Endoscopy, biopsy and endosurgery

image of Endoscopy, biopsy and endosurgery
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The first routine use of endoscopy in birds occurred in the late 1970s for sexing monomorphic species. In the past few years it has become important for diagnostic purposes (including biopsy) and more recently for endoscopy-guided surgery. This chapter reviews technical requirements, preparation and contraindications, laparoscopy, tracheobronchoscopy, gastroscopy, endoscopy-guided biopsy, endoscopic findings, and surgical endoscopic procedures.

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13.1 Different endoscopes, top to bottom: 1.9 mm, 2.7 mm, 4 mm diameter. The inset shows 0 and 30 degrees viewing angles. (© Michael Lierz)
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13.2 A Teflon tube with a flexible 22 gauge needle makes the precise endoscopic application of medicines and the performance of aspiration biopsy (e.g. cysts) easily possible. (© Michael Lierz)
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13.3 Basic set of equipment for endoscopy-guided surgery in birds, connectable to a radiosurgery unit. 1 = monopolar sling; 2 = monopolar scissors; 3 = monopolar grasping forceps; 4 = bipolar coagulation forceps. Fixation plate for birds, specially designed for endoscopic procedures. (© Michael Lierz)
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13.4 Laparoscopy. Internal organs to be evaluated through the entrance (E). 1= lung, 2 = heart, 3 = liver, 4 = intestine, 5 = kidney, 6 = spleen, 7 = proventriculus. The arrow shows the direction of the endoscope for full exploration of the body cavity. 1 = lung, 2 = heart: 3 = liver, 4 = intestine, 5 = kidney, 6 = gonads and adrenal gland, 7 = spleen, 8 = proventriculus, 9 = ventriculus. Triangulation from behind the last rib (A) with the cranial border of the iliotibialis muscle (B), identifies the site of entry into the body cavity (C). The iliotibialis muscle is pushed caudally using curved forceps. Increasing the pressure punctures the body wall and either the caudal thoracic air sac or the abdominal air sac is entered. (© Michael Lierz)
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13.5 Correct handling of the endoscope. The hand should be in contact with the bird. (© Michael Lierz)
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13.6 First view after entering the abdominal air sac; a = kidney; b = gonad (ovary); c = intestine; d = adrenal gland; e = uterus, ureter. Looking slightly more downwards. 1 = spleen; 2 = adrenal gland; 3 = kidney; 4 = intestine; 5 = proventriculus. (© Michael Lierz)
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13.7 First view after entering the caudal thoracic air sac. 1 = liver; 2 = proventriculus; 3 = lung; 4 = retrograde entrance to the lung; 5 = hole in air sac, made by surgeon to enter the abdominal air sac. The connection between the caudal thoracic air sac and lung allows a retrograde internal exploration of the lung, evaluating the honeycomb structure. Such a view is not possible performing a tracheobronchoscopy. (© Michael Lierz)
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13.8 Overview after turning the endoscope cranially. a = liver; b = heart; c = heart fat; d = lung. Pushing the endoscope further cranially. 1 = heart; 2 = left brachiocephalic trunk; 3 = space for pushing the scope further cranial to the thyroid gland. Passing the heart to evaluate the bird further cranially, the brachial plexus can be seen. (© Michael Lierz)
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13.9 Direction of the endoscope to evaluate the thyroid gland; 1 = heart, 2 = left brachiocephalic artery, 3 = thyroid gland. The same view; 1 = thyroid gland, 2 = trachea. (© Michael Lierz)
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13.10 Within the duodenal loop, the pancreas (arrowed) is visible. (© Michael Lierz)
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13.11 Sex determination in females. In juvenile females the suspensory ligament (1) of the ovary is already visible (2 = kidney; 3 = ovary; 4 = adrenal gland). The gonads are sometimes very difficult to distinguish as they are very small in juvenile birds. In some species the ovary may be pigmented. A swollen discoloured follicle is a sign of folliculitis. (© Michael Lierz)
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13.12 Sex determination in males. Although the gonad is very difficult to assess in juveniles, the missing suspensory ligament indicates a male bird (unless it has been removed for sterilization). 1 = kidney; 2 = adrenal gland; 3 = juvenile testis. Sometimes both testes (a) are visible (b = adrenal gland; c = kidney; d = intestine). In very rare cases of hermaphroditism, both testis and ovary are visible. (© Michael Lierz)
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13.13 Tracheoscopy. Correct positioning, extending the neck and using a beak speculum. The opening of the trachea is located at the base of the tongue. (© Michael Lierz)
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13.14 Correct positioning of a falcon for gastroscopy. Intubation and a head position lower than the body avoids aspiration of fluid. (© Michael Lierz)
Image of Endoscope within a working channel for fluid expansion of hollow organs. a = taps; b = working channel for additional instrument; arrows = fluid direction.
Endoscope within a working channel for fluid expansion of hollow organs. a = taps; b = working channel for additional instrument; arrows = fluid direction. Endoscope within a working channel for fluid expansion of hollow organs. a = taps; b = working channel for additional instrument; arrows = fluid direction.
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13.15 View into the cloaca. The white stripes represent the passing of urine within the washing fluid. (© Michael Lierz)
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13.17 Biopsy sites. In the case of a diffuse alteration of the liver, the sample is taken from its border. In the case of a diffuse alteration of the air sac, the sample is taken from the entrance hole for the endoscope. (© Michael Lierz)
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13.19 Air sac. The air sac of a healthy bird is like a window. Organs can be seen behind and there are few vessels. Increased vascularity indicates inflammation. Air sac aspergillosis is often easy to diagnose, as the fungal growth gives a clear picture. Foreign material (here exudate) is a clear sign of infection and can easily be sampled during endoscopy for cytology and microbiology. (© Michael Lierz)
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13.20 Urate crystals within the lung indicate gout. (© Michael Lierz)
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13.21 Kidney and sacral plexus. Above the kidney the sacral plexus is visible. A 30 degree endoscope makes this evaluation much easier. Loss of structure of the kidney indicates severe swelling. Yellow-white foci within the kidney may be gout but may also be a sign of exsicosis (reversible deposits of urate within the tubuli). If the cause is gout, the foci persist following fluid therapy. (© Michael Lierz)
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13.22 Exudate between the intestinal loops is often a sign of peritonitis or may be egg material (egg peritonitis). (© Michael Lierz)
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13.23 Liver. Normal appearance, with homogenous brown-red colour and a sharp liver border. A rounded liver border represents swelling and is a strong indication for biopsy. Colour change is always pathological. Here, haemosiderosis is seen. Multiple white foci are necrosis or granulomas/tubercles. Differentials are , salmonellosis, tuberculosis or herpesvirus infection. (© Michael Lierz)
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13.24 A swollen spleen is often seen with systemic infections. Spleen biopsy may be of value if the agent cannot be detected elsewhere. (© Michael Lierz)
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13.25 Trachea. Normal appearance of the trachea and bifurcation. The complete tracheal rings are clearly visible. A foreign body (awn) in the trachea of a falcon after transportation on straw. As it had just happened, the tracheal mucosa shows only a slight reaction. (© Michael Lierz)
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13.26 The oesophagus of a healthy falcon. (© Michael Lierz)
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13.27 Double-entry technique for minimal invasive surgery in birds: sites for (1) additional working channel for instruments and (2) entrance of the endoscope. (© Michael Lierz)
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13.28 Triple-entry technique for minimal invasive surgery in birds: sites for (1) entrance of the endoscope and (2) two additional working channels for instruments. (© Michael Lierz)
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13.29 Triple-entry technique for minimal invasive surgery by pushing the leg cranially and entering the body cavity ventral to the leg muscles. (© Michael Lierz)
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13.30 Correct triangulation of endoscope (middle) and instruments is vital for successful surgery. (© Michael Lierz)
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13.31 Female sterilization. A diode laser can be used to vaporize the gonads (here ovary) in juvenile birds. Cranial pole of the kidney of a female falcon 6 months after sterilization using a diode laser. Ovarian tissue is absent. (© Michael Lierz)
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13.32 Sterilization of an adult male bird. The deferent duct is lifted and cut with scissors. The procedure must be performed at two places to remove at least 1 cm of the duct to prevent reunion. Remnants of the deferent duct 5 months after sterilization. (© Michael Lierz)
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13.33 Reunion of the two ends of a deferent duct after it was cut, without having a section removed. (© Michael Lierz)
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13.34 Castration of a juvenile male bird. Immediately after vaporization of the testis using a diode laser. 6 months later. Testicular tissue is no longer visible. (© Michael Lierz)
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