laparoscopic removal of an ovarian granulosa cell tumor antonio m. cruz diplomate american college...
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Laparoscopic Removal of an Ovarian Granulosa Cell Tumor
Antonio M. CruzDiplomate American College of Veterinay Surgeons
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Rosie`s History(Horse’s name and picture have been changed to protect identity)
• 10-year-old thoroughbred mare.
• Signs of stallion like behaviour last 2 weeks.
• Rectal palpation: Enlarged left ovarium.
• Never been bred.• Healthy otherwise.
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Rosie’s Physical Examination
• Vital parameters within normal limits.• Rectal examination confirmed a enlarged left ovarium of
~ 8 cm diameter.
Possible diagnoses enlarged ovarium:
- Tumor : Granulosa-theca cell tumor, cystadenoma, germ cell tumor - Ovarian hematoma.- Ovarian abscess.- Pregnancy.- Anovulatory hemorragic follicle
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Complementary Diagnostic Tools
• Transrectal ultrasoundCharacteristic “honeycomb”appearance
Clinical diagnosis:
Granulosa cell tumor
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What is a Granulosa Cell Tumor?
• Sex cord-stromal tissue bening tumor (malignant has also been reported).
• Most common ovarian neoplasia in mares (85% reprodutive tract tumors, 2.5%vequine neoplasms).
• Mature horses (also foals reported).
• Usually unilateral (Bilateral also reported).
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What do I notice with a Granulosa Cell Tumor?
It is a Hormonal active tumor
My Mare has….
Stallion-like behaviour
Anestrus behaviour.
Persistent estrus behaviour.
Difficulty getting pregnant because of…..
OR
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Ovarian (Granulosa Cell) Tumor
• How to know Behaviour
Rectal examination Ultrasound Hormons levels Biopsy/aspiration
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Rosie’s recommended treatment
Surgical removal of the ovary (Ovariectomy)
• Recover normal reprodutive activity• Avoid complications:Ovaria torsion, adhesions, small colon rupture
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Options for Removal of Ovary (ovariectomy)
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Ovariectomy- Through the vagina
• Disadvantadges• Done blindly• Difficult control of hemorrhage.• Difficult preparation for aseptic
surgery.• Risk for surgeon as it is done
standing• Possible complications (Incision
uterine branch of urogenital artery, injuries of cervix, bladder or bowel, eventration).
Adams, Atlas of Eq Surgery.
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Ovariectomy-Through the flank
Standing in the sedated horse
Lat. recumbency in the anaesthetized horse
Disadvantadges.• Poor Cosmetic results if
incision scarring.• Tension placed in
mesovarium.• Longer time of recovery
(around 6 weeks).Adams, Atlas of Eq Surgery.
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OvariectomyThrough the belly
• Removal of ovaries up to 25 cm.
Disadvantadges.• General anesthesia.• Long recovery ( 8-12 weeks).• Increased incidence of post-
operative colic
Adams, Atlas of Eq Surgery.
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Ovariectomy- Minimally Invasive (Laparoscopic)
In the Anesthetized
mare for very large
ovaries
Fischer, Eq. Diag& Surg laparoscopy
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In the standing mare
thorugh the flank for normal
or moderate size ovaries
Loesch, 2003. Comp Cont Educ Vet Pract
Ovariectomy- Minimally Invasive (Laparoscopic)
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• Advantages– Better visualization ovary and
mesovarium.– Decrease potential
postsurgical complications.– Tension free ligation of
mesovarium.– Standing technique: Not costs
nor risk of anesthesia.– Short recovery (2-3 weeks).
• Disadvantages– Specialized equipment– Technical difficulty
Ovariectomy- Minimally Invasive (Laparoscopic)
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OvariectomyPotential Complications
• Post-operatory hemorrhage from mesovarium. • Post-op pain, anorexia, depression.• Incisional swelling, infections, dehiscense, eventration.• Peritonitis.
All of these are reduced during minimally invasive approaches
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Prognosis
Removal tumor.
Hormonal normalization
Normal reproductive activity
ONLY IF 1 OVARY IS REMOVED
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MINIMALLY INVASIVE ELECTED FOR ROSIE
• Laparoscopic ovariectomy in standing mare.
•BEFORE THE SURGERY
Food withheld for 24 hours (rectal examination pre-surgery confirmed sufficient emptying of the intestine)
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IN PREPARATION FOR ROSIE’S SURGERY
• Clipping and scrubbing surgical area
• Sedation• Local anesthesia
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OPERATING ROOM SET UP FOR ROSIE
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STERILE SURGICAL FIELD
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VIDEO OF ROSIE’S PROCEDURE
Click on image
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Rosie’s Post-Operative Care
• Antibiotics for 3 days.• Antiinflammatories for 3 days.• Discharged from hospital 1 day after surgery.• Exercise recommendations:
1st week: stall rest 2nd week: Stall rest + hand walking / turn out in small paddock3rd –4th weeks: turn out. Gradual return to normal exercise.
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END RESULT
• Rosie is back to work with normal reproductive cycle and behavior