Diagnostic and surgical endoscopy

image of Diagnostic and surgical endoscopy
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Reptile cases are frequently mismanaged because of a failure to identify a specific problem and provide precise treatment. Tissue samples offer the most expedient means to a definitive diagnosis, and endoscopy offers a minimally invasive ante-mortem method to collect such material. This chapter provides an overview of equipment and describes common procedures.

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10.2 A 2.7 mm telescope system. (a) 2.7 mm telescope housed within a 4.8 mm operating sheath, connected to a light cable and an endovideo camera. (b) 1.7 mm biopsy forceps inserted down the instrument channel and emerging directly in front of the telescope. (c) A variety of 1.7 mm instruments can be used through the operating channel, including (from left to right) retrieval forceps, biopsy forceps, remote injection/aspiration needle, and single-action scissors. (© SJ Divers, University of Georgia)
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10.3 Human paediatric 3 mm laparoscopy equipment. (a) A 3 mm instrument (1) attached to a standard CLICKline handle (2). The instrument, attached to a radiosurgery unit via a connector on the handle (3), has been inserted through a 3.5 mm graphite/plastic cannula with insufflation port (4). (b) Instrument (1) and handle (2) can be quickly exchanged by pressing on the release button (arrowed). (© SJ Divers, University of Georgia)
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10.4 Diagrammatic representation of the basic video-endoscopy system including the essential components: a light source, camera and monitor. (© Karl Storz GmbH & Co. KG)
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10.5 Correct ergonomic room layout for endoscopy. Note that the monitor and endoscopy equipment are facing the surgeon, with instruments close to the surgeon’s superior (in this case, right) hand. (© K Carter, University of Georgia)
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10.6 Tele Pack Vet X. This mobile unit comprises a standard-definition camera, hybrid xenon light source and air insufflation, and can be used with both rigid and flexible endoscopes. (© Karl Storz GmbH & Co. KG)
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10.7 C-Cam and LED battery-powered light source. (© Karl Storz GmbH & Co. KG)
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10.8 Endoscopy tower capable of both rigid and flexible endoscopy. (© SJ Divers, University of Georgia)
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10.9 Standard two-handed endoscopy technique. Note that the superior hand supports the weight of the telescope–sheath–camera unit while the thumb and forefinger of the inferior hand control the tip. (© K Carter, University of Georgia)
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10.10 Upper GI tract. (a) Air-dilated oesophagus of a loggerhead sea turtle, demonstrating papillae characteristic of most sea turtles. (b) Saline-irrigated oesophagus of a green iguana. (c) Air-dilated stomach of a savannah monitor. (d) Air-dilated stomach of a corn snake, demonstrating a leiomyoma at the pylorus. (© SJ Divers, University of Georgia)
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10.11 Cloacoscopy, cystoscopy and colonoscopy. (a) Endoscopic view of the cloaca of a female yellow-bellied terrapin in dorsal recumbency, demonstrating the clitoris lying on the ventral wall (1), bilateral accessory bladders (2), and opening to the urethra (arrowed) and colon (*) (dorsal recumbency using saline infusion). (b) Close-up of one of the accessory bladders, through which an ovary can be seen (arrowed). (c) Cystoscopy in a female yellow-bellied terrapin demonstrating several trematode parasites (arrowed) attached to the bladder wall. (d) Colonoscopy of a yellow-bellied terrapin with a small faecal mass visible. (e) The single urinary papilla within the urodeum of the royal python. (f) View within the urodeum of a hognose snake, demonstrating the oviductal openings. Note the discharge emanating from one of the oviducts (arrowed) that was associated with retained egg material. (© SJ Divers, University of Georgia, and SJ Stahl)
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10.12 Transglottal pulmonoscopy. (a) Royal python trachea with obvious dorsal ligament (arrowed). (b) Tracheal bifurcation and primary bronchi in a green iguana. (c) Compartmentalized lung in a panther chameleon. (d) Granulomatous pneumonia due to spp. in a royal python. (© SJ Divers, University of Georgia)
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10.13 Royal python transcutaneous pulmonoscopy. (a) Sheathed 2.7 mm telescope inserted through the lateral body wall and introduced into the lung of a research python that has not been draped for photographic purposes. (b) View of the cranial lung demonstrating the distal trachea (t), intrapulmonary bronchus (b), anterior lung lobe (a) and the faveolar lung tissue (f). (c) Close-up view of the faveolar region demonstrating the primary (p), secondary (s) and tertiary (t) septae of the anterior vascular lung. (d) Lung biopsy using the 1.7 mm biopsy forceps. (e) View of the thin transparent caudal air sac through which the caudal edge of the liver (l), fat body (f), gastrointestinal tract (g) and caudal vena cava (arrowed) can be seen. (© SJ Divers, University of Georgia)
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10.14 Chelonian transcarapacial pulmonoscopy. (a) Drilling a 5 mm temporary osteotomy through the carapace of a spur-thighed tortoise to access the lung. (b) Normal view of the chelonian lung through the temporary osteotomy. (c) Fine-needle aspiration (n) of a pulmonary mass (m) within the lung of a juvenile loggerhead sea turtle. (© SJ Divers, University of Georgia)
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10.15 Chelonian transcutaneous pulmonoscopy. (a) Surgical view of the prefemoral fossa of a map turtle following a mini-coeliotomy incision. Two fine stay sutures (arrowed) have been placed to elevate the lung to the skin incision, and a small stab incision has been made through an avascular window of the lung (arrowhead). (b) Endoscopic view of the surface of the lung held by stay sutures, following stab incision. (c) Endoscopic view from within the lung of a chelonian. (© SJ Divers, University of Georgia)
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10.16 Operating room layout and positioning for a left prefemoral approach (in front of the left pelvic limb) in order to access the chelonian coelomic cavity. (© Kip Carter, University of Georgia)
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10.17 Chelonian coelioscopy, left prefemoral approach. (a) Normal liver in a female radiated tortoise. (b) Heart (h) and pericardial fat (f) behind the coelomic membrane of a yellow-bellied terrapin. Note the pale liver (l) within the coelomic cavity. (c) Stomach (s) and oviduct (o) in a red-footed tortoise. (d) Liver (l) and pancreas (p), with closely associated duodenum (d) in a male red-eared terrapin. (© SJ Divers, University of Georgia)
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10.18 Chelonian coelioscopy. (a) Left ovary (o), oviduct (d) and pale liver (l) in a female spur-thighed tortoise (left prefemoral approach). (b) Left testis (t), epididymis (e) and kidney (k) in a male red-eared terrapin (left prefemoral approach). (c) Enlarged left kidney (k) behind a pigmented coelomic membrane but protruding into the coelom in a female leopard tortoise (left prefemoral approach). (d) Normal right kidney (k) clearly visible behind a transparent coelomic membrane, adrenal (arrowed) and renal (v) vein in a female yellow-bellied terrapin (right prefemoral approach). (© SJ Divers, University of Georgia)
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10.19 Neonate chelonian gender identification using a 1.9 mm telescope and saline infusion. (a) Immature testis in a male radiated tortoise weighing 70 g. (b) Immature ovary in a female Chinese box turtle weighing 20 g. (© SJ Divers, University of Georgia)
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10.20 Telescope entry sites for coelioscopy in lizards. (a) For a lateral entry into the coelom, the general entry point (x) is bordered craniad by the last rib (r), dorsad by the lateral processes of the lumbar vertebrae (v), caudad by the musculature of the hindlimb (h), and ventrad by the ventral abdominal (av) and pelvic (pv) veins. (b) For a ventral approach to the coelom, insertion points (x) may be in the midline behind the anastomoses of the lateral pelvic veins (pv), or lateral to the ventral abdominal vein (av), caudal to the last rib (r) and cranial to the pelvic veins (pv). (© SJ Divers, University of Georgia)
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10.21 Left coelioscopy in the green iguana. (a) Ventral surface of the left liver lobe demonstrating multiple small granulomas (arrowheads). (b) Heart (h), liver (l) and deflated left lung (lu). (c) Inflated lung (lu) – note the absence of any postpulmonary membrane in iguanid lizards. (d) Stomach (s). (© SJ Divers, University of Georgia)
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10.22 Left coelioscopy in the green iguana. (a) View of the stomach (s), spleen (sp), left adrenal gland (a) and immature left ovary (o). (b) Left testis (t), closely associated epididymis (e), and adrenal gland (a). (c) Mature left ovary (o) and oviduct (ov). (d) Left kidney (k) and epididymis (e), at the pelvic inlet. (© SJ Divers, University of Georgia)
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10.23 Right coelioscopy in the green iguana. (a) Heart (h) partially obscured by the caudal vena cava (v) and right deflated lung (lu). (b) Liver (l) and gall bladder (g). (c) Pancreas (p) situated caudal to the gall bladder (g). The ventral abdominal vein is also visible (av). (d) Large sacculated colon (c). (© SJ Divers, University of Georgia)
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10.24 Snake coelioscopy. (a) Left lateral approach, 82% snout to vent, revealing the caudal pole of the left kidney (k), fat body (f) and ribs (arrowhead) in a boa constrictor. (b) Ball python liver (l) viewed from within the air sac of the right lung. (c) The air sac and serosal membranes have been incised to expose the liver parenchyma (l). (d) View of the liver (l) following biopsy using 1.7 mm forceps. (© SJ Divers, University of Georgia)
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10.25 Biopsy. (a) Diagram illustrating the technique used to support the camera–sheath–telescope with the inferior hand, while the superior hand can manipulate instruments within the channel of the operating sheath. (b) Enlarged liver in a green iguana due to bacterial hepatitis. (c) Enlarged kidney in a veiled chameleon due to glomerulonephritis. (© SJ Divers, University of Georgia)
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10.26 Liver and kidney biopsy in chelonians. (a) The biopsy forceps are positioned under, and used to elevate, the caudal edge of the liver. (b) The sheath–telescope–forceps is withdrawn slightly until the edge of the liver falls into the open biopsy jaws, and a biopsy sample is collected. (c) The fixed blade of the single-action scissors is inserted through the coelomic membrane over the kidney. (d) The biopsy forceps can then be inserted through this incision to collect a biopsy sample from the kidney. (© SJ Divers, University of Georgia)
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10.28 Endoscopic orchidectomy via the left prefemoral fossa in a chelonian. (a) A mechanical holding arm (c) supports the endoscope and camera (e), which permits the surgeon to, (b) utilize 3 mm grasping forceps (f) and monopolar scissors (s) to dissect the testis (t) free. (© LM Proenca and SJ Divers, University of Georgia)
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10.29 Endoscope-assisted oophorectomy in a terrapin. (a) Following a prefemoral surgical approach to the coelom, the telescope (t) and forceps (f) are introduced and used to locate the ipsilateral ovary. (b) Endoscopic view of the several ovarian follicles (o) associated with the ipsilateral ovary. The closely associated bladder (b) and colon (c) are also visible. (c) Atraumatic 3 mm forceps (f), or long haemostats, are used to grasp the interfollicular tissue to avoid rupturing a follicle. (d) Gently, the ovary is retracted towards the prefemoral incision using the forceps (f). (e) Once the ovary is partially exteriorized the forceps and telescope are placed to one side and gentle digital retraction is used to exteriorize the entire ovary. (f) The ovarian ligament and associated vasculature are ligated before resecting the ovary free. The endoscope and forceps are then reinserted into the coelom to locate the contralateral ovary, which is removed in a similar fashion. A final endoscopic evaluation is performed to ensure adequate haemostasis and that all ovarian tissue has been removed. The coelom is closed in a routine manner. (© SJ Divers, University of Georgia)
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