Laparoscopic Removal of an Ovarian Granulosa Cell Tumor

1
Laparoscopic Removal of an Ovarian Granulosa Cell
Tumor
Antonio M. Cruz Diplomate American College of
Veterinay Surgeons
2
Rosies History(Horses 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.

3
Rosies 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

4
Complementary Diagnostic Tools

• Transrectal ultrasound
• Characteristic honeycomb
• appearance

• Clinical diagnosis
• Granulosa cell tumor

5
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, 2.5vequine neoplasms).
• Mature horses (also foals reported).
• Usually unilateral (Bilateral also reported).

6
What do I notice with a Granulosa Cell Tumor?

• It is a Hormonal active tumor
• My Mare has.

Difficulty getting pregnant because of..
Anestrus behaviour.
Stallion-like behaviour
OR
Persistent estrus behaviour.
7
Ovarian (Granulosa Cell) Tumor

• How to know
• Behaviour
• Rectal examination
• Ultrasound
• Hormons levels
• Biopsy/aspiration

8
Rosies recommended treatment
Surgical removal of the ovary (Ovariectomy)

• Recover normal reprodutive activity
• Avoid complications
• Ovaria torsion, adhesions, small colon rupture

9
Options for Removal of Ovary (ovariectomy)
10
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.
11
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.
12
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.
13
Ovariectomy- Minimally Invasive (Laparoscopic)
In the Anesthetized mare for very large ovaries
Fischer, Eq. Diag Surg laparoscopy
14
Ovariectomy- Minimally Invasive (Laparoscopic)
In the standing mare thorugh the flank for
normal or moderate size ovaries
Loesch, 2003. Comp Cont Educ Vet Pract
15
Ovariectomy- Minimally Invasive (Laparoscopic)

• 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

16
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

17
Prognosis

• Removal tumor.
• Hormonal normalization
• Normal reproductive activity

ONLY IF 1 OVARY IS REMOVED
18
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)

19
IN PREPARATION FOR ROSIES SURGERY

• Clipping and scrubbing surgical area
• Sedation
• Local anesthesia

20
OPERATING ROOM SET UP FOR ROSIE
21
STERILE SURGICAL FIELD
22
VIDEO OF ROSIES PROCEDURE
Click on image
23
Rosies 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 paddock
• 3rd 4th weeks turn out.
• Gradual return to normal exercise.

24
END RESULT

• Rosie is back to work with normal reproductive
  cycle and behavior