laparoscopic removal of an ovarian granulosa cell tumor antonio m. cruz diplomate american college...

Laparoscopic Removal of an Ovarian Granulosa Cell Tumor

Antonio M. CruzDiplomate American College of Veterinay Surgeons

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.

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

Complementary Diagnostic Tools

• Transrectal ultrasoundCharacteristic “honeycomb”appearance

Clinical diagnosis:

Granulosa cell tumor

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).

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

Ovarian (Granulosa Cell) Tumor

• How to know Behaviour

Rectal examination Ultrasound Hormons levels Biopsy/aspiration

Rosie’s recommended treatment

Surgical removal of the ovary (Ovariectomy)

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

Options for Removal of Ovary (ovariectomy)

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.

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.

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.

Ovariectomy- Minimally Invasive (Laparoscopic)

In the Anesthetized

mare for very large

ovaries

Fischer, Eq. Diag& Surg laparoscopy

In the standing mare

thorugh the flank for normal

or moderate size ovaries

Loesch, 2003. Comp Cont Educ Vet Pract

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

Ovariectomy- Minimally Invasive (Laparoscopic)

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

Prognosis

Removal tumor.

Hormonal normalization

Normal reproductive activity

ONLY IF 1 OVARY IS REMOVED

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)

IN PREPARATION FOR ROSIE’S SURGERY

• Clipping and scrubbing surgical area

• Sedation• Local anesthesia

OPERATING ROOM SET UP FOR ROSIE

STERILE SURGICAL FIELD

VIDEO OF ROSIE’S PROCEDURE

Click on image

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.

END RESULT

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