Laparoscopic Spay: Less Pain, Except on the Wallet

This article is a version of one that originally appeared in Your Dog, the newsletter of The Cummings School of Veterinary Medicine at Tufts University. You will be seeing several more of these articles in the coming weeks, as Will My Dog Hate Me moves towards its final days.

I’ll continue to mention this countdown so you can’t say I didn’t warn you.

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Tested on Humans (though not the spaying, per se)

Following upon the heels of its success in human medicine, laparoscopic surgery — performed using instruments with optical devices — is becoming increasingly popular in veterinary practices. Its benefits for pain reduction and recovery speed are evident in such common procedures as canine spaying, with the greatest benefits seen in larger dogs.

Surgical specialist Rob McCarthy, DVM, at Cummings School of Veterinary Medicine at Tufts University, has seen the number of laparoscopic spays increase exponentially in the past five years. “Because they now know about laparoscopy in humans, more and more dog owners are expressing interest in this method of spaying as they learn about its availability,” he says.

Still, Dr. McCarthy estimates that fewer than 5% of all practices in New England currently offer laparoscopic surgery, in part because of the expense of the equipment and in part because of the difficulty of getting veterinary surgeons trained in traditional methods to feel comfortable with the new technique.

[stextbox id="alert" caption="What about the males?"]

If laparoscopic neutering is a good option for female dogs, why is it not available for males? Put simply: Because female reproductive organs are internal, and male reproductive organs are external. Dr. McCarthy explains: “The way laparoscopic procedures work is that you need a space in order to see what you’re doing. Think of it as working inside a balloon as opposed to working in a closed dark box. In the abdomen, where the ovaries and uterus are located, you are able to inflate the space with carbon dioxide.”

In contrast, with a normal descended testicle, there is no space you can distend in order to perform the surgery. Or, to be more precise, it could be done — in humans, thyroids are removed by distending the tissues in the neck — but it’s not worth the trouble because removing the testicles is not a very invasive surgery to begin with, requiring an incision that’s only a few centimeters long.

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How does laparoscopy work?

With an “open” procedure, as traditional surgeries are called, the surgeon makes a large incision in the abdomen in order to remove the reproductive organs. With laparoscopic spay, a small incision is made just behind the umbilicus (belly button), and a long optical surgical instrument is inserted. After the first ovary is located, another small incision is made to the front and side of it. The ovary is grabbed through this opening, pushed against the body wall and held there with a suture while the blood vessels are fused together and severed. After the first ovary is removed, the process is repeated on the other side.

“When we’re done, we’re left with just two small incisions, one behind the umbilicus, one in front of it,” Dr McCarthy says, adding, “Aside from the surgical technique, the other thing that we do differently from the traditional spay [ovariohysterectomy] is that we don’t remove the uterus, just the ovaries.” The ovariectomy, as it’s known, is effective at preventing pregnancy, and surgical complications such as pyometra (infection of an incompletely removed uterus) and urinary sphincter incontinence are avoided.

Less Pain, Speedier Recovery

The main advantage of laparoscopic spay is lessening trauma and pain. “The incision is small, and the blood vessel fusion device eliminates a lot of extra ligatures in the body,” Dr. McCarthy explains.

A study reported in the Journal of the American Veterinary Medical Association in 2005 compared dogs who underwent open ovariohysterectomies with those who had the same procedure done laparoscopically. Nine of the 10 dogs in the traditional surgical group required additional pain medication after the operation, whereas none of the dogs in the laparoscopic surgical group did.

According to Dr. McCarthy, this concern with pain is relatively new. “Some 30 years ago, when I was a resident, we didn’t consider animal pain very much,” he said. “Now it is the overriding consideration. We’ve become very sensitive to that and so have owners.”

A greater speed of recovery from surgery done laparoscopy was documented in a 2009 study in the Journal of the American College of Veterinary Surgery. Ten small dogs who underwent open ovariectomies were found to be far less inclined to return to their usual activities postoperatively than ten dogs of the same size who had their ovaries removed laparoscopically.

Although this study was done with small dogs, Dr. McCarthy says it’s large dogs who stand to benefit most from the less invasive procedure. “The larger the dog, the larger the cut in the abdomen. With small dogs and cats, the difference between the laparoscopic incision and the open surgical incision is a few centimeters,” he notes. “It not nearly as dramatic as the difference between the size of the incision with large dogs.” The lessening of pain and speed of recovery from the surgeries is therefore more pronounced too.

Why is laparoscopy so rare?

Why, then, don’t more veterinary practices offer laparoscopy, which is also useful for biopsies and other common diagnostic procedures?

One factor is the expense of the equipment, including the computer technology that allows the procedure to be viewed on screen. “You’re talking about an initial investment of maybe $50,000 dollars, which is a lot,” Dr. McCarthy says. “And some of the instruments we use in laparoscopy are not indefinitely reusable. You have to keep replacing them.”

Another problem is the steep learning curve for surgeons who are unfamiliar with the newer technique, which is not routinely taught in veterinary schools. “As surgeons, we’re used to opening things up and staring at them. With spaying, we learn how to hold the ovary in the hand and clamp and tie it,” Dr. McCarthy says.

With laparoscopy, surgeons are literally at a remove because the procedures are done with instruments long enough to reach into the abdomen, sometimes measuring 10 to 12 inches. In addition, surgeons view their hands on a computer monitor, rather than looking directly at them. According to Dr. McCarthy, it is initially difficult to determine where you are in the body, and how to get reach the part that you are operating on.  “With laparoscopy, it’s like looking through a pair of binoculars. There’s a limited sense of depth,” he explains.

Proficiency with the procedure takes time to achieve, and it can be frustrating at first. “Surgeons get discouraged,” says Dr. McCarthy, who teaches the laparoscopic technique at Tufts’ Foster Hospital for Small Animals. “They know they can spay a dog in 15 or 20 minutes, and now they find themselves working at it for more than 35 minutes.” Of course, “As they gain experience it gets much easier and the speed increases,” he says, “but it takes a while to get there.”

Moreover, the training videos that are widely available for traditional surgery don’t exist to the same extent for laparoscopic surgery.

Add the additional training required to the cost of equipment, and laparoscopic surgery becomes a considerable investment of resources for a veterinary practice. Dr. McCarthy says that he doesn’t see this price structure changing. “I think we’re going to be stuck with it forever,” he concludes.

And those prices are passed along to the owners.

As a result, laparoscopic surgery isn’t for everyone.  “A lot of owners in this economy can’t afford it,” Dr. McCarthy says. Nevertheless, many others seek it out, even traveling long distances to find places that offer the surgery, because they are willing to pay more for a noninvasive procedure that will cause a minimum of pain.

 

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