteochondrosis is a failure of endochondral
ossification and, in the shoulder, is most commonly
seen on the caudal third of the humeral head, although
occasionally the caudal glenoid may be affected (see
below). The classic lesion is an under-run cartilage
flap on the caudal humeral head. The flap may remain
in situ (Figure 13.25) or break off and float around the
joint (a so-called joint mouse); it may also be
reabsorbed or mineralize.
198
Ch13 Endo.indd 198
13.25
OCD: in-situ lesion.
Although medical management is an option for
shoulder OCD, surgery is the treatment of choice
(Person, 1989; Van Ryssen et al., 1993a). The disease
is often bilateral and with the use of arthroscopy both
shoulders can be treated during one surgical session
if necessary. The area should have a wide clip, in
case of the need to convert to an arthrotomy, although
with practice, this is very unlikely. A hanging limb
preparation offers the greatest freedom of movement
of the limb. A standard lateral arthroscope portal,
using a 2.7 mm 30 degree forward oblique arthro-
scope, and a craniolateral egress portal are used,
with the dog positioned in lateral recumbency. The
instrument portal is established caudolaterally unless
the OCD lesion has been displaced.
After a complete joint inspection, grasping forceps
are introduced through the instrument portal. If the
flap is still well attached (typically medially), it is better
to elevate it using a probe or fragment elevator to
facilitate grasping. The OCD lesion is grasped and
gently rolled (Figure 13.26). In situ fragments may roll
up, which aids removal. The surgeon can decide to
grasp, twist and remove small pieces of the flap or,
using larger forceps, grasp the whole flap, twist and
remove in one go. Although the latter technique is
potentially very fast, it is dependent on appropriately
sized forceps and runs the risk that the flap may
become loose within the joint if removal is unsuccessful.
If grasped in toto, the flap is often too large to pass
through the cannula and extreme care must be taken
not to lose the flap in the joint to leave a joint mouse.
A loose cartilage flap within the joint can be frustrating
to grasp again because it will usually lodge in the
medial gutter and be relatively inaccessible. The soft
tissue surrounding the cannula can be gently widened
using mosquito forceps and the flap, forceps and
13.26
OCD fragment
being grasped.
(Courtesy of B Van
Ryssen)
4/3/08 09:46:40

cannula removed as one. The instrument cannula
can then be re-established using a switching stick.
After complete removal of the flap, the remaining
edges of articular cartilage are curetted back to
healthy cartilage. Ideally, the edges of the cartilage
lesion should be vertical in order to allow the inflow of
the surrounding cartilage matrix. The subchondral
bone surface is then milled using a hand drill or power
shaver. The surface is abraded until it readily bleeds,
though overzealous curettage should be avoided. If
the fluid flow is high then bleeding may not be
observed; temporary cessation of fluid flow will readily
highlight the presence of subchondral bone bleeding.
Microfracture techniques can be employed to release
mesenchymal stem cells and promote the healing
process: 1–2 mm deep holes, 4 mm apart, are created
in the subchondral bed using a micropick and mallet
(or a 1.1 mm Kirschner wire secured in a Jacob’s
chuck). On completion of this, the joint should be
flushed for 5 minutes at a high rate in order to remove
as much debris as possible. The portals are then
sutured using non-absorbable fine suture material or
a skin stapler.
Occasionally the lesion is no longer attached to
the humeral head and is free within the joint. The
lesion most commonly displaces to the caudal joint
recess where it may cause no pain, and lameness
may resolve. However, occasionally the flap may
lodge in the bicipital groove or, rarely, between the
MGHL and the joint capsule. These latter scenarios
may result in continued lameness and require
intervention to remove the flap. For those cases
where the fragment is behind the biceps tendon, a
craniolateral instrument portal should be used. For
cases where the lesion is in the medial position, the
instrument cannula is positioned caudolaterally. The
fragment can sometimes be drawn towards the egress
cannula by virtue of the direction of fluid flow; grasping
forceps can then be introduced to capture the
fragment. Displaced fragments are often less flexible
(due to mineralization) and therefore do not roll up.
Care must therefore be taken with these to ensure
that the opening in the joint capsule is large enough to
accommodate the fragment during removal.
The prognosis for shoulder OCD is generally
good, with 75% of dogs regaining full limb function
(Rudd et al., 1990). Most dogs should have restricted
exercise for 6–8 weeks whilst the defect fills with
fibrocartilage. Normal exercise can usually be started
approximately 12 weeks after surgery.
Incomplete ossification (IOCG)/osteochondral
fragmentation (OFCG) of the caudal glenoid
Lesions of the caudal glenoid are uncommon.
Sometimes, in young dogs, a separate centre of
ossification is noted on the caudal glenoid on plain
radiographs; this normal variant has a smooth,
non-displaced appearance and should not be inter-
preted as a pathological lesion. Arthroscopy can
be used to identify true lesions and assess the sta-
bility of the fragment (Figure 13.27). Mobile lesions
and those that have failed to respond to conserva-
tive management should be resected (Olivieri et
al., 2004).
Ch13 Endo.indd 199
Chapter 13 Rigid endoscopy: arthroscopy
13.27
Incomplete
ossification of the
caudal glenoid.
Medial shoulder instability (MSI)
The medial aspect of the glenohumeral joint consists
of the subscapularis muscle tendon of insertion,
medial glenohumeral joint (Cook et al., 2005a). All
cases of MSI should undergo arthroscopic examination
in order to determine the cause of the instability, as
radiography is often unrewarding. Tears to the
subscapularis muscle tendon of insertion (Figure
13.28) and cranial arm of the MGHL result in MSI.
Concurrent capsular tears are sometimes evident.
Treatment options can be either arthroscopic, using
thermal capsulorrhaphy, or via an open approach and
placement of a medial prosthesis (Fitch et al., 2001;
Pettitt and Clements 2007).
13.28
Subscapularis tear.
Thermal capsulorrhaphy has been commonly
employed for treating human patients with gleno-
humeral instability. It has been reported in dogs as a
treatment for MSI (O’Neill and Innes, 2004; Cook et
al., 2005b). The procedure involves the arthroscopi-
cally guided use of a radiofrequency probe (e.g.
Capsure 3 mm straight wand, ArthroCare) to shrink
the capsular and ligamentous structures of the medial
aspect of the joint through thermal denaturation of
collagen (Figure 13.29). Capsular shrinkage provides
a shrunken scaffold for fibrosis during repair. Tissue
healing following shrinkage shows a rapid reduction
in strength by 7–14 days before returning to normal
pretreated levels by 90–180 days.
A standard lateral arthroscope portal is used with
the instrument portal established craniolaterally. After
a thorough examination of the joint, the radiofrequency
probe is introduced. This often needs to be through
an open portal as the diameter of the probe (3.2 mm)
is too large for most instrument cannulae used in
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 Chapter 13 Rigid endoscopy: arthroscopy

13.29 13.30 LGHL

tear.
A 3.0 mm
Capsure
probe being
used to shrink
the medial
compartment
of the
shoulder joint.

canine arthroscopy. The radiofrequency probe should An LGHL rupture has been repaired arthroscopi-
be set on its lowest setting and the probe placed cally by the authors (Figure 13.31). Using a hanging
1 mm away from the tissue. A 5-second burst of limb position and a craniomedial arthroscopic portal, a
energy is then applied to the probe and the capsule suture anchor loaded with Fiberwire suture was
should be seen to shrink. This procedure should be inserted in the craniolateral scapula just proximal to
repeated in a ‘spot welding’ or ‘paintbrush’ pattern the glenoid, via a craniolateral portal and under
across the medial aspect of the joint. Islands of viable arthroscopic guidance. Using an additional caudo-
tissue must be left to allow for repair. Fluid flow is lateral portal and an arthroscopic lasso instrument,
essential when performing thermal capsulorrhaphy to each strand of the suture was shuttled separately
prevent overheating of the tissues. through the ligamentocapsular tissue before being
Postoperative care for these patients is different returned to the craniolateral portal and tied using an
from other cases of shoulder disease because of the arthroscopic knot-pusher.
initial weakening of the tissues. In humans, careful The prognosis for shoulder instability is fair to
rehabilitation is considered to be paramount to the good. Imbrication or thermal capsulorrhaphy is usually
success of capsular shrinkage. This is an area where successful, at least in the short term, but postoperative
veterinary surgeons are at a distinct disadvantage. management of these cases is critical and may be
The authors currently recommend the affected limb is prolonged. It is common for lameness to resolve but
placed in a custom-made, non-weightbearing sling for the condition may recur.
at least 6–8 weeks in order to protect the repair.
Rehabilitation starts when the jacket is removed after 13.31
this time. Arthroscopic
repair of a
Lateral glenohumeral ligament tears LGHL tear.
Diagnosing LGHL tears is more difficult than MGHL (a) Placement of
tears due to the difficulty of viewing this area from a the suture
anchor. (b)
lateral portal. If there is any doubt regarding the
Advancement of
integrity of the lateral capsule, a craniomedial portal the suture
should be established. Indeed, if arthroscopic sur- material into the
gery to stabilize lateral instability is being considered, joint, to ensure
then a craniomedial portal is recommended. The adequate
ligament is usually taut with the limb held neutrally or visualization.
(continues)
in slight adduction and lax when the limb is abducted. (a)
As for the medial structures, the LGHL should be
assessed for tears (complete or partial; Figure 13.30),
fraying or inflammation. Probing the ligament is diffi-
cult but should be attempted. Instability should be
suspected if the ligament is lax in the neutral or
adducted position or if pathology is evident on inspec-
tion and probing.
Treatment options for tears to the LGHL are similar
to those for MGHL tears. Thermal capsulorrhaphy can
be employed as described in the section on MSI. The
arthroscope portal should be established cranio-
medially with the instrument portal caudolaterally.
Complete tears to the ligament should be recon-
structed using either an open arthrotomy (Mitchell and
(b)
Innes, 2000) or arthroscopically, using suture anchors.

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 Chapter 13 Rigid endoscopy: arthroscopy

13.31 normal tendon appears as a smooth white structure

with variable amounts of vasculature and some fat
(continued) and synovial folds proximally. Changes that occur
Arthroscopic
repair of a LGHL
with this disease include thickening and/or
tear. (c, d) A discoloration of the tendon, and synovitis (Figure
lasso is used to 13.33) and adhesions of the tendon sheath. Care
extract the must be taken in interpreting this as primary BTS
suture through because synovial hyperplasia may occur secondary
the capsular to other pathological processes in the shoulder, such
tissue.
as OCD or MSI. Treatment of the primary cause will
often resolve these changes seen on the tendon and
in the authors’ opinion synovitis of the tendon sheath
is merely an extension of generalized synovitis of the
(c) shoulder due to pathology other than BTS.
13.33
Arthroscopic view
of the biceps,
showing severe
synovial
hyperaemia.

Conservative management, involving strict rest

(d)
Bicipital tenosynovitis (BTS)
Before the advent of arthroscopy, BTS was the most
commonly diagnosed shoulder injury. The diagnosis
was usually based on history, clinical findings and
results of radiography or arthrography. Only rarely
was the diagnosis based on a visual assessment or
histopathology. BTS is difficult to diagnose accurately
and in the authors’ opinion is an uncommon or rare
condition. Ultrasonography has also been shown to
detect pathology of the biceps tendon parenchyma
reliably (Figure 13.32).
Standard lateral portal arthroscopy allows
inspection of the biceps brachii tendon of origin. The
and analgesia, is recommended for at least 4–6
weeks. At the end of arthroscopy, long-acting corti-
costeroid (e.g. 1.33 mg/kg methylprednisolone) may
be injected intra-articularly. It is reported that approx-
imately 50% of painful shoulders in adult dogs treated
in this way will respond. In cases where this fails to
resolve the lameness, then tenodesis/tenotomy is
recommended. This can be performed either arthro-
scopically or via an open arthrotomy. The authors’
preference is to perform an arthroscopic tenotomy
without reattaching the tendon to the proximal
humerus. Although a tenodesis can be performed by
arthroscopic guidance it is technically more demand-
ing and may be unnecessary. An arthroscopic teno-
tomy is a relatively straightforward procedure
(Holsworth et al., 2002) and seems to produce results
comparable to those of tenodesis. A lateral arthro-
scope portal is used, with the instrument portal placed
craniolaterally. Alternatively, the instrument portal can
be created in a craniomedial position, just over the
proximal bicipital groove. The tenotomy is performed
using an arthroscopic hook knife, scissors or a radio-
frequency probe. It has been shown that sharp
transsection is quicker than radiofrequency but haem-
orrhage may be a problem due to bleeding from the
small vessels in the centre of the tendon.

Biceps rupture (partial or complete)

Transverse ultrasound image of the biceps
13.32
tendon, showing a hypoechoic ‘core’ lesion.
Partial or complete ruptures of the biceps tendon occur
occasionally. Complete rupture of the biceps tendon
can be confirmed clinically by observing hyperexten-
sion of the elbow when the shoulder is fully flexed
(Figure 13.34). Pain during this manoeuvre may indi-
cate partial rupture of the biceps tendon but this is not
a specific test. Diagnostic arthroscopy is indicated in
cases of complete rupture to ensure no other shoulder
pathology is present requiring treatment.

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 Chapter 13 Rigid endoscopy: arthroscopy

The elbow joint

Arthroscopy is the current gold standard for diagnosis
of elbow pain in young dogs. Radiography is insensi-
tive to pathology of the elbow joint and, although CT
and MRI have increased sensitivity and specificity
when compared with radiography, arthroscopy is still
superior. In addition, arthroscopy is more widely avail-
able than CT or MRI and allows surgery to be per-
formed immediately on diagnosis.
The elbow is the most common site of thoracic
limb lameness, especially in young medium to large
(a)
dogs. Arthroscopy provides an excellent view and
allows palpation of the intra-articular structures of the
elbow with minimal trauma. The elbow joint is
potentially the easiest joint of the dog to arthroscope
due to its superficial position and readily identifiable
landmarks. Arthroscopy of the elbow allows a much
better view of pathology than does an open arthrotomy.
Treatment of pathology within the joint is relatively
straightforward, especially as the surgeon becomes
more proficient at handling and using the
instrumentation.

Indications
Indications for use of arthroscopy for elbow disease
(b) include:
13.34 (a) Normal biceps: with the shoulder in full
flexion, the elbow cannot fully be extended. • Dia nosis and treatment of elbow dysplasia
(b) Ruptured biceps: the elbow can be fully extended. (fragmented coronoid process, FCP), OCD,
ununited anconeal process (UAP)
Partial ruptures may be treated by arthroscopic • ana ement of elbow osteoarthritis ( A)
tenotomy (Figure 13.35). It is important in cases • r ical mana ement of septic arthritis
where rupture is suspected, but not conclusive, that • Dia nosis of incomplete ossification of the
the tendon is palpated carefully using a small joint humeral condyle (IOHC).
probe. In the normal tendon the probe should be able
to pass around the complete tendon. The prognosis Instrumentation
for partial biceps ruptures treated by tenotomy, or for A 30 degree oblique 2.4 mm arthroscope is most
complete rupture, appears to be good, with most dogs commonly used in the elbow of medium to large dogs,
returning to normal function after 6–10 weeks. although a 1.9 mm arthroscope should be considered
in small breeds. Three portals should be used (egress,
13.35 arthroscope and instrument) as it is advisable to
palpate all the intra-articular structures. Some lesions
(a) Partial
rupture of the associated with elbow dysplasia and IOHC are not
biceps tendon. obvious until the cartilage is carefully probed.
(b) Tenotomy Instruments required for arthroscopy of the elbow
using include probes, cannulae (and switching stick),
arthroscopic various grasping forceps, milling drill, curette and
scissors. elevators. The use of a power shaver is optional (see
(Courtesy of
B Van Ryssen) below). Other instruments are discussed under the
relevant procedures.
(a)
Patient preparation and positioning
The patient should be clipped as for an open
arthrotomy. As the surgeon increases in experience,
a small clip on the medial aspect is all that is required.
The patient is placed in lateral recumbency with the
affected limb down. A sandbag is placed under the
elbow to act as a fulcrum. The limb can be draped
either as a hanging limb preparation or with a single
drape placed medially. If bilateral arthroscopy is to be
performed the dog can be placed in either lateral or
dorsal recumbency. Lateral recumbency requires the
(b)
dog to be rolled when changing elbows but makes

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viewing the joint easier, especially in more complex
cases. Dorsal recumbency does not require the
animal to be moved but does require a larger clip, and
the procedure can be more difficult technically.
Procedure
Various portals for inspecting the elbow have been
reported and include medial, craniolateral and caudal
portals. The authors prefer the medial portal (Figure
13.36) for inspection and treatment of lesions
associated with elbow dysplasia. The craniolateral
portal is useful for assessing incongruency, especially
that associated with short radius syndrome, and
reduction of humeral condylar fractures. The value of
the caudal portal remains unproven to date.
13.36 Model demonstrating the position of portals for
elbow arthroscopy. A = Arthroscope portal;
E = Egress portal; I = Instrument portal.
Medial portal
A 20 gauge hypodermic needle, with an attached
10 ml syringe, is inserted into the proximocaudomedial
joint capsule between the anconeal process and the
medial supracondylar ridge. Joint fluid is usually
aspirated when negative pressure is applied to the
attached syringe; 6–10 ml of saline (or lactated
Ringer’s solution) is injected intra-articularly. Correct
placement of the needle allows easy injection of the
fluid and the joint capsule is seen to bulge. Surgeons
with minimal experience of arthroscopy should identify
the medial epicondyle (used for location of the
arthroscope portal) prior to injection of the fluid.
Palpation of the epicondyle may be difficult after the
fluid has been injected. The fluid line is then connected
to the needle to prevent fluid loss.
In some cases fluid is not aspirated from the
needle. The surgeon has two choices in these
situations. If they feel that the needle is in the joint,
then fluid can start to be injected; if the needle is intra-
articular, fluid should enter under minimal pressure.
Care must be taken to ensure that the fluid is not
going into the periarticular tissues, as this will cause
collapse of the joint capsule and subsequently may
prevent introduction of the arthroscope trocar without
causing iatrogenic damage. An alternative is to inject
Ch13 Endo.indd 203
Chapter 13 Rigid endoscopy: arthroscopy
the fluid via another portal. Another 20 gauge
hypodermic needle is placed perpendicular to the
skin, approximately 1.5 cm distal to the medial
epicondyle. Slight adjustment of the needle direction
may be needed to enter the joint. Aspiration of synovial
fluid from this portal ensures correct placement of the
needle. The authors will often adjust the proximo-
caudomedial needle when injecting fluid to ensure its
correct placement. A small stab incision is made
through the skin adjacent to the second needle and
the arthroscope cannula introduced. A coned trocar is
always used to minimize damage to the articular
cartilage. Internal rotation and flexion over a fulcrum
will widen the joint space and help introduction of the
cannula.
Inspection of the joint from the medial portal allows
visualization of:
• Anconeal process
• Caudal joint recess
• edial h meral condyle
• ateral h meral condyle
• ateral coronoid process
• ateral oint caps le
• edial coronoid process
• adial head
• Craniomedial oint caps le
• Ann lar li ament
• edial collateral li ament
Inspection of the elbow should follow a logical
standardized order (Figure 13.37). The authors’
recommended start position is with the light post in
the 9 o’clock position so that the anconeal process is
visualized. The light post is then rotated through 180
degrees as the medial trochlear ridge of the ulna and
medial condyle of the humerus are inspected. It is not
uncommon to see a region of the central trochlear
notch to be devoid of cartilage. This is a normal finding
and probably reflects the lack of loading of this region.
The underlying subchondral bone appears normal.
This is known as a synovial fossa. In order to visualize
the lateral capsule and lateral coronoid process, the
arthroscope is carefully advanced whilst rotating the
light post slowly in a clockwise direction. External
rotation of the elbow may help at this point. From this
position the light post is placed in the 2–3 o’clock
position in order to visualize the radial head. In some
cases the camera needs to be moved caudoproximally
to allow the radius to enter the field of view. Further
leaning of the camera head allows the medial coronoid
process to be examined. Advancing the arthroscope
from this position allows a more complete inspection
of the central and cranial aspects of the medial
coronoid process.
After careful examination of the elbow an instru-
ment portal should be established cranially to the
arthroscope. The light post should be rotated so that
the craniomedial portion of the joint can be seen. A
20 gauge needle is inserted approximately 1–1.5 cm
cranial to the arthroscope. The needle should be
almost parallel to the arthroscope portal in order to
prevent ‘crossing over’ of the needle with respect
to the arthroscope cannula within the joint. It is easier
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 Chapter 13 Rigid endoscopy: arthroscopy

CeTN
CaTN

(a) (b) (c)

H
CrTN

CrTN
RH

LCP
(d) (e) (f)

13.37 Normal arthroscopic anatomy of the elbow: (a) humerus and anconeal
process; (b) caudal trochlear notch; (c) central trochlear notch;
(d, e) cranial trochlear notch; (f) lateral coronoid process and radial head; and
ICF (g) radial head and intercondylar fossa. CaTN = Caudal troachlear notch;
CeTN = Central trochlear notch; CrTN = Cranial trochlear notch; H = Humerus;
ICF = Intercondylar fossa; LCP = Lateral coronoid process; RH = Radial head.

RH

(g)

to observe the instruments rather than the monitor Pathological conditions

when trying to triangulate. A useful indicator for place-
ment of the needle in most canine elbows is to observe
the light under the skin. This is often visible due to the
minimal soft tissue overlying the joint on the medial
aspect of the elbow and is a good marker for needle
placement. Once the needle is visualized on the mon-
itor a small stab incision is made in the skin, taking
care not to inadvertently penetrate the joint capsule. A
switching stick is then introduced parallel to the nee-
dle until it enters the joint. The use of an instrument
cannula is at the discretion of the surgeon. A large
clean open portal may be preferential to an instru-
ment cannula as the latter can sometimes inhibit the
use of instruments such as grasping forceps.
Careful palpation of the joint, especially the
articular cartilage, using a 2 mm right-angled probe, is
paramount. Some cases of FCP have normal cartilage
overlying large subchondral defects.
Fragmented medial coronoid process
FCP of the ulna is the most common cause of elbow
lameness in young, rapidly growing, medium to large
dogs and leads to OA. Many breeds are affected but
the Labrador Retriever, Rottweiler and Bernese
Mountain Dog are over-represented. It is often a
bilateral disease, although most presentations are for
unilateral thoracic limb lameness. The aetiology of
the disease is not fully understood and many theories
exist, including radioulnar incongruency, humeroulnar
incongruency and osteochondrosis. The reader is
referred to the BSAVA Manual of Canine and Feline
Musculoskeletal Disorders for further detail.
A complete orthopaedic examination is required in
order to rule out other juvenile orthopaedic conditions,
such as panosteitis, metaphyseal osteopathy and
septic arthritis. Diagnosis of FCP is not straightforward

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due to the difficulty in visualizing the lesions with radio-
graphy. An inference can be made based upon signal-
ment, history, clinical findings, presence of secondary
osteoarthritic changes on radiographs, and the elimi-
nation of other known causes of arthritis. The earliest
change on radiographs is sclerosis of the trochlear
notch. As the disease progresses, osteophytosis of
the joint is evident. This is initially noted on the dorsal
border of the anconeus. It is uncommon to visualize
an FCP lesion directly on radiographs because of the
superimposition of the coronoid on the adjacent radius.
A ‘lazy’ craniocaudal view of the elbow (where the
elbow is laid on the table in the neutral position) will
skyline the coronoid region and may reveal a dis-
placed lesion. However, most FCP lesions are only
minimally displaced, if at all. Elbow dysplasia should
still be suspected in these cases, based on the signal-
ment, history and clinical signs. It is not uncommon for
significant intra-articular pathology to be present in
cases where no radiographic changes are evident.
The advent of arthroscopy means that a minimally
invasive examination of the elbow can be performed
and can be used as a diagnostic tool. Arthrocentesis
of the joint may reveal an effusion, with cell counts in
the range 2000–5000 cells/µl. CT allows visualization
of FCP lesions that may not be evident on plain radio-
graphs, and may demonstrate fissuring of the subchon-
dral bone that may not be evident on arthroscopic
examination. If CT is not performed, this may be
missed at the time of surgery, which explains why
careful probing of the articular surface is needed.
However, CT is not widely available and it is not nec-
essary to justify arthroscopic examination.
(a) (b)
(d) (e)
Ch13 Endo.indd 205
Chapter 13 Rigid endoscopy: arthroscopy
Although medical management is an option for
FCP, surgery is the treatment of choice. The disease
is often bilateral and, with the use of arthroscopy, both
elbows can be treated in one sitting. A hanging limb
preparation offers the greatest freedom of movement
of the limb.
Positioning of the patient is as previously
described. Arthroscopy for FCP (and other causes of
elbow dysplasia) is performed through a medial portal.
After placement of the egress needle and injection of
fluid into the joint, the arthroscope portal is established.
A visual examination of the whole joint is performed
initially and the degree of cartilage integrity is graded
using the modified Outterbridge scale. Other lesions
within the elbow that may be identified in conjunction
with FCP include: OA of the medial compartment;
OCD; and UAP. These other pathologies occur
frequently and their management is described
separately.
FCP lesions vary in severity from chondromalacia
(abnormal softening of the cartilage) through to large
displaced fragments (Figure 13.38). Once the visual
examination is complete, an instrument portal is
established in order to probe the articular cartilage
and facilitate removal of FCP lesions. The instrument
portal is established as previously described. The
coronoid region is carefully probed to assess the
integrity of the articular cartilage. If chondromalacia is
present it appears as a soft fragile surface. More
severely diseased cartilage is readily elevated and
the yellow avascular subchondral bone is evident
beneath (Figure 13.39). Fragments are often visible
and may remain in situ or become displaced.
(c)
13.38 Varying degrees of pathology,
from cartilage fissure to
complete displacement of fragment,
seen with fragmentation of the coronoid
process.
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 Chapter 13 Rigid endoscopy: arthroscopy
13.39
Synovitis
associated with
elbow pathology, in
this case a
displaced
fragmented
coronoid visible
below inflamed
synovium. The
yellow discoloration
of the bone is
caused by
necrosis.
Removal of these fragments can sometimes be
technically challenging. Often they are quite large
and the small size of the elbow joint means that it is
not possible to get sufficiently large forceps into the
joint to grasp the fragment. The fragments are
necrotic and disintegrate when grasped; this is
usually not a problem as the fragment can be removed
in a number of pieces, though care should be taken
not to displace any sizeable fragments into non-
accessible areas of the joint. If this does occur, fluid
flow should be increased to try and flush the fragment
back towards the instrument portal. Placement of a
cannula may facilitate this. Alternatively, an arthro-
scopic curette can be pushed past the fragment and
used to guide it back into the working window. The
annular ligament attaches to the medial and the
lateral coronoid. Some fragments are well adhered to
this ligament and sharp dissection may be needed in
order to remove the lesion. Alternatively, the lesion
can be grasped and rotated several times in order to
tear away the soft tissues. Non-displaced fragments
may need to be elevated using a curette or
arthroscopic elevator before they are free enough to
be removed. Very occasionally, displaced fragments
may continue to grow and can become very large.
These can sometimes be removed in one piece,
although it is often easier to break them down. A
power shaver is useful in these situations to burr the
lesions rapidly and remove the debris through the
suction channel; hand milling can be performed but
is usually laborious and lengthy. These situations
occasionally need to be converted to an open
arthrotomy when the surgeon is relatively inexperi-
enced with arthroscopy.
After removal of any fragments or diseased
cartilage, the remaining cartilage and subchondral
bone needs to be treated. The remaining edges of
articular cartilage are curetted back to healthy
cartilage. Ideally the edges of the cartilage lesion
should be vertical in order to allow the inflow of the
surrounding cartilage matrix. The subchondral bone
surface is then milled using a hand drill. The surface
is abraded until it readily bleeds, which can be easily
observed if fluid ingress is temporarily stopped.
After complete removal of the fragments and
treatment of the subchondral bone, the joint is lavaged
under pressure (40–100 mmHg) for 5 minutes in order
to remove any debris. Closure is then routine, using
non-absorbable monofilament suture material.
206
Ch13 Endo.indd 206
The prognosis for FCP varies considerably and is
probably dependent upon the severity of the disease
at the time of presentation and postoperative man-
agement of the dog. About 60% of dogs treated
arthroscopically may return to normal function (Meyer-
Lindenberg et al., 2003) without the use of analgesia,
although some (25–30%) remain lame and will show
a progressive lameness. Elbow OA may require life-
long treatment and in very severe cases total elbow
replacement, arthrodesis, amputation or even eutha-
nasia may be required.
Osteochondritis dissecans
The aetiology and pathogenesis of elbow OCD is
poorly understood but the condition is believed to be
due to necrosis around the vascular channels in the
articular–epiphyseal region, which leads to a fissure
in the articular cartilage (see above). The lesion often
occurs bilaterally and is seen on the weight-bearing
outer surface of the centromedial portion of the
humerus. OCD may be seen concurrently with FCP
and/or OA.
The presentation and diagnosis are similar to that
of FCP, with radiographs demonstrating secondary
osteoarthritic changes. On the craniocaudal view of
the elbow, there may be a radiolucent region in the
subchondral bone of the medial humeral condyle; the
film sometimes needs to be taken as a craniolateral–
caudomedial oblique view in order to see this. The
lesions seen radiographically can be subtle and,
once proficiency with arthroscopy is achieved, it
may be prudent to examine both elbows in one sit-
ting. In cases of long standing, this lesion may
become mineralized or displace and lodge in the
caudomedial aspect of the joint. Occasionally, dis-
placed bone can continue to grow, forming a linear
osteochondral ossicle. Although CT is well reported
to define the extent of OCD lesions it is not neces-
sary for diagnosis.
Basic instrumentation is required to treat elbow
OCD and should include curette, milling drill, probe
and grasping forceps. An instrument portal can be
established through the arthroscope portal using a
switching stick. The authors prefer not to use an
instrument cannula for cases of OCD as they can be
difficult to maintain. An open portal is sufficient for the
therapeutic management of elbow OCD. If the lesion
is in situ, forceps can be introduced through the instru-
ment portal to grasp the flap. A second instrument,
such as a probe or small curette, can be introduced at
the same time and used to elevate the periphery of
the lesion gently. Normal cartilage is difficult to
remove, so minimal further damage is caused by gen-
tle application of this technique. Once released, the
flap can be removed through the portal. Some OCD
lesions can be up to 15 mm across and so may require
removing in multiple pieces, or the portal may need to
be enlarged. After removal of the fragment the under-
lying subchondral bone is treated as discussed above
for OCD of the shoulder. Concomitant lesions (e.g.
FCP) should then be treated. The joint is lavaged for
5 minutes prior to closure.
The dog should be placed in lateral recumbency,
with the affected limb nearest the table. The authors
4/3/08 09:46:49

use the same position for bilateral elbow arthroscopies
and choose to roll the dog between elbows. An
alternative is to place the animal in dorsal recumbency,
from which position both elbows can be arthroscoped.
A standard medial portal, as described previously, is
used to examine the elbow joint and visualize the
lesion. If an OCD lesion is observed (Figure 13.40) it
is often adjacent to the arthroscope portal. These
lesions are often large and so it is advisable to move
the arthroscope caudally in these cases to see the
whole lesion. Lesions may appear as a softened
region of cartilage or as an obvious flap.
13.40
Non-displaced
OCD lesion of the
medial humeral
head of the
humerus.
The prognosis for elbow OCD, as for other
causes of elbow disease, depends on the severity
of the lesion. Cartilage pathology is often more
severe than that seen with FCP, although the
underlying subchondral bone often bleeds much
more readily. This releases mesenchymal cells
from the bone, and the lesions readily fill with fibro-
cartilage. The OA will continue to progress despite
the treatment and is often the cause of lameness
seen in older animals that have undergone previ-
ous surgery.
Ununited anconeal process
The aetiology of UAP is thought to relate to humero-
ulnar incongruency. UAP is predominantly seen in
German Shepherd Dogs and is also prevalent in
Bloodhounds and Basset Hounds. A secondary
centre of ossification exists in these three breeds,
which should unite with the proximal ulna by 20
weeks of age. The use of arthroscopy for the direct
treatment of UAP has been described (Meyer-
Lindenberg et al., 2006), although its main indication
is to assess the stability of the anconeus and to
inspect the joint for the presence of concomitant
lesions (e.g. FCP).
UAP is readily diagnosable from a flexed medio-
lateral view of the elbow (Figure 13.41). Animals
should be at least 20 weeks old before a definitive
diagnosis can be made. A radiolucent line exists
between the proximal ulna and the anconeus, and
there are often signs of secondary osteoarthritic
changes. Arthrocentesis may reveal an effusion
similar to that seen in other causes of elbow dysplasia,
i.e. an increased volume of fluid with a low viscosity.
Cell counts are approximately 2000–5000 cells/µl and
there is a predominance of mononuclear cells.
Ch13 Endo.indd 207
Chapter 13 Rigid endoscopy: arthroscopy
13.41
A non-displaced
UAP.
Treatment for UAP includes medical and surgical
options, although medical therapy is often
unsuccessful. Surgical options include: proximal ulnar
osteotomy (PUO) (Sjöström et al., 1995), with or
without an intramedullary pin (Turner et al., 1998);
PUO combined with lag screw fixation of the anconeus
(Krotscheck et al., 2000); or fragment removal
(Guthrie, 1989). Lag screw fixation of the anconeal
process can be via arthrotomy or arthroscopy.
Arthroscopy is used to view the fragment during
tightening of the compression screw but its other role
is to diagnose and treat concomitant lesions.
The portal sites for surgical exploration and
treatment of UAP are as for other causes of elbow
dysplasia. In most cases a 2.4 mm 30 degree forward
oblique arthroscope is suitable. A full exploration of
the joint is performed initially and the authors prefer to
treat any other lesions first. After this, the UAP is
palpated to assess its stability using a caudal
instrument portal. This is established approximately
1 cm caudal to the arthroscope portal in the same
way as described previously for other portals. The
authors usually leave the egress needle caudal as
well, although if this interferes with the procedure the
egress portal can easily be re-established cranially.
For arthroscopic placement of the lag screw, a
small Kirschner wire is initially placed from the caudal
ulna through the fibrous tissue and into the anconeal
process, until it is visualized exiting the process. This
is very important to ensure the subsequent correct
placement of the lag screw. It is very easy for the
Kirschner wire to exit the fragment laterally and not be
seen. It is preferable to overdrill the Kirschner wire
with a 2.5 mm cannulated drill bit to ensure the same
track is followed. If a cannulated bit is not available, a
second Kirschner wire should be placed parallel to
the first one but 5 mm caudally. The initial wire can
then be removed and a 2.0 mm drill bit used to create
the pilot hole for the screw. The authors prefer to use
a 4.0 mm partially threaded cancellous screw for lag
screw fixation of UAP, although a 3.5 mm fully
threaded cortical screw, placed as a lag screw, can be
used as an alternative. A proximal ulnar osteotomy is
then performed. This last procedure is essential if a
lag screw has been placed to prevent breakage of the
screw due to shearing forces.
A distal ulnar osteotomy has been reported as an
alternative to PUO. Placement of the pin to stabilize
the osteotomy is at the discretion of the surgeon; it
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 Chapter 13 Rigid endoscopy: arthroscopy
does reduce the morbidity of the surgery in the short
term but is associated with complications of its own.
The prognosis for UAP is better than that for OCD/
FCP provided early treatment is performed. In one
study of 20 dogs (22 joints), 70% of cases had an
excellent outcome (Sjöström et al., 1995). Secondary
OA will continue to progress and may result in
lameness as the dog ages.
Elbow osteoarthritis
OA (Figure 13.42) is a secondary change seen as a
consequence of a primary disease such as elbow
dysplasia. Secondary OA changes probably occur as
a direct result of increased articular loads due to
incongruency. The disease is chronic and can be very
difficult to manage satisfactorily. Most cases of elbow
dysplasia are biphasic in their presentation. Initially,
the cause of the lameness is the primary lesion but as
the OA progresses, the secondary changes become
a source of pain.
13.42
Significant medial
compartment OA.
Note the distinct
demarcation
between the medial
and lateral
compartments of
the joint.
The intra-articular management of OA is recom-
mended in humans but there is little long-term evi-
dence to support it. Certainly the benefits of removing
loose fragments or managing acute trauma cases
that have disrupted the fibrocartilaginous layer are
obvious in trying to restore the layer. However, in
cases where a precipitating cause is not evident, and
so unlikely to be addressed, the benefits are less
clear. Inflammatory mediators present in the synovial
fluid will be diluted thus offering short-term relief to
the patient. The modified Outterbridge scale can be
used to assess severity of disease and may help to
formulate a treatment plan. Full-scale erosions heal,
by the formation of fibrocartilage, more quickly than
partial thickness erosions and so the surgeon must
decide on whether there is benefit in developing these
partial thickness erosions. In most cases of chronic
OA the underlying subchondral bone is often ebur-
nated and milling of this can be very unrewarding,
especially without the aid of a motorized shaver unit.
Management of elbow OA using arthroscopy is
two-fold. Flushing of the joint will remove inflam-
matory mediators and provide temporary relief to the
patient. Abrasion arthroplasty will attempt to release
mesenchymal cells from the subchondral bone in
order to promote a protective fibrocartilaginous layer.
This layer, whilst offering some degree of protection,
208
Ch13 Endo.indd 208
is not as resilient to trauma as normal hyaline carti-
lage, so it is important to combine any surgery with
the judicious use of controlled exercise. Some
authors recommend the use of microfracture tech-
niques to release further mesenchymal cells from the
deeper layers.
A standard medial portal is used as described
previously. The instrument portal is usually created
cranially with respect to the arthroscope, although for
abrasion of the caudal aspects of the joint a caudal
instrument portal is preferred. An instrument cannula
is not usually used as they are not large enough to
accommodate the power shaver blade. A 3.5 mm or,
in larger dogs, a 4.5 mm bone-shaving head is used
to abrade the remaining cartilage and subchondral
bone. Extreme care must be exercised with these
instruments as much iatrogenic damage can be done.
The lateral compartment is normal in most cases of
elbow OA and must be preserved. Iatrogenic damage
to the radial head must be minimized when using the
shaver in the region of the medial coronoid process.
Microfracture can be performed using a dedicated
microfracture instrument and mallet, although the
authors prefer to use a small (1.1 mm) Kirschner wire
held in a Jacob’s chuck. Holes of 1–2 mm depth
should be made into the bone, 3–4 mm apart across
the affected region.
The prognosis for elbow OA, as for elbow dys-
plasia, depends upon the severity of the disease.
Radiographic evidence of OA is not linked to severity
of disease. Combination of medical and surgical
management is more likely to be beneficial than
either entity singularly. The use of weight manage-
ment, analgesia, controlled exercise and ancillary
aids such as hydrotherapy, nutraceuticals, acupunc-
ture and other such modalities may be beneficial
although, at present, there is little scientific evidence
to support this.
Incomplete ossification of the humeral condyle
IOHC is predominantly reported in spaniels (Marcellin-
Little et al., 1994; Butterworth and Innes, 2001) and
Labrador Retrievers, although many breeds may be
affected. The distal humeral condyle has two separate
centres of ossification that should fuse to each other
by 20 weeks of age. Failure of the two centres to fuse
results in a circumferential articular defect which
extends into the subchondral bone. This predisposes
the distal humerus to fracture, due to the eccentric
loads across it. Early diagnosis and fixation is
indicated to prevent catastrophic failure.
Diagnosis is possible with a craniocaudal
radiograph of the elbow, although multiple slightly
angled views may be needed before visualization of
the radiolucent defect is possible. A slight increase in
the kV setting is often necessary. Care must be taken
not to confuse IOHC with the Mac line that is often
seen in rotated craniocaudal views of the elbow joint.
CT is a more sensitive indicator of IOHC but arthro-
scopy remains the gold standard. The lesion is evident
as an articular cartilage defect that traverses the
central region of the humeral condyle (Figure 13.43).
Careful palpation of this region is very important,
especially in cases where IOHC is suspected but not
4/3/08 09:46:50
 Chapter 13 Rigid endoscopy: arthroscopy

13.43 Instrumentation
For medium- and large-breed dogs a 2.4 mm, 30
Incomplete
ossification of the
degree oblique arthroscope is preferred. For small
humeral condyle. dogs and cats, a 1.9 mm arthroscope is mandatory.
A circumferential Small instrumentation is required for all patients.
cartilage defect
(arrowed) can be Patient preparation and positioning
seen clearly in the The limb is clipped from just proximal to the main pad
centre of the
to the mid-antebrachium. The foot is covered in an
humeral condyle.
impervious barrier, such as a plastic bag or used
surgical glove, which is taped in place. The patient is
positioned in dorsal recumbency with the operative
limb suspended. The limb is free draped to allow
manipulation of the limb intraoperatively.

evident arthroscopically. Occasionally, the surface of Procedure

the cartilage appears normal but palpation exposes The arthroscope portal is between the common digital
the defect that would otherwise be overlooked. extensor tendon laterally and the extensor carpi
Arthroscopy is also used in cases of IOHC to assess radialis tendon medially (Figure 13.44). The egress
for concomitant lesions and can be used for portal can be placed lateral to the common digital
intraoperative assessment of screw placement to extensor tendon. Because there is limited working
confirm that the screw is not placed intra-articularly. space in the carpus, if instruments are required, they
As described previously, a medial portal is used to are placed at the egress portal site.
examine the elbow joint and treat any obvious lesions.
If arthroscopy is used for intraoperative assessment it
can be left in situ whilst another surgeon places the
transcondylar screw, or it can be removed from the
joint and replaced after the screw has been inserted.

Sepsis
In cases of non-responsive septic arthritis it is possible
to flush a joint with a significant volume of fluid in a
relatively short period of time, using a fast flow system
under high pressure. Synovial biopsy specimens can
be taken at the same time and then sent for culture.

Fractures
The use of arthroscopy to assess fracture alignment
is possible, although sometimes impractical. In cases
of humeral condylar fractures (or treatment of IOHC)
where the joint may have been arthroscoped prior to
fracture repair, it is feasible to arthroscope the joint
again afterwards to assess alignment.

The antebrachiocarpal joint

The carpus is a three-level hinge (ginglymus) joint.
Only the antebrachiocarpal joint is available for
arthroscopic inspection; the other joints are low-
motion joints with insufficient space for arthroscopy.
Carpal arthroscopy is performed infrequently at the
current time but the radiocarpal joint is amenable to
arthroscopic examination and there are occasions
when arthroscopic examination may be beneficial for
patient management. These include: assessment of
intra-articular fractures, such as radiocarpal bone
fracture (Li et al., 2000); assessment of soft tissue
injuries; grading of arthritis; and synovial biopsy.
Diagnosis of carpal ligamentous injuries in racing
Greyhounds is another potential indication for
arthroscopy. Because the carpus is often involved in
inflammatory joint disease, it is a good location for
arthroscopic synovial biopsy if one is required.
Model demonstrating the position of portals for
13.44
carpal arthroscopy. A1 and A2 = Represent
alternative suggested arthroscope portal sites.
The procedure is started with placement of a
hypodermic needle at the arthroscope portal site and
the carpus in full flexion to open the antebrachiocarpal
joint space. The needle should enter the radiocarpal
joint space easily. The joint is inflated with 2–5 ml of
Hartmann’s solution and the needle withdrawn. A stab
incision is made with a no. 11 scalpel blade at the
arthroscope portal site and this should extend to enter
the joint capsule. The blade should be oriented
vertically to avoid damage to tendinous structures
either side of the portal. The arthroscope sleeve is

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 Chapter 13 Rigid endoscopy: arthroscopy

inserted with a blunt obturator locked in place. The The hip joint
obturator is removed and the arthroscope inserted.
Arthroscopy of the hip is not performed commonly but
Arthroscopic anatomy is very achievable for the experienced arthroscopist.
Upon entering the joint, the radial articular surface The hip is a common site of lameness in dogs, with
is seen at 12 o’clock, with the radiocarpal bone at hip dysplasia and OA being particularly common. Hip
6 o’clock (Figure 13.45). The arthroscope may be dysplasia is usually diagnosed using a combination of
moved left or right to inspect the joint surfaces. If the clinical and radiographic examinations, as is OA.
joint is extended slightly and the arthroscope inserted Whilst arthroscopy of the hip can be used to stage OA
further, the palmar joint capsule can be observed. accurately, this is usually not performed at the current
time. However, there is no doubt that arthroscopy is
more sensitive to the early changes associated with
13.45
OA, such as chondropathy and synovitis.
Normal
arthroscopic view Indications
of the antebrachial Indications for hip arthroscopy include:
carpal joint. The
radius is at the top,
with the radiocarpal • diopathic hip pain in the absence of radiolo ical
bone below. changes
• iopsy of the syno i m
• ta in of A (e d rin decision-ma in for
triple pelvic osteotomy)
• Dia nosis and treatment of infecti e arthritis of
the hip.

Pathological conditions Instrumentation

The carpus is a complex hinge joint, stabilized
medially and laterally by collateral ligaments. Palmar
stability is provided by flexor tendons, the palmar
radiocarpal and ulnocarpal ligaments and the palmar
fibrocartilage. This latter structure is critical and failure
results in a palmigrade stance. The radiocarpal bone
develops as two separate centres of ossification and
there can occasionally be incomplete ossification of
this bone, resulting in susceptibility to fracture. This is
noted particularly in Boxers (Li et al., 2000). Figures
13.46 and 13.47 illustrate some pathological condi-
tions of the carpal joint.
13.46
Cases of severe
carpal synovitis
can be investigated
arthroscopically.
(Courtesy of
J Cook)
Choice of arthroscope is dependent on patient size.
In large dogs, a long 30 degree oblique 2.7 mm
arthroscope is used. A 2.4 mm arthroscope should be
considered in small-breed dogs. Although a 1.9 mm
arthroscope could be used in small dogs too, the
operator must be very careful not to damage such a
fragile arthroscope through bending in the soft tissues
between the skin and the joint. Instruments required
for arthroscopy of the hip include probes, cannulae,
switching stick and synovial biopsy forceps.
Patient positioning and preparation
The dog is placed in lateral recumbency, with the
affected limb uppermost. To facilitate movement of
the joint and limb during arthroscopy, a hanging limb
preparation is recommended. The lower limb is
covered with an impervious sterile impervious drape.
Procedure
Portal placement
Portals for the hip were described originally by Person
(1989). If one considers the hip as a clock face, for
the right hip the egress cannula is placed at 5 o’clock

(a) (b) (c)

13.47 Carpal chip fracture. (a) Fracture in situ. (b) Fragment being removed using 2.7 mm grasping forceps.
(c) Power shaver being used to debride the carpal defect in the subchondral bone. (Courtesy of J Cook)

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 Chapter 13 Rigid endoscopy: arthroscopy

and the arthroscope portal at 12 o’clock. Should an the capsule. The obturator is removed and the
instrument portal be required, this is placed at 2 surgeon should observe fluid egress from the open
o’clock (Figure 13.48). For the left hip, these portal sleeve, confirming the intra-articular position of the
positions are mirrored. end of the sleeve. The arthroscope is then inserted.

Arthroscopic anatomy
The hip is a ball and socket joint. External and internal
rotation of the femoral head during arthroscopy can
allow inspection of the majority of the articular surface
of the femur. The teres (round) ligament of the femoral
head can also be viewed as it emerges from the
acetabular fossa and inserts on the femoral head.
The acetabulum is otherwise covered in hyaline
cartilage and also has a fibrocartilage extension
dorsally, called the labrum. The joint capsule extends
from the margins of the acetabulum to the femoral
neck. Normal anatomy is depicted in Figure 13.49.
(a)

13.49
Normal
arthroscopic
CrAR anatomy of the
right coxofemoral
joint. CaAR =
Caudal
acetabular rim;
CaFH = Caudal
femoral head;
CrFH CrAR = Cranial
acetabular rim;
CrFH = cranial
femoral head;
JC = Joint
(a)
capsule.
(continues)

CaAR
(b)

13.48 Hip portals. (a) Model demonstrating the

position of portals for right hip arthroscopy.
A = Arthroscope portal; E = Egress portal; I = Instrument
portal. (b) Clinical arthroscopy of the left hip (dorsal
surface uppermost; head is to the left).
CaFH
The egress portal is established with a 20 gauge
(1.5–2 inch) hypodermic needle, depending on patient
size. The needle is placed immediately cranial to the
greater trochanter in a similar position to that used for (b)
arthrocentesis. Often the surgeon will feel the needle
puncture the joint capsule. Aspiration may reveal
some synovial fluid but there is often minimal joint
fluid in the hip. The joint is then distended with lactated
Ringer’s solution (typically 4–8 ml).
The arthroscope portal is then established. A 20 JC
gauge (1.5–2 inch) hypodermic needle is used to
locate the correct position for the portal, using a ‘trial
and error’ approach, making sure that the selected
location will allow movement of the arthroscope CaFH
circumferentially from 9 o’clock to 3 o’clock. Once the
desired location is found, a no. 11 blade is placed
alongside the needle and used to make a stab incision
down to the joint capsule. The arthroscope sleeve
(c)
with the blunt obturator in place is then inserted into

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 Chapter 13 Rigid endoscopy: arthroscopy

13.49 Infective arthritis

In common with other joints, infective arthritis of the
Mid acetabulum (continued) hip (Figure 13.50) is an indication for the use of
Normal
arthroscopic
arthroscopy, although this is not mandatory. However,
anatomy of the arthroscopy can be used for joint lavage and inspection
right of the joint, as well as biopsy of the synovium for
coxofemoral bacteriological culture and sensitivity testing.
AcF joint. AcF =
Acetabular
TL fossa; CaFH = 13.50
Caudal femoral Septic arthritis in
head; CaJC = the hip of a dog
Caudal joint presented for total
capsule; FH = hip replacement.
FH Femoral head;
(d) (Courtesy of
FN = Femoral J Cook)
neck; TL = Teres
ligament.

Ca acetabulum
AcF
Idiopathic hip pain
Occasionally a dog will present with apparent hip pain
but normal radiographic appearance. The authors
have seen a few patients in this category and have
used arthroscopy for further evaluation. In a propor-
tion of such dogs, chondropathy and synovitis have
been identified. This again illustrates the sensitivity
of arthroscopy for detection of intra-articular path-
FH
(e) ology and indicates that a small number of dogs may
develop osteoarthritic changes in the hip without
apparent osteophytosis on plain radiographs.
However, compared with the elbow joint, this sce-
CaFH nario appears to be unusual.

Radiographic silent hip pain

Minimally displaced acetabular fractures or soft tissue
injuries of the hip may also be diagnosed using
arthroscopy (Figure 13.51).
FN

13.51
CaJC
Mildly displaced
acetabular fracture
with concomitant
(f) labral tear.
(Courtesy of
J Cook)
Pathological conditions

Hip dysplasia
It is not currently widespread practice to evaluate hip
joints arthroscopically in dysplastic dogs. Holsworth
et al. (2005) reported the use of arthroscopy to
evaluate young dogs with hip laxity and pain, which
were being considered for procedures such as triple
pelvic osteotomy (TPO); traditional opinion has
indicated that dogs with pre-existing OA should not be
considered for TPO. The results indicate that
arthroscopy is more sensitive than radiography for
the detection of intra-articular pathology. However,
the significance of these arthroscopically identified
lesions with respect to the outcome of TPO is not
known at the current time. However, this study has
indicated that arthroscopy is a sensitive modality in
the hip joint.
Other uses
Occasionally the clinician may need to biopsy the
synovium of the hip joint (e.g. suspected infective or
immune-mediated arthritis, suspected neoplasia,
osteochondromatosis). However, the need for such a
procedure is very uncommon.
The stifle joint
Knee arthroscopy is the most common orthopaedic
intervention in human surgery. However, the canine
stifle is a challenging joint for the inexperienced
arthroscopist as it is relatively small and dogs are

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prone to proliferative synovitis once the stifle becomes
diseased. This hyperplastic synovium (Figure 13.52)
obscures the surgeon’s view and can be problematical
and frustrating. The infrapatellar fat pad can also
obscure the viewing window. For these reasons,
inexperienced arthroscopists are advised to master
their skills in the shoulder and elbow before taking on
stifle arthroscopy. That said, stifle arthroscopy is now
established as a standard procedure for many
orthopaedic surgeons.
13.52
Hyperplastic
synovium. This may
need removing in
order to visualize
the intra-articular
structures.
Indications
The stifle is the most common site of lameness in
dogs; many conditions of the stifle can be diagnosed
arthroscopically, and a growing number can also be
treated using arthroscopic techniques. Conditions
that can be diagnosed arthroscopically include:
• Cranial cr ciate li ament in ry
• edial meniscal in ry
• Lateral meniscal injury
• A and chondropathy
• CD
• atellar l ation
• on di ital e tensor tendon a lsion
• Ca dal cr ciate li ament in ry
• opliteal tendon a lsion
Instrumentation
For very small dogs and cats a 1.9 mm arthroscope is
used and for small dogs a 2.4 mm arthroscope works
well. However, for the majority of patients, most of
whom are medium to large dogs, a 2.7 mm arthro-
scope is used. In large- and giant-breeds some
surgeons use a 4 mm arthroscope. The larger
arthroscopes have the advantage of greater depth of
field and greater irrigation, both aspects that are
important in stifle arthroscopy.
It is very useful to have a fluid pump for stifle
arthroscopy because the fluid volumes used can be
large and positive pressure can facilitate a clear
viewing window.
An egress cannula is also very useful and in larger
dogs the authors prefer disposable plastic cannulae
with a threaded exterior surface (Figure 13.53). These
cannulae are atraumatic and retain their position in
the joint despite flexion and extension. They also
have side holes in the tip which avoid blockage by
soft tissues, and an on/off switch to allow joint
Ch13 Endo.indd 213
Chapter 13 Rigid endoscopy: arthroscopy
13.53
(a) Placement of a
disposable plastic
egress cannula into
the proximolateral
pouch of the stifle.
(b) Femoropatellar
joint space with the
patella above. The
egress cannula can
just be seen on the
left side of the
image.
(a)
(b)
distension under increased pressure. Smooth-
surfaced cannulae tend to displace from the joint
during manipulation. The cannula should be attached
to a suction tube to collect fluid.
A motorized shaver system is very useful in the
stifle joint to debride the fat pad and hyperplastic
synovium. An aggressive full radius cutting blade of
an appropriate size is used in oscillate mode at 3000
rpm. Suction tubing is connected to the shaver
handpiece to facilitate synovial tissue entering the
blade tip during the pause between oscillations.
A radiofrequency unit (bipolar or monopolar) can
also be very useful in the stifle joint but must be used
with caution. The probe can be used to remove hyper-
plastic synovium and has the advantage of simultane-
ous haemostasis during use. Some surgeons use an
electrosurgery unit for haemostasis. Other probe
heads can be used to cut or remove meniscal tissue
or debride a torn cranial cruciate ligament.
Patient preparation and positioning
The operative limb is clipped from the level of the
proximal crus to just above the tarsus. The foot and
distal limb are covered with an impervious barrier
(Figure 13.54) and the limb suspended for aseptic
preparation. The patient is positioned in dorsal
recumbency, with the operative limb upwards.
Procedure
Portal placement
The main portals for the stifle joint are craniomedial
and craniolateral either side of the patellar ligament
(Figure 13.55). Some surgeons prefer to make these
portals at the distal end of the patellar ligament but
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 Chapter 13 Rigid endoscopy: arthroscopy

femoropatellar joint space to exit the joint capsule

proximolaterally. The stick is pushed so that it
protrudes and causes the skin to tent. A scalpel blade
is then used to cut down on the stick and the stick is
pushed through the skin incision to exit. The egress
cannula is then placed over the stick and pushed into
the joint. Once the cannula tip is in the joint, the stick
is removed to leave the cannula. The cannula can
then be positioned in the lateral joint space adjacent
to the lateral femoral condyle and the long digital
extensor tendon of origin.
The arthroscope sleeve, with blunt obturator
(a) locked in place, is then inserted into the craniomedial
portal. Once in the joint, the obturator is removed and
the arthroscope inserted.
A craniolateral portal is also established as an
instrument portal and this is achieved with a stab
incision using a no. 11 blade. The arthroscope and
instrument portals are interchangeable and it is
common for the surgeon to swap back and forth
during a procedure to obtain the optimal positions for
arthroscope and instrument.

Arthroscopic anatomy
The stifle is a complex hinge joint. Although primarily
it acts as a hinge joint, the menisci allow the femoral
(b) condyle to glide during movement so that the axis of
(a) Stifle prepared and draped for arthroscopy.
rotation varies with the degree of flexion. The
13.54 femoropatellar joint space is best viewed with the joint
(b) Impermeable plastic drape used to prevent
breakdown of asepsis. in extension because this releases tension on the
quadriceps mechanism. The femorotibial joint is best
13.55
viewed in flexion. The stifle has several significant
soft tissue structures including the cranial and caudal
Model demonstrating cruciate ligaments, the menisci and the long digital
position of portals for extensor tendon of origin (Figure 13.56).
stifle arthroscopy.
A = Arthroscope
portal; E = Egress 13.56
portal; I = Instrument
Origin of the long
portal.
digital extensor
tendon.

The cranial cruciate ligament (Figure 13.57)

the authors prefer to site the portals at the mid-point
of the patellar ligament. The egress portal is placed
either proximolaterally or proximomedially using a
push-through technique.
The procedure is started by distending the joint
with 5–20 ml of Hartmann’s solution using a hypo-
dermic needle and syringe. A stab incision is made for
the craniomedial portal using a no. 11 scalpel blade.
The blade is oriented vertically to avoid damage to
the patellar ligament. A switching stick is placed into
the portal and into the joint space. With the joint in full
extension, the switching stick is pushed through the
originates on the caudolateral intercondylar region of
the femur and runs distally, cranially and medially to
insert on the craniomedial tibial plateau. The caudal
cruciate ligament originates on the craniolateral
intercondylar region of the femur and runs distally,
caudally and laterally to insert on the caudolateral
tibial plateau.
The menisci are attached to each other by the
cranial intermeniscal ligament and each meniscus is
attached to the tibia by the cranial and caudal
meniscotibial ligaments. The medial meniscus (Figure
13.58) has an additional attachment to the medial
collateral ligament.

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 Chapter 13 Rigid endoscopy: arthroscopy

13.57 Following CCL injury, particularly complete injury,

the menisci are at risk from degeneration and tearing.
Normal cruciate The medial meniscus is torn in 40–60% of stifle joints
CaCL ligament.
CaCL = Caudal
with complete CCL rupture. The lateral meniscus
cruciate ligament; rarely sustains clinically important injury although
CrCL = Cranial minor injuries are common.
cruciate ligament. The medial meniscus may sustain a variety of
types of tear (Bennett and May, 1991), some of
CrCL
which appear to be more important than others in
terms of the pain caused to the patient. The most
important medial meniscal pathology seems to be a
fold of the caudal horn of the medial meniscus
(Figure 13.59). In reality, this tear is a bucket handle
tear in which the majority of the caudal horn of the
13.58 medial meniscus forms the ‘bucket handle’ and a
(a) Flounce of small peripheral portion of the caudal horn remains
normal medial in situ. The caudal horn injury allows a significant
meniscus section of meniscal tissue to be mobile within the
(arrowed). joint. During stance phase of the gait cycle this
(b) Normal medial meniscal tissue can become displaced and trapped
meniscus
(arrowed).
causing pain.
Arthroscopic inspection of the menisci requires
some practice. The arthroscope is positioned in
the medial or lateral femorotibial joint space and the
light pole is oriented medially or laterally, respec-
(a) tively. The joint is flexed to bring the menisci into
view. The menisci should be probed, paying particu-
lar attention to the caudal horn of the medial men-
iscus to ensure that it is secure and not torn. In
addition, flexion and extension of the joint whilst
inspecting the menisci can be useful to check men-
iscal stability.

13.59
Medial meniscal
caudal horn fold.
(a) The
(b)
meniscus (M)
appears normal
until the joint is
Pathological conditions flexed. (b) After
M the stifle is flexed
Cranial cruciate ligament injury the caudal horn
Cranial cruciate ligament (CCL) injury is the most (CH) is folded
common pathology of the stifle joint and probably the cranially.
most common orthopaedic problem of dogs that (continues)
requires surgical intervention. The CCL has three
functions: to limit internal rotation of the tibia with (a)
respect to the femur; to limit cranial translation of the
tibia; and to limit hyperextension of the stifle joint.
Whilst many cases of CCL injury result in overt
instability of the stifle joint with a positive cranial draw
test, a considerable number involve either partial
tearing of the CCL or insidious pathology that can be
compensated for by periarticular fibrosis. Therefore,
there may not be an obvious cranial draw and the
clinician may require confirmation of CCL rupture.
Although some other modalities such as MRI and
ultrasonography can help in this respect, arthroscopy CH
probably has the highest sensitivity and specificity for
CCL injury. The CCL is readily inspected arthro-
scopically but should be probed with a blunt hooked
(b)
probe to ensure torn fibres are not missed.

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 Chapter 13 Rigid endoscopy: arthroscopy
13.59
(continued)
Medial meniscal
caudal horn fold.
(c, d) Treatment
with
radiofrequency
ablation.
(c)
(d)
A caudal horn tear of the medial meniscus can be
removed under arthroscopic guidance. The authors
use a variety of techniques to achieve this, depending
on the exact pathology and the size of the patient. In
larger joints, the loose meniscal tissue can be grasped
with forceps whilst small hook and push knives are
used to transect each limb of the ‘bucket handle’. In
smaller patients, forceps can be used to remove small
pieces of meniscal tissue by grasping and rotating the
forceps. Repeating this manoeuvre several times can
remove the desired amount of tissue. Alternatively, a
motorized shaver or radiofrequency probe can be
used to remove meniscal tissue, although care must
be taken to avoid collateral damage to surrounding tis-
sues. Smaller axial tears can be treated using arthro-
scopic forceps, a punch or a radiofrequency probe.
Arthroscopic medial meniscal release
Some surgeons prefer to perform medial meniscal
release in conjunction with surgical treatment for CCL
injury. It is possible to perform this technique under
arthroscopic guidance by guiding a hypodermic
needle into the medial joint immediately caudal to the
medial collateral ligament under arthroscopic
inspection. Once the hypodermic needle is in the
desired location, a no. 11 scalpel blade may be guided
alongside this needle oriented in a proximodistal
direction to avoid medial collateral ligament damage.
The blade can be viewed arthroscopically as it enters
the joint and the medial meniscus can be sectioned.
Osteochondritis dissecans
OCD occurs in the stifle in medium to large dogs but
is uncommon. The lesion is usually located either on
216
Ch13 Endo.indd 216
the medial (Figure 13.60) or lateral femoral condyles.
Dogs with stifle OCD typically present with lameness
at 4–6 months of age, with associated stifle joint
effusion. Flattening of the femoral condyle is usually
visible radiographically. Arthroscopic confirmation of
the diagnosis is usually straightforward, although
some cases have extreme synovial hyperplasia which
can limit the viewing window. The use of a motorized
shaver or radiofrequency unit may assist the surgeon
obtain a suitable viewing window.
13.60
In situ stifle OCD
lesion of the
FC medial trochlear
ridge. FC =
Femoral condyle;
OCD = OCD
lesion.
OCD
Arthroscopic treatment of OCD lesions is achieved
through a combination of craniomedial and cranio-
lateral portals, with the arthroscope and instruments
positioned in the respective portals to suit the location
of the lesion. The cartilage flap is removed, either as
a single piece or in smaller pieces, using suitably
sized grasping forceps. Following removal of the flap,
the subchondral defect is subjected to light curettage
of the margins and/or forage of the defect base. The
latter is aimed at allowing pluripotential mesenchymal
cell migration through the subchondral bed to form
repair tissue (fibrocartilage) in the defect. This can be
achieved by micropick technique or by drilling small
holes with a Kirschner wire (e.g. 0.9–1.1 mm); both
can be performed under arthroscopic guidance.
Arthroscopically assisted CCL surgery
Arthroscopic treatment of CCL rupture has not yet
become widely established in veterinary surgery. In
humans a common technique is to use either a graft
of bone–patellar ligament–bone (B–PL–B) taken from
the middle third of the patellar ligament, or a hamstring
tendon graft, and to place this under arthroscopic
guidance in a minimally invasive fashion. The smaller
size of dogs has limited such an approach, although
B–PL–B allografts have been used and placed
arthroscopically.
Recently, arthroscopically assisted suture stabili-
zation has been reported for canine CCL injury. The
technique appears to have acceptable results from
the limited published information and the authors
have used this technique in small, medium and large
dogs. However, the arthroscopic part of the surgery
is the inspection of the joint, and diagnosis and
treatment of meniscal lesions prior to a lateral suture
stabilization performed through limited incisions but
without the need for arthroscopic assistance.
4/3/08 09:47:02

The talocrural joint (tarsus)
The tarsus is a composite multiple joint consisting of
four separate joints. Only the talocrural joint is available
for arthroscopic inspection and this allows a slightly lim-
ited examination of the articular surfaces of the tibia,
fibula and talus. In addition, part of the calcaneus and
deep digital flexor tendon can also be viewed.
Indications
Indications for talocrural arthroscopy include:
• CD of the medial talar rid e
• CD of the lateral talar rid e
• CD of the distal tibia
• nfecti e arthritis
• yno ial biopsy
Instrumentation
The talocrural joint is a small and rather superficial
space and thus a small arthroscope (1.9 mm or 2.4
mm) is required. Small hand instruments are also
required for any operative arthroscopy.
Patient preparation and positioning
The limb is clipped from the mid-tibia to just above the
main pad. The foot is covered in an impervious layer
and a hanging limb preparation is performed. Bilateral
talocrural arthroscopy is possible and may be
indicated is some patients (e.g. with bilateral talar
OCD). Positioning of the patient depends on portal
selection (see below). The patient may be positioned
in ventral (plantar portals) or dorsal (dorsal portals)
recumbency, or occasionally a hanging limb position
(all portals) may be utilized.
Procedure
There are four traditional portals for the talocrural
joint: dorsolateral, dorsomedial, plantarolateral, and
Lateral Long
digital digital
extensor extensor
(a) (b)
Ch13 Endo.indd 217
Chapter 13 Rigid endoscopy: arthroscopy
plantaromedial (Figure 13.61). These can be used in
combination, although rarely all at once. Portal selec-
tion is dependent on the lesion suspected and this is
often directed by the results of imaging modalities.
For example, plain radiographs or CT examination
may reveal that an OCD lesion is located more dor-
sally on the medial ridge of the talus; in such a case,
the dorsal portals are utilized. However, if the lesion is
more plantar, the plantar portals are selected.
Dorsal portals
The patient is placed in dorsal recumbency with the
pelvic limb extended caudally. The talocrural joint
space is located dorsally with palpation and ‘trial and
error’ use of a 23 gauge hypodermic needle. Once
the joint space is located optimally, synovial fluid is
aspirated and sent for analysis if required. The joint is
then inflated with 3–8 ml of Hartmann’s solution. A
no. 11 scalpel blade is then used to make a proximo-
distally oriented stab incision at the location of the
hypodermic needle. The arthroscope sleeve with a
blunt obturator is inserted into the joint and the obtu-
rator removed prior to insertion of the arthroscope.
An instrument portal is established in the opposing
dorsal portal position. A narrow gauge hypodermic
needle is used initially to locate the optimal portal
location prior to a proximodistally oriented stab
incision to the depth of the capsule. Only small
instruments can be used and a cannula is not
recommended in such a superficial joint cavity.
WARNING
One of the major problems of talocrural
arthroscopy is the small articular space and
the superficial nature of the joint cavity. It is
very easy for the arthroscope to slip out of the
joint cavity and cause leakage of extracapsular
fluid and consequent joint collapse.
13.61 Models demonstrating
portals for tarsal
arthroscopy: (a) dorsal tarsal
portals; (b) plantar tarsal
portals. A1 and A2 = Represent
alternative suggested
Flexor
hallicus arthroscope portal sites.
longus
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 Chapter 13 Rigid endoscopy: arthroscopy

Plantar portals 13.62

The patient is placed in ventral recumbency with the
pelvic limb extended caudally. The patient needs to (a) In situ OCD
lesion on the lateral
be supported with several sandbags or a cradle to trochlear ridge.
allow the joint to be oriented such that the os calcis is (b) Synovitis
directed towards the ceiling. secondary to an
The talocrural joint space is located from a plantar OCD lesion; the
direction (medially or laterally depending on which deep digital flexor
portal is required for the arthroscope) with palpation tendon is to the left,
lateral trochlear
and ‘trial and error’ use of a 23 gauge hypodermic (a) ridge to the right.
needle. Once the joint space is located optimally, (Courtesy of B Van
synovial fluid is aspirated and sent for analysis if Ryssen)
required. The joint is then inflated with 3–8 ml of
Hartmann’s solution. A no. 11 scalpel blade is then
used to make a proximodistally oriented stab incision
at the location of the hypodermic needle. The
arthroscope sleeve with a blunt obturator is inserted
into the joint and the obturator removed prior to
insertion of the arthroscope.
An instrument portal is established in the opposing
plantar portal position. A narrow gauge hypodermic
needle is used initially to locate the optimal portal
location prior to a proximodistally oriented stab (b)
incision to the depth of the capsule. Only small
instruments can be used and a cannula is not normally sometimes necessary to perform a limited arthrotomy
useful is such a superficial joint space. to remove such large fragments.
Arthroscopic anatomy Osteochondritis dissecans of the lateral talar
As discussed, the talocrural joint may be viewed from ridge
a plantar or dorsal perspective but both give a limited This is a very uncommon condition noted very
view of the articular surfaces. Little more than the occasionally, particularly in the Rottweiler (Gielen et
articular surfaces can be inspected because of the al., 2005). The approach to arthroscopic inspection
tightness and congruity of the joint. Some parts of the and treatment is as for medially located lesions,
joint capsule can also be seen and, from the although obviously the positions of the arthroscope
plantaromedial portal, a portion of the deep digital and instrument portals are reversed.
flexor tendon can be seen.
Synovial biopsy
Pathological conditions This can be performed using any of the portals,
Osteochondritis dissecans of the medial talar although the authors prefer the plantar portals as
ridge these provide greater access to synovial tissue. Tarsal
Careful evaluation of radiographs or CT scans is a osteoarthritis is a sequelae to primary tarsal path-
prerequisite to arthroscopy of the talocrural joint for ology. Arthroscopy allows this to be graded and also
OCD of the talus. The location of the lesion in a allows for cartilage debridement when indicated
dorsoplantar direction will guide the surgeon as to (Figure 13.63).
portal selection and patient positioning:
13.63
• or dorsally located lesions the dorsal portals
are selected Tarsal OA with full
thickness cartilage
• he arthroscope is placed dorsolaterally and loss and two visible
used to inspect the joint dorsally before settling wear lines.
on a view of the medially located lesion. A
dorsolateral instrument portal is established and
small grasping forceps are used to grasp pieces
of the loose cartilage and bone
• or more plantar lesions the plantar portals are
selected but the general approach is similar.

In cases of talar OCD the lesions can contain a

significant amount of bone and can be relatively large
(Figure 13.62). Although the bone is often necrotic
and therefore rather soft, it can still be difficult to
grasp with small forceps, or the forceps may be
placed under undue strain risking damage to, or
breakage of, the pin within the instrument. It is
Acknowledgements
The authors are indebted to Mr Alan Bannister, Faculty
of Veterinary Science at the University of Liverpool,
for his valuable assistance with the preparation of
many of the figures in this chapter.

218

Ch13 Endo.indd 218 4/3/08 09:47:03


References and further reading
Barr FJ and Kirberger RM (2006) BSAVA Manual of Canine and Feline
Musculoskeletal Imaging. BSAVA Publications, Gloucester
Bennett D and May C (1991) Meniscal damage associated with cruciate
disease in the dog. Journal of Small Animal Practice 32, 111–117
Butterworth SJ and Innes JF (2001) Incomplete humeral condylar fractures
in the dog. Journal of Small Animal Practice 42, 394–398
Cook JL, Renfro DC, Tomlinson JL and Sorensen JE (2005a) Measurement
of angles of abduction for diagnosis of shoulder instability in dogs
using goniometry and digital image analysis. Veterinary Surgery 34,
463–468
Cook JL, Tomlinson JL, Fox DB, Kenter K and Cook CR (2005b) Treatment
of dogs diagnosed with medial shoulder instability using radiofrequency-
induced thermal capsulorrhaphy. Veterinary Surgery 34, 469–475
Danielson KC, Fitzpatrick N, Muir P and Manley PA (2006) Histomorphometry
of fragmented medial coronoid process in dogs: a comparison of
affected and normal coronoid processes. Veterinary Surgery 35,
501–509
Fitch RB, Breshears L, Staatz A and Kudnig S (2001) Clinical evaluation
of prosthetic medial glenohumeral ligament repair in the dog (ten
cases). Veterinary and Comparative Orthopaedics and Traumatology
14, 222–228
Frostick SP, Sinopidis C, Al Maskari S et al. (2003) Arthroscopic capsular
shrinkage of the shoulder for the treatment of patients with
multidirectional instability: minimum 2-year follow-up. Arthroscopy
19, 227–233
Gielen I, van Ryssen B and van Bree H (2005) Computerized tomography
compared with radiography in the diagnosis of lateral trochlear ridge
talar osteochondritis dissecans in dogs. Veterinary and Comparative
Orthopaedics and Traumatology 18, 77–82
Guthrie S (1989) Some radiographic and clinical aspects of ununited
anconeal process. Veterinary Record 124, 661–662
Guthrie S, Plummer JM and Vaughan LC (1992) Post natal development
of the canine elbow joint – a light and electron-microscopic study.
Research In Veterinary Science 52, 67–71
Hoelzler MG, Millis DL, Francis DA and Weigel JP (2004) Results of
arthroscopic versus open arthrotomy for surgical management of
cranial cruciate ligament deficiency in dogs. Veterinary Surgery 33,
146–153
Holsworth IG, Schulz KS and Ingel K (2002) Cadaveric evaluation of
canine arthroscopic bicipital tenotomy. Veterinary and Comparative
Orthopaedics and Traumatology 15, 215–222
Holsworth IG, Schulz KS, Kass PH et al. (2005) Comparison of arthroscopic
and radiographic abnormalities in the hip joints of juvenile dogs with
hip dysplasia. Journal of the American Veterinary Medical Association
227, 1091–1094
Houlton JEF, Cook JL, Innes JF and Langley-Hobbs, SJ (2006) BSAVA
Manual of Canine and Feline Musculoskeletal Disorders. BSAVA
Publications, Gloucester
Innes JF (2005) Laboratory evaluation of joint disease. In: BSAVA Manual
of Canine and Feline Clinical Pathology, 2nd edn,ed. E Villiers and L
Blackwood, pp. 355–363. BSAVA Publications, Gloucester
Krotscheck U, Hulse DA, Bahr A and Jerram RM (2000) Ununited anconeal
process: lag-screw fixation with proximal ulnar osteotomy. Veterinary
and Comparative Orthopaedics and Traumatology 13, 212–216
Ch13 Endo.indd 219
Chapter 13 Rigid endoscopy: arthroscopy
Li A, Bennett D, Gibbs G et al. (2000) Radial carpal bone fractures in 15
dogs. Journal of Small Animal Practice 41, 74–79
Marcellin-Little DJ, De Young DJ, Ferris KK and Berry CM (1994)
Incomplete ossification of the humeral condyle in Spaniels. Veterinary
Surgery 23, 475–477
Meyer-Lindenberg A, Fehr M and Nolte I (2006) Co-existence of ununited
anconeal process and fragmented medial coronoid process of the
ulna in the dog. Journal of Small Animal Practice 47, 61–65
Meyer-Lindenberg A, Langhann A, Fehr M and Nolte I (2003) Arthrotomy
versus arthroscopy in the treatment of the fragmented medial coronoid
process of the ulna (FCP) in 421 dogs. Veterinary and Comparative
Orthopaedics and Traumatology 16, 204–210
Mitchell RAS and Innes JF (2000). Lateral glenohumeral ligament rupture
in three dogs. Journal of Small Animal Practice 41, 511–514
Olivieri M, Piras A, Marcellin-Little DJ et al. (2004) Accessory caudal glenoid
ossification centre as possible cause of lameness in nine dogs.
Veterinary and Comparative Orthopaedics and Traumatology 17,
131–135
O’Neill, T and Innes JF (2004) Treatment of shoulder instability caused
by medial glenohumeral ligament rupture with thermal capsulorrhaphy.
Journal of Small Animal Practice 45, 521–524
Person MW (1986) Arthroscopy of the canine shoulder joint. Compendium
on Continuing Education for the Practicing Veterinarian 8, 537
Person MW (1989) Arthroscopic treatment of osteochondritis dissecans
in the canine shoulder. Veterinary Surgery 18, 175–189
Person MW (1989) Arthroscopy of the canine coxofemoral joint.
Compendium on Continuing Education for the Practicing Veterinarian
11, 930–935
Pettitt R and Clements DN (2007) Journal of Small Animal Practice 48(11),
625–630
Rudd RG, Whitehair JG and Margolis JH (1990) Results of management
of osteochondritis dissecans of the humeral head in dogs: 44 cases
(1982–1987). Journal of the American Animal Hospital Association
26, 173–178
Scholz J, Kuhling T and Turczynsky T (1992) The advantages of
arthroscopic knee surgery. Biomedizinische Technik 37, 11–13
Schulz KS, Holsworth IG and Hornof WJ (2004) Self-retaining braces for
canine arthroscopy. Veterinary Surgery 33, 77–82
Sjöström L, Kasström H and Kallberg M (1995) Ununited anconeal process
in the dog – pathogenesis and treatment by osteotomy of the ulna.
Veterinary and Comparative Orthopaedics and Traumatology 8,
170–176
Turner BM, Abercromby RH, Innes J, McKee WM and Ness MG (1998)
Dynamic proximal ulnar osteotomy for the treatment of ununited
anconeal process in 17 dogs. Veterinary and Comparative
Orthopaedics and Traumatology 11, 76–79
Van Ryssen B and van Bree H (1997) Arthroscopic findings in 100 dogs
with elbow lameness. Veterinary Record 140, 360–362
Van Ryssen B, van Bree H and Missinne S (1993a) Successful arthroscopic
treatment of shoulder osteochondrosis in the dog. Journal of Small
Animal Practice 34, 521–528
Van Ryssen B, van Bree H and Vyt P (1993b) Arthroscopy of the shoulder
joint in the dog. Journal of the American Animal Hospital Association
29, 101–105
Wolschrijn CF, Gruys E and Weijs WA (2005) Microcomputed tomography
and histology of a fragmented medial coronoid process in a 20-week-
old golden retriever. Veterinary Record 157, 383–386
219
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 Chapter 14 An introduction to laser endosurgery
14
An introduction to laser
endosurgery
David Sobel and Jody Lulich
Introduction
The theoretical concept of using light as a substan-
tial source of energy was originally hypothesized
by Albert Einstein in 1916, based on the previous
works of Neils Bohr. The term ‘laser’ is actually an
acronym, standing for Light Amplification by the
Stimulated Emission of Radiation. The first workable
experimental laser, a pulsed ruby laser, was devel-
oped in 1960 by Theodore Maiman. Medical lasers
were first introduced in the mid-1960s, but early
lasers were large, inefficient and prohibitively
expensive. The 1980s showed renewed interest in
the development of simple, cost-effective, efficient
lasers for clinical use. The 1990s allowed the
introduction of lasers into veterinary practice,
with carbon dioxide lasers becoming more and
more common.
Laser physics
A basic knowledge of optical laser physics is useful in
understanding the clinical applications of laser energy.
The essential element of a laser is the production of
light in the form of a photon. Light simply refers to a
portion of the spectrum of electromagnetic radiation.
How then is a laser different from the light that is
generated by a basic light bulb? A laser stores,
concentrates and releases its energy in a coherent
powerful manner.
Atoms resting within an appropriate lasing medium
a b
1 2
Singlet
state
Energy levels
Metastable
state
1 2
Ground
state
1 2
Time
220
Ch14 Endo.indd 220
(e.g. diodes, holmium–YAG, carbon dioxide, ruby
and garnet) are, for the most part, in a ground state of
energy (Figure 14.1a). Statistically, at any one point in
time some of them are moving between high and low
energy states. When energy, in the form of electricity,
is applied to the lasing medium, more atoms are
excited and move to a higher energy state. Specifically,
atoms move to the higher and much less stable,
singlet state (Figure 14.1b). As the singlet state is so
unstable, the atoms rapidly return to the more stable,
metastable state (Figure 14.1c). Atoms then sponta-
neously drop back to the stable ground state. In this
rapid random return to the lower energy state, energy
is lost in the form of a photon. This photon stimulates
another atom to return to the ground state, emitting
another photon (Figure 14.1d). This sequence
produces a photon cascade.
When this process is performed within a laser
optical chamber, with a partially reflective medium at
one end of the lasing chamber, and a completely
reflective material at the other, a coherent,
monochromatic light is produced (Figure 14.2). As
light travels in waves, the wavelength and frequency
of the cycles are the variables that give a particular
laser light its individual characteristics. These vari-
ables are unique to the lasing medium (e.g. carbon
dioxide, helium, argon, gold and ruby). A series of
lenses and delivery systems transmit the photons that
escape the lasing chamber in a focused, controlled
and direct manner, to the desired source.
14.1 (a) Atoms resting in a
c d ground state of
energy. (b) When bombarded
with electrons (electricity),
atoms move from a ground state
to a singlet state of energy.
(c) When excited, atoms drop
from the singlet state to the
metastable state of energy. This
change in state results in the
loss of energy in the form of a
photon. (d) If a photon collides
with a metastable atom as it is
dropping to the ground state
1 2 (which invariably happens),
energy is lost in the form of a
photon. = Photon.
4/3/08 09:47:21
 Chapter 14 An introduction to laser endosurgery

Power supply

Flash
Ruby crystal lamp
Al2O2 + Cr2+

Laser
beam 14.3 Diode laser equipment. (Courtesy of Diomed
Ltd)

of the laser, the time of the pulsed wave, and the

100% silvered Partially silvered
reflective end reflective end
interval between pulses (if an intermittent mode is
selected). A red emergency override switch is usually
14.2 Laser optical chamber. The power supply prominent on the front panel. Buttons allowing the
pumps energy, in the form of electrons, through operator to choose the operational mode and a ready/
the lasing medium. There is a fully reflective surface at standby function are also present. The LED display
one end of the chamber and a partially reflective surface
at the other end. The release of the photons within the
panel contains the main functional menu of the
chamber produces a bright, intense, high-energy microprocessor, and allows the operator to perform
monochromic light. many maintenance, set up and control functions. The
rear of the unit has portals for the foot pedal and for a
‘deadman’ switch that can be connected to the
Instrumentation operating theatre door, to automatically shut off the
laser (see Laser safety).
The most commonly used laser in veterinary medi- Diode fibres consist primarily of a solid quartz
cine is the carbon dioxide laser. These efficient, core, insulated and sheathed, with an optical lens at
economical and highly effective lasers are excellent one end, which inserts into the laser aperture, and the
for general surgical use. However, the underlying operative end, which is available in several different
physics of these lasers means that their use in endo- tip shapes and sizes (Figure 14.4). The long flexible
scopic applications is limited. Most medical carbon fibres (Figure 14.5) can be inserted into a variety of
dioxide lasers emit light in the 1020–1090 nm range. different rigid and flexible endoscopes and sheaths/
This has advantages in that the depth of penetration cannulae, as well as into handpieces for standard
of these lasers, assuming the same power output, is open surgical use. The contact mode tips can be
limited. However, light in this range is highly attenu- either flat, conical or orb shaped, whilst the non-
ated by water and other fluid media and is poorly contact fibres have a flat bare end (Figure 14.6). The
absorbed by biological pigments. This makes the use fibres are available in a variety of diameters, from
of carbon dioxide lasers for endoscopic applications
involving fluid irrigation and haemorrhage extremely
limited. In addition, the delivery systems, whilst pro-
prietary in nature, usually involve some form of either
hollow semi-rigid internal reflective tube or a series of
articulated arms using a series of mirrors. These
delivery systems make transmitting the light into
endoscopes and related equipment very difficult. 14.4 Flat bare fibre non-contact laser tip.
By comparison, diodes, emitting light in the
810–980 nm range, are attenuated very little by
water or other fluids and are highly absorbed by
biological pigments. This effect is maximized at
810 nm, providing an increased thermal effect with
less energy input. Additionally, the fibreoptic delivery
systems are ideal for use with the operating channels
of both rigid and flexible endoscopes.

Diode laser systems

The diode laser systems available for veterinary
clinical use are simple, compact and easy to operate.
The units generally consist of a metal cabinet box
housing the laser and the microprocessor for unit
control, an aperture from which the laser light exits,
and a control foot pedal (Figure 14.3). The dials on
14.5 Laser fibres.
the front of the instrument control the power (wattage)

221

Ch14 Endo.indd 221 4/3/08 09:47:22

 Chapter 14 An introduction to laser endosurgery

(a)

14.6 Optical fibres. (a) Sculpted fibre tips. Top: Conical

tip. This is used for precise, delicate procedures
requiring a fine incision. Bottom: Orb tip. This is used for a
broader incision in vascular tissue. (b) Contact and non-
contact fibres. Top: Bare flat-end fibre. This is used for both
contact and non-contact procedures. Bottom: Non-contact fibre
(water- or air-cooled). This is used for gastroenterology and (b)
pulmonary applications. (Courtesy of Diomed Ltd)

400 µm to 1000 µm, which facilitate insertion into a
variety of endoscopes and surgical locales. The fibres
are designed for single use, but can be either gas
sterilized or soaked in glutaraldehyde (see Chapter
2). Should fibre tips fracture or break, they can be
refashioned using a simple fibre stripper and cleaver.
Contact and non-contact modes
The diode fibre can be used in direct apposition
to the tissue (contact mode) or at a distance from
the tissue (non-contact or free-beam mode). In the
contact mode, the diode fibre, coated with a thin
layer of carbon (either from a manufacturing pro-
cess or via the process of ‘charring’), uses the laser
energy to heat the tip of the fibre. As the tip of
the fibre contacts the tissue, the laser heats the fibre
tip, creating a thermal tip effect. This hot fibre tip
can be used to excise, incise and vaporize tissue.
The tissue immediately around the tip is vaporized,
and a well controlled zone of thermocoagulation
provides excellent haemostasis. Minimal lateral
damage from the laser is encountered (usually within
300–600 µm), giving a well controlled surgical effect.
Blood vessels of up to 2 mm in diameter can be
sealed and cauterized.
In the non-contact mode, the beam is directed
towards the tissue from a distance. As the broader flat
beam contacts the tissue, high localized temperatures
create excellent tissue vaporization with a broader
and potentially deeper margin of coagulation. Using
both variable power and time settings, different tissue
effects can be achieved: less power over more time
will produce a greater coagulation effect, with rela-
tively less tissue vaporization. Conversely, as the time
is decreased and the power increased, a small focal
area of tissue is ablated.
For surgical procedures in which careful control of
surgical effect is of paramount importance, the contact
mode is of greatest benefit. For situations where
larger amounts of tissue need to be vaporized, with
good control of haemorrhage, the non-contact mode
is preferred (Figure 14.7).

High power Low power

Carbonization
Damage vaporization Coagulation
Oedema

Coagulation

Irreversible

Reversible Oedema
Vaporization
Coagulation
(b)

14.7 Tissue interaction with non-contact fibres. (a) Light emitted at

810–900 nm is highly absorbed by haemoglobin and melanin, and
generates high temperatures at the tissue surface. This results in rapid
vaporization with underlying coagulation of up to 3 mm. (b) The effects of
high power (left) and low power (right) on the surrounding tissue.(Courtesy of
Diomed Ltd)
(a)

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Ch14 Endo.indd 222 4/3/08 09:47:25


Laser safety
There are several specific areas of safety that need to
be considered when using lasers in the operating
theatre. Training of operating room personnel in the
proper use and care of lasers and in patient care is
essential. Proper eyewear is necessary to protect the
eyes of all personnel present in the room. This
eyewear can be obtained from equipment manufac-
turers and is specific to the particular wavelength of
light. Whilst the risk from direct laser exposure is
greater than when visualized on a video monitor dur-
ing endoscopic surgery, eye protection should be in
use at all times.
To avoid accidental laser scatter and the resultant
thermal damage, it is necessary to take care that instru-
ments used in laser surgery are either specially coated
with a non-reflective surface that will not scatter the
beam, or kept well away from the beam. A moistened
surgical sponge should be kept covering adjacent tis-
sues to minimize accidental thermal damage. The foot
pedal operating the laser should be kept only in the
reach of the foot of the intended operator, and should
be covered with a safety case to avoid accidental step-
ping and firing. In addition, whenever the laser is not in
active use it should be turned off or, if during a proce-
dure, placed in standby mode. Flammable (alcohol)
antiseptics should be avoided during the preparation of
the skin and other surfaces for surgery.
Flammable anaesthetic gases should be avoided,
and care should be taken to ensure that there are no
oxygen leaks present in the anaesthetic lines to the
patient and within the anaesthetic machine. Specially
coated endotracheal tubes are available but it is
adequate to ensure that the endotracheal tube cuff is
well inflated, and that the tube is covered in saline-
soaked gauze sponges if the surgical site is in or
around the oral cavity. Many lasers come equipped to
hook up a ‘deadman’ switch to the door. This means
that if a person were to enter the room during the use
of the laser, the machine would automatically trip off.
These devices are rarely used in veterinary medicine,
but the door of the operating theatre should be posted
with a ‘Laser in Use’ sign, stating the specific
wavelength in use and instructing those entering to
wear protective eyewear. Local health and safety
regulations should always be consulted as required
and adhered to.
Laser surgery does produce smoke, and this
vapour does contain potentially toxic materials.
Infectious materials as well as potentially viable
cellular DNA can be present. This produces the
theoretical risk of disease transmission. The risk of
specific disease transmission from veterinary patients
is probably substantially less. However, prudence
suggests exposure to these agents is minimized
wherever possible. A smoke evacuator vacuum
should be used to ensure that plume does not enter
the operating theatre air, and personnel present in the
operating theatre should wear facemasks designed to
remove particulate matter present in laser vapour.
Consultation with appropriate governmental
agencies regarding the safe and legal use of all laser
equipment is advised for all practices.
Ch14 Endo.indd 223
Chapter 14 An introduction to laser endosurgery
Selection
Prior to beginning laser endosurgery, the operator
must be familiar both with basic diagnostic endoscopy
of the particular area of interest and with lasers in a
surgical setting. Depending on the particular surgical
procedure to be performed, the veterinary surgeon
should carefully select the appropriate endoscope.
Flexible fibreoptic endoscopes for most gastrointesti-
nal (GI) and tracheal lesions are standard. Rigid
endoscopes and appropriately selected cannulae are
used for nasal, sinus and lower urinary tract surgery
as well as for thoracoscopy and laparoscopy. All
endoscopic work is performed under video guidance,
as the larger field of view and distance from the oper-
ative site make the procedures easier and cleaner.
However, if an operator is familiar and comfortable
using the oculus of the endoscope rather than a cam-
era, this is acceptable provided appropriate protective
eyewear is used.
The size and type of fibre used is often dictated by
the size and type of endoscope. Different instrument
channels can accommodate fibres of up to 1000 µm
but more commonly 400 µm or 600 µm fibres are used.
Orb tip contact fibres are often too large to fit through
the instrument channels of endoscopes but can be
used in the pleural and peritoneal spaces. It is impor-
tant to make sure that all fibres used in laser endo-
surgery are well insulated and that the instrument
channels are intact, by performing a leak test prior to
use. This will ensure that the endoscope is not dam-
aged by leakage of thermal energy from the laser.
Mass resection
Nasal
The operator has a choice of either flexible or rigid
rhinoscopes to use for nasal mass resection (Figure
14.8). As discussed in Chapter 8, rigid rhinoscopy is
preferable with the exception of addressing lesions at
the posterior nares/choanae, in which case a flexible
endoscope using the ‘J’ manoeuvre over the soft pal-
ate, transorally, can be performed. The fibre used is
dictated by the type and size of the endoscope used.
A right-angle fibre is also useful. If it is not possible to
delineate the points of attachment of the mass, which
is often the case, the fibre can be used in a sort of
‘interstitial mode’. The fibre is inserted into the interior
of the mass and in the short pulse intermittent mode,
using power up to 15 W, as much tissue as possible is
ablated. It is important to bear in mind that the thermal
necrosis that ensues may mean that tissue is not
removed at the time or at surgery, but rather that the
tissue may slough over a period of time. Even if clean
surgical margins are not reasonable to obtain, the
nasal lumen can often be opened up and masses
debulked to the point that the animal’s clinical situation
is dramatically improved. The frontal sinus can be
addressed as well by trephining into the sinus with
either a Steinmann pin or a Michel trephine, and using
the laser to ablate neoplastic tissue within the sinus. If
the communication between the frontal sinus and the
nasopharynx is closed due to neoplastic disease, the
laser can be very useful in re-establishing patency.
223
4/3/08 09:47:25
 Chapter 14 An introduction to laser endosurgery
14.8
Nasal mass resection.
Alimentary tract
Polypoid masses can often be resected en bloc and
diffuse or circumferential masses can be partially
resected or debulked endoluminally (Figure 14.9). It
is important that the clinician knows the approximate
thickness of the lesion to ensure that accidental bowel
perforation does not occur. Selection of the appropriate
size fibre is dictated by the size of the endoscope and
channel, but a conical contact fibre or a right-angle
fibre is often useful. With the laser in continuous
contact mode, the operator should attempt to free the
224
Ch14 Endo.indd 224
mass at the base of its attachments if possible, or to
ablate the tissue in a free beam mode. Power at
8–15 W is often necessary, with special care being
taken to ensure that the depth of penetration of the
laser is controlled. Tissue specimens for biopsy, if not
taken preoperatively, should be taken before the
actual resection is attempted.
Lower urinary tract
Whilst the current use of diode lasers in veterinary
medicine does not usually offer the possibility of cura-
tive laser surgery for bladder and urethral tumours,
more often than not masses can be debulked and the
clinical effects of the mass lesions mitigated. A rigid
2.7 mm 30 degree or a 4.0 mm 30 degree cytoscope/
sheath is usually used for transurethral urethro-
cystoscopy (see Chapter 10). These devices will
accommodate a 1000 µm fibre. For male cystoscopy,
a small-diameter endoscope is necessary, mandating
at best a 400 µm fibre. Dogs (males) and cats (both
sexes) can also be approached using the technique
of laparoscopic-assisted cystoscopy (see Chapter
11). If the basal stalk of a lesion can be identified, an
attempt should be made to remove it at its point of
origin (Figure 14.10). Inflammatory polyps can be
resected in this manner. If this is not possible, the
14.9
Pre-, intra- and
postoperative images of
laser resection of a
colonic adenocarcinoma.
Note the use of a right-
angled fibre. The beam
leaves at a right angle to
the long axis of the fibre.
14.10
Intra- and postoperative
images of laser resection
of a urethral transitional
cell carcinoma. Not the
use of a sculptured
pointed tip fibre, allowing
the surgeon to perform
more delicate tissue
vaporization.
4/3/08 09:47:26
 Chapter 14 An introduction to laser endosurgery

fibre should be used in contact mode to ablate tissue
focally and facilitate dehiscence. Care must be taken
to avoid perforation of either the urethra or the blad-
der. Power up to 15 W may be needed. A urinary
catheter is usually left in place for a day or two follow-
ing this procedure to allow the surgical site to heal.
Laparoscopy and thoracoscopy
The laser can be used during laparoscopic surgery to
debulk tumours, laser adhesions, cut ovarian pedicles
during ovariohysterectomy, and perform interstitial
therapy of solid organ lesions. A specially designed
fibre housed in a laparoscopic cannula can be used,
or a fibre can be inserted via a laparoscopic cannula.
This 1000 µm contact fibre is used with power up to
15 W. In the chest, the laser can be used during
thoracoscopic pericardectomy to debulk thoracic
masses or to aid in adhesionolysis.
Transurethral laser lithotripsy
Use of lasers for transurethral lithotripsy is a relatively
new concept. In 1968, investigators first reported in
vitro fragmentation of uroliths with a ruby laser
(Mulvaney and Beck, 1968). However, because the
fragmentation of stones was associated with genera-
tion of sufficient heat that would likely damage adja-
cent tissues, it could not be used to treat patients.
Likewise, use of carbon dioxide laser energy was con-
sidered to be unsuitable for clinical use because it
could not be delivered through non-toxic fibres and via
a suitable medium for urethrocystoscopic procedures.
However, in 1986 researchers using a 504 nm, pulsed
dye laser treated human patients with ureteroliths suc-
cessfully and safely. The holmium–YAG laser is one of
the newest devices available for clinical lithotripsy.
The mechanism of stone fragmentation with the
holmium–YAG laser is mainly photothermal, and
involves a thermal drilling process rather than a
shockwave effect (Razvi et al., 1996). Holmium–YAG
laser energy is transmitted from the crystal to the
urolith via a flexible quartz fibre. To achieve optimum
results, the quartz fibre tip must be guided with the aid
of a cystoscope so that it is in direct contact with the
surface of the urolith.
Performing transurethral laser lithotripsy
in bitches and queens
Laser lithotripsy is performed via urethrocystoscopy
in anaesthetized patients (Figure 14.11). Although
patient positioning is often the choice of the operator,
bitches and queens tend to be positioned in dorsal
recumbency. A rigid cystoscope is passed retrograde
into the vestibule and through the urethral lumen to
allow visualization of urocystoliths. The urinary tract is
lavaged with sterile warm normal saline, and then
refilled. During lithotripsy continuous irrigation is
provided to flush urolith debris and fragments from
the visual field as stones are fragmented, and to
absorb stray laser energy.

(a) (b)

(c) (d) (e)

14.11 (a) Lateral abdominal radiograph of a spayed 10-year-old Miniature Schnauzer bitch with radiopaque densities
in the caudal abdomen. (b) To confirm the location, size and contour of the abdominal radiopaque densities, a
double contrast cystogram was performed. The dark structures in the centre of the urinary bladder are urocystoliths.
(c) Cystoscopic view of uroliths in the lumen of the bladder after initiation of laser lithotripsy. A 365 µm diameter flexible
quartz laser fibre is positioned near the surface of the urolith, creating a crater in the stone. (d) Double contrast cystogram
after transurethral lithotripsy and voiding urohydropropulsion to remove urolith fragments. The radiograph is consistent with
complete urolith removal. (e) Urolith fragments. The uroliths were composed of 100% calcium oxalate.

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 Chapter 14 An introduction to laser endosurgery
Laser energy is delivered via a quartz lithotripsy
fibre that is passed through the working channel of
the cystoscope. The fibre tip is guided with the aid of
a cystoscope, so that its tip is in direct contact with the
surface of the urolith. A foot-operated switch activates
release of energy from the lithotriptor. The laser
energy selected will vary depending on urolith size
and location; however, initial settings to fragment
most uroliths have been between 0.5 and 0.7 J at 5 to
7 Hz. The energy of the laser can be adjusted for
efficiency based on operator experience and desired
fragmentation process.
Once uroliths have been sufficiently shattered,
such that they are small enough to pass through the
urethra, fragments can be removed by a variety of
methods. Larger fragments are initially removed with
a stone basket to verify that they are of a sufficiently
small size to pass unimpeded through the urethra. If
larger fragments are safely retrieved, continued
removal using a stone basket or voiding urohydropro-
pulsion can be performed to evacuate the remaining
pieces (Figure 14.11e).
In some instances, bladder inflammation and
trauma during lithotripsy result in extravasation of
blood and subsequent clot formation. If the clot
adheres to the bladder wall and entraps minute stone
fragments, complete urolith evacuation in unlikely. In
the author’s [JL] experience, blood clots detach within
24 hours. At that time, residual stone burden can be
removed by voiding urohydropropulsion or allowed to
pass spontaneously during routine voiding.
Performing transurethral laser lithotripsy
in male dogs
In male dogs, the size of the os penis and flexure of
the male urethra limit the size and deflectability of
cystoscopes that can be introduced into the urinary
bladder. However, small-diameter (7.5 Fr) flexible
endoscopes used for evaluation of human ureters
pass easily through the urethra of most dogs weighing
more than 6–8 kg. It is usually more efficient and
effective to capture bladder stones with a basket and
place them in the urethra prior to fragmentation.
Urethroliths are more readily fragmented because
their movement out of the laser field is inhibited by
(a)
14.12 (a) Lateral abdominal radiograph of a neutered 9-year-old male Labrador Retriever with radiopaque uroliths in
the distal urethra. (b) A Foley catheter was positioned with its balloon proximal to the urethroliths. Inflating the
balloon prevented the urethroliths and urolith fragments from migrating into the urinary bladder during lithotripsy.
226
Ch14 Endo.indd 226
the small size of the urethral lumen. To prevent
urethroliths from travelling back into the bladder
during lithotripsy, the urethra proximal to the stone
should be occluded. This can be accomplished by
inserting a gloved index finger into the rectum and
firmly pressing the urethra against the ischium. In
some cases, the distensible balloon of a Foley
catheter can be placed transurethrally proximal to
the urethral stones (Figure 14.12). Distending the
balloon will occlude the urethra. The very small
diameter of the urethra in male cats prohibits
application of transurethral laser lithotripsy.
Potential complications
It is logical to question whether or not lasers capable
of shattering stones would likely damage the urinary
tract. Because laser energy is delivered in a pulsed
fashion and readily absorbed by water, complications
are rare, rapidly reversible or clinically unimportant
(Figure 14.13). Continuous irrigation of the urinary
bladder during lithotripsy quickly absorbs and
disperses stray energy. Under these conditions the
thermal effect of the holmium laser is localized to
within approximately 1 mm of the laser fibre tip. In a
prospective study of 598 human patients with kidney
or ureteral stones fragmented by laser lithotripsy,
complications were observed in only one patient
(ureteral trauma) (Sofer et al., 2002). These results
suggest that when properly used, laser lithotripsy can
be safely used in dogs and cats.
Conclusion
The laser can be an important addition to the surgi-
cal offerings of all small animal practitioners. This
cutting edge technology allows the veterinary sur-
geon to offer clients and patients a safe, painless
and more effective alternative to traditional surgery
in many cases. Clients with increased medical
knowledge are aware of these new technologies in
human medicine, and the veterinary profession is
in the enviable position of being able to offer these
technologies in a cost-effective and medically effec-
tive manner.
(b)
4/3/08 12:40:17
 Chapter 14 An introduction to laser endosurgery

Complication Occurrence Avoidance

Bladder rupture Rare Bladder perforation is possible during excessive or forced over-distension with fluid, or by direct trauma via
careless advancement of cystoscopes. Monitoring bladder fullness and cystoscope position will minimize
iatrogenic trauma even in bladders with pre-existing weakness
Bladder perforation can also occur when incorporating voiding urohydropropulsion to remove urolith fragments.
Keeping the size and volume of urolith fragments to a minimum, and ensuring adequate anaesthesia to promote
complete urethral relaxation, will minimize intravesicular pressure during manual compression. If the integrity of
the bladder wall is questionable, the urolith fragments should be removed with a stone retrieval basket

Cyanide Rare Thermal decomposition of uric acid to cyanide can occur during lithotripsy. However, attempts to detect cyanide in
production the effluence during lithotripsy of uroliths composed of purines have been unsuccessful. Nonetheless, continuous
irrigation of saline and frequent evacuation of the urinary bladder during lithotripsy is recommended to prevent
cyanide from potentially accumulating to harmful concentrations

Mucosal Common Haemorrhage obscures working visibility. In addition to strategies recommended to minimize urethral swelling,
haemorrhage lower laser power settings (0.6 J and 6 W) should be used to minimize urolith recoil during fragmentation

Mucosal Rare Mucosal perforation is rare because holmium–YAG laser energy is delivered in 350 µs pulses and is quickly
perforation dispersed in the fluid surrounding the tip of the laser fibre. Care should be taken to ensure that the laser is
activated only when the fibre is in contact with the surface of the stone. This will avoid urothelial perforation

Retention of Common Urolith fragments approximately 0.5 mm or less in diameter can become trapped in blood oozing from and
small urolith attached to denuded urothelium. If not passed, fragments may serve as a nidus for future uroliths. Voiding
fragments urohydropropulsion 24 hours or longer following lithotripsy is often sufficient to completely evacuate the bladder. In
some cases, these minute fragments will spontaneously pass during routine urine voiding

Urethral Rare Complete obstruction is rare because irregular-shaped fragments are unlikely to form an occlusive seal within the
obstruction urethral lumen. However, urethral obstruction may occur when a large number of fragments are voided through the
urethra simultaneously. If this occurs, the laser should be used to break up the fragment conglomeration and
reduce fragment size. If anticipated, a portion of the fragments can be removed with a stone basket prior to voiding
urohydropropulsion

Urethral Common Urethral swelling impedes evacuation of uroliths and increases the likelihood of urethral obstruction. The degree of
swelling swelling is proportional to the frequency with which cystoscopes are passed and urolith fragments removed
through the urethral lumen. To minimize this complication, well lubricated endoscopes should be passed gently,
endoscopes with a smaller working diameter than the urethra should be chosen, the stones should be fragmented
into smaller fragments before removal, and any infections should be corrected prior to lithotripsy. If urethral
obstruction is eminent, a short period (24 hours) of continuous transurethral catheterization should be considered
until the swelling subsides

14.13 Potential complications of transurethral laser lithotripsy.

References and further reading

Mulvaney WP and Beck CW (1968) The laser beam in urology. Journal 156, 912–914
of Urology 99, 112–115 Sofer M, Watterson JD, Wollin TA et al. (2002) Holmium:YAG laser
Razvi HA, Denstedt JD, Chun SS and Sales JL (1996) Intracorporeal lithotripsy for upper urinary tract calculi in 598 patient. Journal of
lithotripsy with the holmium:YAG laser. Journal of Urology Urology 167, 31–34

227

Ch14 Endo.indd 227 4/3/08 12:40:17

 Index

Index

Numbers in italic type indicate figures Bacteraemia after GI endoscopy Cameras 24

71–2 Cannulae 19, 20–1
Acetabular fracture 212 Bacterial rhinitis/sinusitis 122 for arthroscopy 191, 213
Adenocarcinoma Balloon dilation, oesophageal for laparoscopy 161
colonic 81 stricture 64 for thoracoscopy 176
laser surgery 224 Benign mucosal antral polyp 59 Carbon dioxide lasers 221
gastric 60 Benign nasal polyp 127 Carcinoma, gastric 60
intestinal 61 Biceps rupture 201–2 Cardia 51
nasal 124–5 Bicipital tenosynovitis 201 Carpal chip fracture 210
Aiming device for arthroscopy 193 Biopsy Carpal synovitis 210
Allergic rhinitis 122 in arthroscopy 218 Carts 27, 30
Anaesthesia in bronchoscopy 92 Cervical abnormalities 154
for arthroscopy 194 in colonoscopy 75 Cervical catheterization 156
for bronchoscopy 97–8 in duodenoscopy 53–4 Cholecystectomy 173
for colonoscopy 76 in gastroscopy 52 Cholesteatoma 139
for endosurgery 97–8 in flexible endoscopy 39–41 Chondrosarcoma, nasal 125–6
for laparoscopy 159 forceps 16, 21, 40, 75 Client education 7
for respiratory tract endoscopy intestinal 43 Coagulating electrode 16
86–7 laparoscopic 162–5 Coccidioidomycosis 95
for rhinoscopy 98, 114 in oesophagoscopy 49 Colitis 79–80
for thoracoscopy 98, 177–8 in otoendoscopy 137 Colonic neoplasia 81
for upper GI endoscopy 48 in rhinoscopy 116–17, 119–20 laser surgery 224
Analgesia for arthroscopy 194 in thoracoscopy 179–80 Colonic vascular ectasia 82
Antrum 50–1 in urethrocystoscopy 146 Colonoscope, use in oesophagus
Arthroscopes 19, 189–90 Bipartite biceps tendon 197 54–5
for the carpus 209 Bougienage, oesophageal stricture Colonoscopy
for the elbow 202 dilation 64 anaesthesia/sedation 76
for the hip 210 Brachycephalic airway obstruction biopsy 75
sheaths 20 syndrome (BOAS) 94 indications 73–4
for the shoulder 195 Bradycardia after GI endoscopy 71 instrumentation 74–5
for the stifle 213 Breeding time assessment in the normal findings 77–8
for the tarsus 217 bitch 154–6 patient positioning/preparation
Arthroscopy Bronchoalveolar lavage 91 76–7
anaesthetic considerations 194 Bronchoscope controls/handling 35 procedure 77–9
analgesia 194 Bronchoscopy/Tracheobronchoscopy Constipation 82
carpus 209–10 flexible Cruciate ligament injury 215–16
elbow 202–3 biopsy 92 Cryptorchidism 170–1
hip 210–12 complications 95–6 Cystitis 152
indications 188 contraindications 85 Cystoscopes 18, 19
instrumentation 24, 26–7, indications 84 Cystoscopy
189–93 instrumentation 85–6 laparoscopic 171–3
patient preparation/positioning normal findings 88, 89, 90 transabdominal 147
193–4 postoperative care 95 (see also Urethrocystoscopy)
postoperative care 195 procedure 87–90 Cystostomy tube placement 147
preoperative work-up 188–9 rigid Cystourethroscopes 145
shoulder 195–8 anaesthesia/sedation 97–8 Cytology brush 16, 85
stifle 212–15 Brush cytology
tarsus 217–18 bronchial 91, 92
Aspergillosis 121 equipment 16, 85 Diaphragmatic hernia 182
topical therapy 127–30 flexible endoscopy 39 Digital imaging 25–6
Aspiration/lavage catheter 85 Diode laser systems 221–2
Disinfection of instruments 29
Dislodger 16
Duodenal biopsy 53–4

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Duodenal foreign bodies, removal
63
Duodenoscopy
indications 46
normal findings 56–7
procedure 52–4
Duodenostomy tube placement 166
Ear
abnormalities 136–9
cleaning/flushing 133–5
complications 140
normal appearance 135
Electrosurgical equipment 26
Empyema, tympanic bulla 139
Endometrial disease 154
Endoscopes
care/cleaning 28, 32
disinfection 29
flexible 11
for colonoscopy 74–5
comparison with rigid 9
controls 34–6
for GI endoscopy 46–7
handling 32, 33–4
instruments 15–16
for rhinoscopy 114, 117
selection 14–15
structure 12–13
for tracheobronchoscopy 85,
86
for urethrocystoscopy 144,
145
video versus fibreoptic
13–14
history 1–5
hybrid 86
light sources 21–3
rigid
for colonoscopy 75
comparison with flexible 9
for endosurgery 99–100
handling 100
instruments 19–21
for laparoscopy 99–100
for proctoscopy 75
for rhinoscopy 117
selection 18–19
structure 17–18
for thoracoscopy 99–100,
175–6
for urethrocystoscopy 145
for vaginoscopy 147
viewing angles 17
semi-rigid 18
sterilization 29
storage 29–30
(see also specific scopes)
Endoscopy, basic technique
flexible
handling/care of equipment
33–4, 37–8
health and safety 31
patient considerations 31–2
preparation 33
record keeping 41
sampling 39–41
rigid
health and safety 97
Index Endo DIGITAL.indd 229
Index
insufflation 98–9 Gastric biopsy 52
patient preparation/ Gastric dilatation, after gastroscopy
positioning 98 71
(see also specific procedures) Gastric foreign bodies 62
Endosurgery removal 63
anaesthetic considerations 97–8 Gastric neoplasia 59, 60
closure 107 Gastric over-distension 71
future developments 9–10 Gastric ulcers/erosions 59, 60
haemostasis 102 Gastritis 59, 60
health and safety 97 Gastrointestinal perforation 71
instruments 99–100 Gastrointestinal tract
insufflation 98–9 laser surgery 224
irrigation 102 lower
knot tying biopsy 75
extracorporeal 103–104 indications for endoscopy
intracorporeal 104–107 73–4
laser 223–7 instrumentation 74–5
patient positioning 100 patient preparation/
port placement 100–1 positioning 76–7
postoperative care 107–8 procedure 77–9
procedure 101–2 upper
sampling 103 complications 71–2
suction 102 contraindications to
tissue dissection 102 endoscopy 46
(see also specific procedures) indications for endoscopy
Enemas 76, 82 42–6
Enteritis 61 instrumentation 46–7
Enteroscopes 47 patient preparation/
Eosinophilic colitis 80 positioning 47–8
Eosinophilic enteritis 61 procedure 48–54
Ergonomics 28, 36 (see also specific conditions and
procedures)
Gastropexy 167
‘ alse middle ear’ 38 Gastroscopes 3, 12, 13, 34–6, 47
eeding tubes see Duodenostomy, Gastroscopy
Gastrostomy, Jejunostomy indications 45
ibrescopes normal findings 56
comparison with video- procedure 49–52
endoscopes 13–14 theatre set up 28
history 4 Gastrostomy tube placement 65–70,
ibrosing pleuritis 8 166
ine-needle aspiration, flexible Granulomatous colitis 80
endoscopy 39
lexible endoscopes see
Endoscopes and specific scopes Haemorrhage
luid management systems for after biopsy 173
arthroscopy 193 in GI endoscopy 39, 71
orceps in rhinoscopy 119, 130
biopsy 16, 21, 75 Haemostasis in endosurgery 102,
grasping 16, 21, 191, 192 168
oreign bodies Half hitch knot 107
duodenal 63 Halogen light sources 22
gastric 62 Hand drill, arthroscopy 191, 192
nasal 122–3 Hasson technique 161
nasopharyngeal 121 Health and safety
oesophageal 58, 59 ear flushing 133
otic 137 endosurgery 97
removal flexible endoscopy 31
nasopharyngeal 117 lasers 223
tracheobronchial 95 Hiatal hernia 58
upper GI tract 62–4 Hip dysplasia 212
ractures Hip pain 212
acetabular 212 Histiocytic colitis 80
carpal 210 Hypertrophic pylorogastropathy 59,
humeral 209 60
ragmented medial coronoid process Hysteroscopy 149
( CP) 2 4–
riction brakes 3
rontal sinus exploration 2 Ileocaecocolic junction 78
undus 5 Ileoscopy, indications 46
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30/04/2013 09:23
 Index

Incomplete ossification history 3, 4–5 Nasal masses 123–7

caudal glenoid 199 instrumentation 158–9 laser resection 223–4
humeral condyle 208–9 insufflation 99 Nasopharyngeal polyps 126–7
Inflammatory bowel disease 60, 61, Hasson technique 161 Nasopharyngeal stenosis 121–2
79–80 Veress needle technique Neoplasia
Instrument channels 12 160–1 colonic 81
Instrumentation laser surgery 225 duodenal 60, 61
for arthroscopy 189–93 port placement 100–1, 161–2 gastric 59, 60
elbow 202 for intestinal biopsy 165 nasal 123–27
hip 210 for liver biopsy 163 oesophageal 59
shoulder 195 postoperative care 107–8 otic 136–7
stifle 213 procedure 101–2, 162 pulmonary 181
tarsus 217 suction/irrigation 102 urethral 136
for flexible endoscopy 15–16 surgical approaches 159–60 vaginal 154
for foreign body removal 62–3 theatre set up 28 (see also specific tumours)
for haemostasis 102 (see also specific surgical
for laparoscopy 158–9 procedures)
for laser endosurgery 221–2 Laryngeal paralysis 88 Oesophageal diverticulum 58
for otoendoscopy 131–2 Lasers Oesophageal foreign bodies 59
for rhinoscopy 114 carbon dioxide 221 removal 62
anterior 117 diode 221–2 Oesophageal neoplasia 57, 59
caudal 115 health and safety 223 Oesophageal stricture 57, 58, 59, 64
for rigid endoscopy 19–21 lithotripsy 225–7 dilation 64–5
for thoracoscopy 175–7 mass resection 126, 223–4 Oesophagitis 57, 58, 63
for tracheobronchoscopy 85–6 principles 220 Oesophagoscopy
(see also Endoscopes and other selection 223 indications 45
specific instruments) in urethrocystoscopy 147 normal findings 55–6
Insufflation Lateral glenohumeral ligament tears procedure
complications 99 200–1 flexible 49
equipment 23 Laxatives prior to colonoscopy 76 rigid 54–5
in GI tract flexible endoscopy 12, Leakage testing 13 Ollulanus triscuspis 59, 60
37, 48 Leiomyoma, oesophageal 58 One-lung ventilation 178
technique 98–9 Ligamentum arteriosum division Oslerus osleri 94
Hasson 161 184–5 Osteoarthritis of the elbow 208
Veress needle 160–1 Light sources 21, 22–3 Osteochondritis dissecans
in vaginoscopy 148 Lithotripsy, laser endosurgery 225–7 elbow 206–7
Intestinal adenocarcinoma 61 Liver biopsy 162–4 shoulder 198–9
Intestinal biopsy 43, 165–6 Lung lobe torsion 181–2 stifle 216
Intussusception Lymphangiectasia 60, 61, 62 tarsus 218
gastro-oesophageal 58 Lymphocytic–plasmacytic colitis Osteosarcoma, nasal 126
79–80 Otic biopsy 137
ileocolic/ileocaecal 82
Lymphoid follicles, reproductive tract Otic discharge 133, 137
Irrigation 12
153 Otic foreign bodies 137
in laparoscopy 102
Otic masses 136–7
in otoendoscopy 132, 134 Lymphoid hyperplasia 116, 153
Otitis externa 133, 136, 138, 140
Irritable bowel syndrome 81 Lymphoma
Otitis media 132, 133, 135, 137,
colonic 81
138, 140
gastric 60
Otoendoscopy
Jejunoscopy nasal 124
complications 140
indications 46 Lymphoplasmacytic enteritis 61
indications 131
procedure 54 Lymphosarcoma
instruments 131–2
Jejunostomy tube placement 70–1, intestinal 61
normal findings 135
166 mediastinal 182
patient preparation 132
nasal 121
postoperative care 140
preoperative work-up 132
Knot tying
procedure 132–135
extracorporeal 103–4 Masses
sampling 133, 134
intracorporeal 104–7 laser surgery 223–5
Otoscopes 18, 23, 131–2
otic 136–7
Ovarian remnant removal 170
(see also Neoplasia) Ovariectomy 169–70
Laparoscopes 18, 19 Medial meniscus injury 215–16 Ovariohysterectomy
Laparoscopy Medial shoulder instability 199–200 laparoscopic 167–9
anaesthetic considerations 159 Mediastinal biopsy 180 patient positioning 98
biopsy Mediastinal debridement 182
intestinal 165–6 Megaoesophagus 57, 58
liver 162–4 Melanoma, nasal 125 Pancreatic biopsy 4
pancreatic 164 Monitors 24, 25 Paramesonephric septum 53
renal 164–5 Myringotomy 138–9 Parasites
closure 107 complications 140 gastric 59, 60
complications 173–4 intestinal 60, 61, 62
endoscope choice 99–100 (see also individual species)

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 Index

Patent ductus arteriosus (P ), ovariohysterectomy 167 patient preparation/

occlusion 185 pericardectomy 182 positioning 117–18
Patient assessment/stabilization thoracic duct ligation 185 procedure 118–19
8–9, 31 thoracoscopy 100–1, 179 caudal
Patient preparation/restraint/ Postoperative care biopsy 116–-17
positioning 33 after arthroscopy 195 foreign body removal 117
for arthroscopy 193–4 after bronchoscopy 95 instrumentation 114
carpus 209 after laparoscopy 107–8 normal findings 116
elbow 202–3 after oesophageal stricture patient preparation/
hip 210 dilation 64–5 positioning 114–15
shoulder 195 after otoendoscopy 140 procedure 115–16
stifle 213 after rhinoscopy 130 rigid 117
tarsus 217 after thermal capsulorrhaphy complications 130
for endosurgery 98 200 indications 110–12
for GI endoscopy 47–8, 76–7 after thoracoscopy 186 intraoperative work-up 112–13
for otoendoscopy 132 after urethrocystoscopy 157 laser surgery 223–4
for respiratory tract endoscopy Power shavers 2 – , 2–3 postoperative care 130
87 Premedication/sedation preoperative work-up 112
for rhinoscopy for bronchoscopy 97 Rigid endoscopes see Endoscopes
anterior 117–18 for colonoscopy 76 and specific scopes
caudal 114–15 for respiratory tract endoscopy Rod lens system 17
for thoracoscopy 177 86 Roeder knot 104, 105
for urethrocystoscopy 145 for rhinoscopy 114
for vaginoscopy 147–8 for upper GI endoscopy 48
P tubes 66, 67 Pre-oxygenation for respiratory tract Scissors 16
contraindications 66 endoscopy 86, 98 Sedation see Premedication/sedation
indications 66 Pressure valve 3 Septic arthritis
placement 67–9 Probes, arthroscopic elbow 209
problems 70 Proctoscopy hip 212
removal 70 indications 73 Shavers 26–7, 192–3
use 69–70 procedure 79 Sheaths 19, 20
Pericardectomy 82–3 Prostatic disease 5 Snares 16
Pericardial disease 8 Pseudomonas aeruginosa 134, 136 Specimen retrieval bags 103
Pericardial fenestration 186 Pulmonary biopsy 8 Spirocerca lupi 57, 59
Pericardiocentesis 82 Pulmonary oedema 95 Squamous cell carcinoma,
Peristalsis 50 Pumps 23 oesophageal 58
Persistent hymen 53 for arthroscopy 24 Sterilization 29
Peyer’s patches 57 Pyloric intubation 53 Suction 12
Pyloric stenosis 59 artefact 35
Physaloptera 59, 60
in laparoscopy 102
Pleural biopsy –8
in otoendoscopy 132, 134
Pleural effusion 181
Rectal adenomatous polyps 82–3 Synovial biopsy, tarsal 218
Pneumolobectomy
Rectal stricture 83
complete 184
Red-out 37
partial 183–4
Remnant hymen 153 T-adaptor, swivel tip 86
Pneumoperitoneum 8
Renal biopsy 164–5 Teamwork 27
Pneumothorax
Respiratory tract Telescopes 17
spontaneous 181
anaesthesia 86–7 Theatre set up 7, 27–8, 189
for thoracoscopy 98, 179
indications for endoscopy 84 Thermal capsulorrhaphy 199–200
Polyps
instrumentation 85–6 Thoracic duct occlusion 185–6
auropharyngeal 121
patient preparation/positioning Thoracoscopy
benign mucosal antral 59
87 anaesthesia 98, 177–8
bladder 172
premedication 86 biopsy 179–80
nasopharyngeal 126–7
(see also specific conditions and closure 107
otic 136, 137 complications 186
procedures)
rectal adenomatous 82–3 indications 175
Rhinitis
urinary tract, laser resection instrumentation 99–100, 175–7
allergic 122
224–5 bacterial 122 laser surgery 225
vaginal 154 chronic 121 normal findings 180–1
Port placement foreign body 122–3 patient preparation/positioning
arthroscopy fungal, topical therapy 127–30 98, 177
carpus 209 Rhinoscope 18 port placement 100–1, 179
elbow 203 Rhinoscopy postoperative care 186
hip 210–11 anaesthesia 98 preoperative work-up 177
shoulder 195–6 anatomical considerations procedure 102, 178–80
stifle 213–14 109–10 Tonsillar inflammation 113
tarsus 217–18 anterior Toxocara 61
laparoscopy 100–1, 161–2 biopsy 119–20 Tracheal collapse 93–4
intestinal biopsy 165 instrumentation 117 Tracheal mass 94
liver biopsy 163 normal findings 118–19 Tracheal stent 94

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 Index

Tracheobronchitis 92 Ureteral ectopia 147, 151–2 Uroliths

Tracheobronchoscopy see Ureteroceles 152 laser lithotripsy 225–7
Bronchoscopy/ Urethral dys-synergia 151 removal 147
Tracheobronchoscopy Urethral neoplasia 147, 151
Training 8, 31 laser surgery 224
Transabdominal cystoscopy 147 Urethral obstruction 151 Vaginal hyperplasia 154
Transbronchial aspiration/biopsy Urethral sphincter mechanism Vaginal neoplasia 154
needles 86 incompetence (USMI) 151 Vaginal polyps 154
Transitional cell carcinoma Urethrocystoscopes 148 Vaginoscopy
bladder 153 Urethrocystoscopy/urethroscopy breeding time assessment in the
urethral 147, 151 anatomical considerations 142–3 bitch 154–6
laser surgery 224 biopsy 146 complications 157
Transmissible venereal tumour (TVT) complications 157 endoscopes 147
154 indications 143 normal findings
Transurethral laser lithotripsy 225–7 instrumentation 144–5 non-oestrous bitch 149
Trichuris vulpis 78, 82 intraoperative work-up 144 oestrous changes 149–50,
Trocars 20 laser techniques 147, 224 155
Tympanic membrane normal findings 146 patient preparation/positioning
absence 137 patient preparation/positioning 147–8
displacement 138 98, 145 procedure 148–9
normal findings 135 postoperative care 157 Veress needle 23
rupture 138 preoperative work-up 144 technique 160–1
Typhlitis 82 procedure 145–7 Vestibulovaginal stenosis 153–4
urolith removal 147 Video-endoscopes
Urethroliths 226 comparison with fibrescopes
Ulcerative rhinitis 119 Urethroscopy see Urethrocystoscopy 13–14
Ulcers Urinary tract controls 36
ear canal 136 infection (UTI) 152–3, 157 imaging systems 24–5
gastric 59 lower, laser surgery 224–5 structure 13
Ultrasonic broncho-fibre-videoscope (see also specific conditions and Video-otoscopy see Otoendoscopy
86 procedures)
Uncinaria 62 Urocystoliths 225
Ununited anconeal process 207–8 Urolithiasis 153, 225 Xenon light sources 22

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 BSAVA Manual of
Canine and Feline

BSAVA Manual of Canine and Feline Endoscopy and Endosurgery

Endoscopy and Endosurgery
Edited by Philip Lhermette and David Sobel

Surgery in the human field is

carried out using minimally invasive
techniques wherever possible. The
advantages of these techniques are
considerable: improved visualization
of the surgical field; improved access
to the surgical site; reduced scarring,
morbidity and postoperative pain; and
more rapid healing. People nowadays
expect minimally invasive surgery for
themselves, and are very receptive to
these procedures for their pets.

The BSAVA Manual of Canine and Feline Endoscopy and Endosurgery

provides a practical guide for general practitioners worldwide who wish
to use minimally invasive techniques. It gives detailed information on the
instrumentation required for different techniques, and practical tips and advice
on its care. The principles and basic techniques of diagnostic endoscopy and
endosurgery are explained, illustrated by a wealth of colour photographs and
specially commissioned diagrams.

CONTENTS
n introduction to endoscopy and endosurgery; Instrumentation; lexible endoscopy:
basic technique; lexible endoscopy: upper gastrointestinal tract; lexible endoscopy:
lower gastrointestinal tract; lexible endoscopy: respiratory tract; igid endoscopy and
endosurgery: principles; igid endoscopy: rhinoscopy; igid endoscopy: otoendoscopy;
igid endoscopy: urethrocystoscopy and vaginoscopy; igid endoscopy: laparoscopy;
igid endoscopy: thoracoscopy; igid endoscopy: arthroscopy; n introduction to laser
endosurgery; Index.

Philip Lhermette BSc (Hons) CBiol MIBiol BVetMed MRCVS

Philip completed a Sc in animal physiology at the University of
ottingham in and graduated from the oyal eterinary College,
London in 82. fter five years in mixed practice he founded lands
eterinary Clinic in ent. He has studied endoscopy and endosurgery
since 5 and laser surgery since 2 . He trained with avid Sobel in
the US and has received advanced training in human minimally invasive
surgery at the Spire Tunbridge ells Hospital. He pioneered many
minimally invasive techniques including laparoscopic ovariohysterectomy
and laser surgery in the U and currently runs an endoscopy referral
service. He is a special lecturer in veterinary endoscopy and endosurgery
at the University of ottingham School of eterinary edicine.

David Sobel DVM MRCVS

avid began his veterinary training at the University of lasgow, before
returning to the United States where he received his in 2. He
received advanced training in human minimally invasive surgery at the
ew ngland edical Centre in oston, assachusetts. He currently
owns and operates etropolitan eterinary Consultants, a mobile
service offering diagnostic ultrasound and echocardiography, endoscopy,
endosurgery and laser endosurgery to small animal practitioners across
ew ngland. He is also a consultant at the eterinary eferral Centre
of ew Hampshire. He is fortunate to be able to consult on occasion at
lands eterinary Clinic in ent.

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