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Proceedings of the
51st British Equine Veterinary
Association Congress
BEVA
Sep. 12 – 15, 2012
Birmingham, United Kingdom

Next Congress:

11th-14th September 2013 – Manchester, UK

Reprinted in IVIS with the permission of the British Equine Veterinary Association – BEVA
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Thurs Hall 9_Layout 1 08/08/2012 14:28 Page 72
Reprinted in IVIS with the permission of BEVA
Hall 9 n Thursday 13th September
15.05–15.30
How to perform a successful ovariectomy in the mare
Tim J. Phillips
The Liphook Equine Hospital, Hampshire, UK.
Introduction
There are 2 main purposes for performing ovariectomy in the
mare:
1) To moderate unwanted ‘oestrus’ behaviour traits.
2) To remove a pathological ovary (usually a granulosa-theca cell
tumour).
The relevance of the indication for surgery to the surgical method
selected is that:
1) To moderate a mare’s normal oestrus behaviour requires a
bilateral procedure, whereas ovarian pathology is typically
unilateral.
2) Pathological ovaries tend to be enlarged, sometimes grossly
so.
Possible surgical approaches for ovariectomy are:
1) Colpotomy
2) Flank laparotomy
3) Ventral laparotomy
a) midline
b) paramedian
c) diagonal paramedian
4) Laparoscopy
These definitions are not necessarily mutually exclusive.
Laparoscopic techniques have been used to assist ventral
laparotomy approaches and, especially in the case of enlarged
ovaries, laparoscopic approaches become a flank laparotomy at
the point of removal of the organ from the abdomen.
1) Colpotomy
Colpotomy is an entry to the peritoneal cavity per vaginam, via
incisions through the vestibular wall either side of the cervix. It is
effectively performed ‘blind’, with ovaries handled through the
incision and removed from their pedicles by means of an
ecrasseur. It has the advantages of being performed without
general anaesthesia (epidural analgesia is preferred), of providing
reasonably easy access to the ovaries and of being relatively
undemanding of specialist equipment and expertise. It has the
disadvantages of a lack of full control over asepsis or haemostasis,
and leaving open wounds into the peritoneum that are left to
heal by second intention, with risk of peritonitis or herniation. It
is also unsuitable for enlarged ovaries. The procedure is rarely
practised these days, but there remain advocates of its use on
pragmatic grounds.
2) Flank laparotomy
Flank laparotomy is performed on the sedated, standing mare
under local infiltration (or paravertebral) regional analgesia. An
ipsilateral approach is made through the abdominal muscles
behind and centred about the caudal reflection of the costal arch.
Ideally a ‘grid’ approach is used, whereby the internal abdominal
oblique and transversus abdominis muscles are divided along the
direction of their fibres. This reduces the risk of haemorrhage from
muscle wall vessels and facilitates closure, but it also limits the
aperture of peritoneal access somewhat and becomes less
suitable for bigger ovaries, in which case vertical incisions through
all layers remains a practical alternative. Ligation of the ovarian
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Proceedings of the 51st British Equine Veterinary Association Congress 2012 - Birmingham, United Kingdom
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pedicle cannot be performed under direct vision and needs to be
performed blind, either by running loop knots tied from the
outside of the abdomen, or by use of an ecrasseur, neither of
which is without technical difficulty.
The flank laparotomy approach has the advantages of being
able to avoid general anaesthesia (although it can also be
performed in lateral recumbency if wished) and of providing
reasonably direct access to the ovaries. It has the disadvantages
of a lack of full control over haemostasis and of being relatively
invasive, especially in bilateral procedures or for very large ovaries.
The main post operative complication is one of incisional swelling
and/or drainage, but this is rarely long-lived.
3) Ventral laparotomy
Ventral laparotomy has probably been the most commonly used
approach to ovariectomy in recent decades. It can be performed
through midline, paramedian or diagonal paramedian
approaches. A standard midline approach through the caudal
linea alba is probably most suitable for bilateral cases or for very
large ovaries. The diagonal paramedian approach (running
caudomedial–craniolateral) is recommended by some for
unilateral procedures involving relatively smaller ovaries, because
it gives the most direct access to the ovary and its pedicle. Bilateral
diagonal paramedian approaches within one surgical procedure
can also be used although it extends anaesthesia time. It is
difficult to see anything to recommend a normal paramedian
approach over one or other of the alternatives.
With any of the ventral laparotomy approaches the goal is to
exteriorise the ovary in order for ligation of the pedicle to be
performed under visualisation. This is often difficult, requiring
steady traction on the relatively short mesovarian attachment.
Even when achieved, access to the pedicle is limited by
compression against the walls of the laparotomy wound.
Haemostasis can be achieved by hand-tied ligatures (usually
multiple), a thoraco-abdominal stapling device, a vessel sealing
device (Ligasure) or by ecrasseur. With any of these, the
immediate retraction of the pedicle back in to the abdomen after
transection compromises observation for secure haemostasis.
Paradoxically, the procedure is often easier in pathologically
enlarged ovaries because their pedicles tend to have been
stretched already. However, the vasculature in such cases is often
increased in size too, making ligation more difficult. Staplers may
still be effective, but possibly surer haemostasis is obtained with
a series of overlapping loop sutures.
Ventral laparotomy techniques have the advantage of greater
surgical control, albeit with still imperfect surgical access, but the
disadvantage of general anaesthesia for what can be a lengthy
procedure in all but the most experienced of hands. There is a risk
of unseen haemorrhage and also of wound complications, which
as a general rule tend to be more problematic with ventral
compared to flank incisions.
4) Laparoscopy
The use of a laparoscopic approach to ovariectomy has increased
steadily over the past decade and it is now unequivocally the
approach of choice in the author’s hospital. It has the advantage
of providing excellent surgical access without tension, direct
visualisation during haemostasis and the avoidance of general
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Thursday 13th September n Hall 9
anaesthesia. It can be performed bilaterally within one procedure
and is not limited by the size of ovary involved (except that the
removal of the dissected ovary requires a proportionately larger
final incision). Extra-corporeal or intra-corporeal ligating
techniques are available, but secure haemostasis, even for the
larger ovaries, can be achieved without any suturing at all, by use
of a bipolar vessel sealing device. Laparoscopy has the
disadvantage of being relatively demanding of specialist
equipment and expertise. The main potential complications are
those of flank incision healing and are therefore no greater and
probably less than with any of the laparotomy approaches.
Intestinal puncture by a trochar and thermal injury from the
sealing device are rare, but reported possibilities.
Laparoscopic ovariectomy technique
This will be described and illustrated with more detail in the
presentation, emphasising practical aspects based on experience
at the Liphook Equine Hospital. Broadly, the sequence of steps is
as follows:
Preparation for surgery
• Starve the mare of solid food for 48 h, but do not withhold
water.
• An hour or two before surgery premedicate with broad
spectrum antibacterials and nonsteroidal anti-inflammatory
drugs (NSAIDs).
• Immediately before surgery empty the bladder.
• Induce standing sedation with an initial dose of detomidine
combined with acepromazine and morphine, thereafter
continued with a continuous i.v. detomidine drip to effect.
• Perform an initial aseptic preparation of wide areas pre-
clipped on one or both flanks
• Regionally infiltrate surgical sites with local anaesthetic
solution, including deep muscle layers (using 2” x 18 gauge
needles) - at 3 portal sites per flank:
1. Just above level of caudal reflection of the costal arch,
midway between it and the cranial point of the tuber coxa
(in the case of a normal [i.e. small] ovary this infiltration
‘2’ is made more extensive to allow for its enlargement
for ovary retrieval; in the case of large ovaries this
infiltration is continued in a line continuous with ‘3’).
2. At approximately the same level as ‘1’, within the last
intercostal space.
3. Directly below ‘1’, with a spacing of approximately 8–12
cm.
• Complete a final aseptic preparation of the surgical sites.
Surgery
(In bilateral procedures start with the left side; a surgical assistant
is required).
• Introduce a thoracic cannula through the peritoneum and
inflate the abdomen with air through negative pressure.
• Introduce a guarded, valved, laparoscopic trochar through
NOTES
Proceedings of the 51st British Equine Veterinary Association Congress 2012 - Birmingham, United Kingdom
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portal ‘1’, feeling for a peritoneal ‘pop’; point caudal and
proximal to avoid the spleen; attach the CO2 line to the
ingress tap, connected to a pressure-regulator.
• Insert a 0-degree, 57 cm, rigid endoscope and connect the
light source cable and video-camera.
• Under visualisation insert Veress needle through portal ‘2’,
followed by another guarded trochar to avoid the spleen.
Switch the endoscope to this trochar.
• Similarly guide a third trochar into position via portal ‘3’.
Inflate the abdomen with CO2 as necessary (beware: over-
inflation will cause discomfort).
• Assess visualisation of the ovary and its pedicle. Gut may need
to be displaced, either by manipulation or by gas pressure.
Grasp the cranial pole of ovary (usually through portal ‘1’)
with grasping forceps and tense the mesovarium (this is often
resented temporarily).
• Infiltrate the mesovarium liberally with local anaesthetic
solution via a laparoscopic needle introduced usually through
portal ‘3’. Give time for this to take effect!
• For pathologically enlarged GCTs, deflation of haematoma-
like cysts via a thoracic cannula at this stage assists later
removal.
• Varying endoscope and both instrument portals as necessary,
always keeping hold of the ovary in grasping forceps, steadily
apply and fire the vessel sealing/transecting device across the
ovarian pedicle, from the cranial free border to the proper
ligament caudally.
• When the ovary is free, manipulate the instruments such that
it is held via portal ‘1’. Then enlarge portal ‘1’ into a small
laparotomy and steadily tease the ovary through it (either
directly or within a visceral retrieval bag). In a bilateral
procedure it is possible to remove a contra-lateral small-sized
ovary from the same side, by passing it across the abdomen
with long forceps, behind the small intestinal mesentery and
beneath the small colon.
• Close the portals in 2 layers. Close the enlarged laparotomy
portal in 4 or 5 layers.
Post operatively
• Continue broad spectrum antibacterial drugs for 3–5 days.
• Continue NSAIDs for 5–7 days.
• Feed as soon as sedation has worn off and appetite has
returned.
• Provide 4 weeks of rest in relative confinement, with walking
out for grass frequently.
Complications
Most mares will show mild abdominal discomfort/mild pyrexia
for 12–24 h. Incisional swelling and gas crepitus may develop at
the laparotomy site, almost always transient and self-limiting.
Occasional cellulitic swelling occurs, necessitating prolongation
of antibacterial medication. Rarely, incisional discharge may
occur, again responsive to management by first principles.
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