Minimally invasive surgery and the GP: Getting started

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The benefits of providing minimally invasive surgery (MIS) versus conventional surgery for patients are well known (eg, less pain and scarring, lower risk of infection, and shorter recovery time). However, the perks for general practitioners and practices might be less clear.

During a recent Fetch dvm360® virtual conference session, Chris Thomson, DVM, DACVS-SA—who specializes in MIS, surgical oncology, and interventional radiology with the Veterinary Specialty Hospital in San Diego and a clinical researcher with Ethos Discovery—began by spelling out some of the human- and business-based advantages of making the leap into laparoscopy. Considering the benefits to patients, perhaps the most obvious fact is that laparoscopy can elevate a clinic’s standard of care. In turn, this can expand the clinic’s market and improve revenue as new clients are gained. On a more personal level, Thomson noted that learning laparoscopy can provide experienced GPs with a new challenge and increased job satisfaction, also offering fresh avenues for team members to become more engaged.

Still, there is clearly a large, worrisome gap of time and financial investment between deciding to add MIS to your general practice and reaping the benefits listed above. Thomson used his session as an opportunity to flesh out some of the fuzzy details, covering topics like learning curves, feasibility, initial steps, basic equipment needs, and how to maximize your investment in MIS.

Can anyone learn MIS?

“It’s scary to go from something that you’re really good at or familiar with and then jump into [MIS],” said Thomson. “But with appropriate practice and mentorship, the learning curve isn’t that steep.” He cited a 2017 study¹ that retrospectively assessed the rates of intraoperative complications associated with supervised fourth-year veterinary students who performed laparoscopic ovariectomies (OVE). The type of training, said Thomson, was no different than that for traditional OVE. Students received classroom instruction and participated in wet labs. Ultimately, even these novice surgeons were able to perform laparoscopic OVEs safely, efficiently, and with rare minor complications.

Is MIS feasible?

This question led to a quick review of another 2017 study,² which evaluated the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy at a small animal general practice—specifically, a 2-veterinarian general practice clinic in southern California. The cost of equipment and training, as well as the revenue generated, procedures performed, surgery time, complications, and client satisfaction over a 12-month period, were evaluated.

The 2 veterinarians performed 78 endoscopic procedures during the first year, including OVE, prophylactic gastropexy, and video otoscopy, with a total revenue of over $50,000 and no major complications. The cost of equipment and training that year was just under $15,000 (most equipment was financed through a 5-year lease at around $10,000 per year). Although Thomson said the yearly lease did not include other disposables required for the procedures, he noted that the new equipment and training costs would pay for themselves after 2 years.

Where do I start?

Thomson discussed 4 main steps for getting started with MIS, but we will save the fourth for later.

Research and connect

“It starts with delving into the research and figuring out exactly what you want to do within the realm of [MIS],” said Thomson. As the webmaster for the Veterinary Endoscopy Society, he vouched for the site’s usefulness in connecting members with other veterinarians interested in MIS (from newcomers to experts) and encouraged interested practitioners to take advantage of its webinars. The research phase should also include considering potential vendors. “Especially in veterinary medicine, the vendors get really excited about new practitioners and new clinics that are trying to get into this field,” said Thomson. “They’re great at bringing items to your clinic to help you get hands-on time with the equipment, discuss pros and cons, and discuss what would be the best setup for your clinic.”

Gain hands-on experience

Thomson recommended connecting with a nearby GP or surgeon who can act as a mentor and allow you to shadow them, perhaps with them even coming to assist when you are embarking on your first few cases. “There are a lot of subtle tips and tricks that can’t be garnered from simply looking at textbooks and watching videos,” he explained. “Getting hands-on experience with mentorship can really increase the viability of bringing [MIS] into a general practice.” He said wet labs also are important. “There are a ton of great courses offered through Colorado State University Translational Medicine Institute, the University of Georgia College of Veterinary Medicine, and the American College of Veterinary Surgeons that can give you some confidence as you approach your first cases,” Thomson said. He added that although the pandemic has made access to wet labs more difficult, he has heard that the situation should be improving soon.

Buy or lease equipment

“This is where you really make that investment into deciding what exactly is going to be best for you and your clinic,” said Thomson. “This isn’t a cheap thing to delve into. This is something that if you’re interested in it, you really have to commit.”

What equipment do I need?

But what does it take to really commit? According to Thomson, the most basic setup requires 4 main pieces of equipment: a telescope, camera, light source, and monitor.

Telescope

Thomson said the standard rigid endoscope used in veterinary medicine has a 30-cm telescope that is 5 or 10 mm in diameter. He called it the “workhorse” for any laparoscopic procedure. Another facet that needs to be considered is the angle at the end of the telescope, which is typically either 0° or 30°. The former looks straight ahead, so whatever you are pointing the tip of the telescope at is what you will visualize, said Thomson. There is no need for angulation adjustments. The downside, he continued, is that if you are using this for single-incision laparoscopic surgery (SILS) and have multiple instruments from a single port, significant clashing can occur as your instruments are all trying to work in a smaller field. That’s where the 30° scope comes into play, but the challenge here is that you are not always looking straight ahead to where you are pointing the camera and will need to understand triangulation. “Wherever you’re pointing that camera, the telescope can actually look 30° completely around that,” Thomson explained. In addition to having a larger field of view (which can be particularly helpful in procedures like thoracoscopic lobectomies, so you can look around the thoracic cavity), your telescope will be offset, relative to other instruments. The telescope will be placed at a different angle when compared to your working instruments, so there is more freedom of movement for the instruments that are performing the surgery.

Camera

The camera converts the analog image (ie, what the lens sees) into the digital image that is projected onto the monitor. Thomson noted that there are several options regarding cameras. For example, some have digital zoom and others do not. Some of the common brands that offer laparoscopy cameras in the United States, include Karl Storz, Arthrex, and Stryker. Many of these companies have varying advancements and market focuses (eg, laparoscopy, arthroscopy, flexible endoscopy), so speaking to a local representative can be useful to determine what would best fit your specific goals.

Light source

While xenon lights used to be the standard, most of what is sold today is LED, because they are superior to xenon lights in terms of energy efficiency and duration of use. (Thomson said the lifetime of an LED light is roughly 20 times that of a xenon light.) So, although up-front costs are higher, using LED will likely save you money in the long run. Another valuable tip from Thomson: Get a right angle connector for the light post. Since the light post for illuminating everything inside the abdomen connects to the telescope, having the light post positioned in a more ergonomic spot will minimize additional instrument clashing. “It can be a true lifesaver in getting the camera into the position you want without pushing other instruments away,” he explained. “The light post is normally sticking straight out from the telescope, but the right-angle connector can make it parallel to the scope and camera, which can help with efficiency of movement and workflow.”

Monitor

Thomson noted that there is a wide variety available, but that most in veterinary medicine will use a tower setup. “It’s very important to note that anytime you’re going to be purchasing equipment like this, it’s vital that everything talks to each other appropriately—that the camera is talking to the camera computer, and that that computer is talking to your monitor, and that they’re on the same scale,” he explained. “There’s really no value in purchasing a 4k resolution camera if your monitor is only going to be 720p [resolution in pixels].” In other words, if you make an investment in upgrading the camera, make the same investment in the monitor and so forth to ensure your various equipment components are compatible and you’re able to use them to their full potential.

What other accessories and disposables will I need?

Although the above pieces of equipment will be your main investments, there are other MIS-specific accessories and disposables to consider.

Gas

Insufflating gas into the abdomen is key to providing working and viewing space during laparoscopic procedures, and in veterinary medicine carbon dioxide (CO₂) is the most common choice because of its safety and low cost. Despite its usefulness, there are downsides related to CO₂ pressure and absorption, so it’s best to use it as sparingly as possible. “The higher you go with insufflation, the more effects you’ll see in the cardiovascular status of the patient,” said Thomson. “Specifically, the high capacitance vessels within the abdomen, like the caudal vena cava and renal veins, are going to be greatly impacted if you end up using a high pressure. Typically, for most of our patients, whether large or small, 8 to 10 mm Hg is sufficient to be able to do what you need to do.” He added that you can avoid insufflating gas altogether by using an abdominal wall lift, an external device that lifts the abdominal wall up and out, but the working field and visual space may not be as good.

Another tip from Thomson to increase your visual and working space: utilize patient positioning (and gravity) to your advantage, to help keep insufflation levels low. For example, if you’re going to perform a laparoscopic cryptorchidectomy in the caudal half of the patient, he said it can be helpful to actually elevate the caudal half, so the gastrointestinal tract falls away. Similarly, if you’re performing a laparoscopic OVE, positioning the patient in either oblique right or left lateral recumbency can give you easier access to the structures you need.

Ports

These are what you use to create the opening within the body wall to allow you to pass the camera, as well as other instruments, Thomson explained, and there are both disposable and reusable options. The former are pricier and were designed for human medicine, but the reusable options have a downside too. They’re heavier, which can pose problems when working with pediatric and feline patients, said Thomson. There are other design options to consider as well—namely, multiport versus SILS ports. The SILS ports comprise 3 different ports but require only 1 incision and have been shown to reduce surgery times once you get past the learning curve. Unfortunately, the learning curve is significant. “For your earliest procedures,” advised Thomson, “it might be easiest and best to start with a multiport and consider bringing in a SILS as you move into more advanced procedures.”

Instruments

The instruments needed for MIS are similar to those needed for conventional surgeries. Thomson offered some expert tips for these common categories.

Forceps

While there are several options for forceps, Thomson specifically singled out biopsy forceps, because they are highly beneficial if you plan on doing laparoscopic liver biopsies. “That’s one of the most basic procedures I think a lot of people should consider, if you’re going to be starting minimally invasive surgery,” he advised. “Biopsy forceps can be valuable at making that a quick procedure.”

Scissors

If you’re planning to do any suturing in the abdomen, Thomson said it’s important to have suture scissors that can grasp onto the suture.

Needle drivers

On a related note, Thomson said he believes laparoscopic suturing is incredibly valuable and underutilized in veterinary medicine. “This is something that if you start to do a lot more laparoscopic minimally invasive surgery,” he continued, “it is, in my opinion, absolutely vital that you learn how to do laparoscopic suturing. This is going to be a lifesaver if you ever get in a situation where your ligature or your endoscopic clips aren’t available or aren’t working.” Similar to working with a SILS port, this is a skill that requires a lot of practice but will become increasingly important as you advance in MIS.

Retractors

“The blunt probe is probably the most commonly used instrument that’s going to be necessary for anyone who’s performing minimally invasive surgery,” said Thomson. “That blunt probe really replaces your finger in the abdomen, so it’s used for your dynamic feedback, as well as to retract things.” If you plan on doing anything with gallbladders or adrenals, he recommended using a fan retractor, which can effectively move things away (like the kidney and liver).

Suction and irrigation

Similar to conventional surgery, Thomson said there is always a benefit to having both suction and irrigation in MIS.

Retrieval bags

“If you’re going to be pulling anything out of the abdomen, whether it’s neoplastic, or even nonneoplastic ovaries, you could argue it would be of benefit to use a retrieval bag,” said Thomson. “Or if there are any concerns that something is infected, it’s valuable to have a retrieval bag—that way, you’re not seeding any neoplastic cells or infected cells within the body wall.” Surgical gloves offer a low-cost option. For example, if you’re performing an adrenalectomy on a cat, Thomson said you can invert the thumb portion of the glove and use it as a retrieval bag.

Energy devices

“One of the biggest changes in surgery in the last several decades has been the advent of electrosurgery,” Thomson explained, “and that’s no different in [MIS]. I think the use and benefit of electrosurgery really makes a procedure much more feasible and makes a night-and-day difference, in terms of how you can approach things and how much bleeding occurs. It really does affect your visualization to have adequate hemostasis.” Even for entry-level surgeons, Thomson said energy devices are “very beneficial.”

Monopolar instrument

Many clinics are bringing in monopolar devices for surgeries, and Thomson noted that you can adapt almost any of them for use in laparoscopic surgery. They are commonly used for dissection within the abdomen and can seal vessels up to 2 mm in size. However, caution is necessary, because if there is any scratch or change to the lining of the instrument you are using with the monopolar device (eg, endoscopic shears, endoscopic dissectors), you can cause burn injuries.

Vessel-sealing device

Thomson considers this to be one of the most important instruments for anyone entering MIS. “It increases the efficiency of everything—even down to the basic laparoscopic OVE,” he explained. “If you don’t have this, you really do have to expect to learn endoscopic suturing.” These devices can seal vessels as thick as 7 mm and contain blades so you can cut tissue after it’s been sealed.

Ultrasonic dissector

Thomson is less familiar with these but said that a harmonic scalpel can replace a ‘Ligasure’ or vessel-sealing device in many situations. “There are some people who will argue that there’s a significant difference between using an ultrasonic dissector versus a vessel-sealing device,” he added, “but generally they can perform the same (function).”

Maximize your investment in MIS

The fourth main step for getting started with MIS overlapped with Thomson’s first key to success: effective marketing. Everyone on your team needs to be able to communicate the value of what you’re doing. For example, when a client calls the front desk staff to ask about spays, they should be able to explain why you perform laparoscopic OVEs. When that client meets with a veterinary technician, that team member should echo (in greater detail) the benefits discussed by the front desk staff.

Don’t assume that the marketing ends with the procedure. “One of the most effective ways that something like this gets communicated is through pictures and videos,” Thomson advised. “If you can capture any pictures or videos from the surgical procedure itself and share that with the client, you know as soon as they get home that’s going to be shared on social media. The marketing is really just performing these procedures and allowing the word to get spread through the visual representation of what you’re doing.”

The second key to success, particularly as illustrated by the 2017 feasibility study,² is to use your equipment frequently. “Not only were [the 2 veterinarians] using it for laparoscopic [OVE] and eventually laparoscopic gastropexy, but they also used it to do diagnostic video otoscopy,” Thomson explained. “With the number of dogs that present in general practices with ear infections that are difficult to [treat], you can pop a scope in to demonstrate exactly what’s going on in that ear, to visualize [whether] there are any masses, foxtails, or foreign bodies. That’s something you’ll use incredibly frequently.” As a bonus, you can use it to give the client evidence as to why continued treatment and follow-up appointments are necessary. All you’ll need to purchase is the video otoscope, because the only difference in setup between a laparoscopic OVE and video otoscopy is the telescope.

Finally, don’t forget to charge accordingly for your investment. For example, Thomson said GPs who have done this successfully have increased charges for laparoscopic OVEs by 25% to 50%, depending on the location and market.

Sarah Mouton Dowdy is a freelance writer and editor in Kansas City, Missouri.

References

1. Nylund AM, Drury A, Weir H, Monnet E. Rates of intraoperative complications and conversion to laparotomy during laparoscopic ovariectomy performed by veterinary students: 161 cases (2010-2014). J Am Vet Med Assoc. 2017;251(1):95-99. doi:10.2460/javma.251.1.95
2. Jones K, Case JB, Evans B, Monnet E. Evaluation of the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy to a small animal general practice. J Am Vet Med Assoc. 2017;250(7):795-800. doi:10.2460/javma.250.7.795