By Ed Gilsleider, DVM For The Education Center
Originally Published In Veterinary Practice News, November 2019 – Download as a PDF
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- Figure 1: Nile water monitor lizard pre-radiography.
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- Figure 2: DV radiograph revealing radiopacity in left candle quadrant.
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- Figure 3: Anesthetized and intubated for a laparotomy.
Patient
A three-year-old, 4.7-kg, male Nile water monitor lizard presented for decreased appetite of one week, no fecal production for five days, and lethargy (Figure 1). The physical exam was normal. An intestinal foreign body or bowel obstruction was suspected, so full-body radiography was performed. As can be seen on a dorsoventral view, a radiopaque object can be visualized in the left mid-quadrant, probably within the lumen of the intestine (Figure 2). Gas-distended bowel loops were adjacent to this apparent foreign body. An exploratory coeliotomy was recommended to the owner and would be performed the same day.
It was decided to utilize the CO2 laser for the surgery. With the laser, there is virtually no blood loss and the surgical field is clear, so there is less time devoted to hemostasis. In addition, postoperative pain is decreased and the laser cuts in a noncontact mode, which reduces the risk of infection.
Anesthesia
The lizard was anesthetized with sevoflurane via an induction mask and intubated; anesthesia was maintained with a non-rebreather oxygen delivery system. The patient was then placed on a heated surgery table in dorsal recumbency and aseptically prepared for surgery. Pulse oximetry was utilized to monitor his respirations and oxygen saturation.
Laser equipment and settings
The flexible hollow waveguide CO2 surgical laser was utilized (Aesculight, Bothell, Wash.) (Figure 4a). A midline ventral incision was performed utilizing the SuperPulse, continuous wavelength mode at 10 watts. The power for the intestine incision was reduced to 3 watts. The adjustable spot size handpiece was set to 0.25 mm (the handpiece is shown in Figures 4a, 4b, 5, 7a, 7b, and 7c).
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- Figure 4B: Laser incision through skin.
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- Figure 5: Incising the subcutaneous tissue and musculature.
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- Figure 6: Exteriorized intestines with foreign body in lumen.
Procedure
The 3.5-cm skin incision was accomplished to expose the ventral midline vasculature, which could be completely avoided because of a bloodless field of view (Figures 4a and 4b). A paramedian incision was then performed to penetrate the coelomic cavity (Figure 5). Careful exploration revealed the hard foreign body within the lumen of the small bowel. After the affected intestinal segment was exteriorized (Figure 6) and the area was packed off with sterile saline-soaked towels (as a backstop), the laser power was reduced to 3 watts and an incision was made through the serosa and mucosa (Figures 7a and 7b) and into the lumen to identify a small rock (Figure 7c and 7d). The intestinal incision was flushed with sterile saline. The incisions were closed with 3-0 Maxon monofilament absorbable suture material on a taper-point needle (Figure 7e). A simple continuous pattern through the serosa was chosen. Again, the intestines were lavaged with sterile saline and returned to the coelomic cavity, which also was lavaged with sterile saline.
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- Figure 7A: Laser enterotomy.
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- Figure 7B: Laser enterotomy.
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- Figure 7C: Rock encountered through enterotomy.
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- Figure 7D: Rock now visible.
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- Figure 7E: Closure of enterotomy site.
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- Figure 8: Appearance immediately post-surgery.
Wound closure
Two-layer closure of the body wall was next, utilizing the 3-0 Maxon suture material on a cutting needle in a simple continuous pattern, burying the last layer (Figure 8).
Postoperative recovery and care
Meloxicam @ 0.2 mg/kg and amikacin @ 5 mg/kg were administered by subcutaneous injection postoperatively. Recovery took place in a heated ICU chamber and was uneventful.
Amikacin @ 2.5 mg/kg was dispensed at discharge to be administered in 48 hours. The owner was instructed to offer a third of the patient’s normal prey 36 hours from surgery, and to keep him out of water for 14 days post-op. If he ate well, the amount of food could be increased over the next 72 hours. The patient ate but did not produce feces for 48 hours, so oral metoclopramide was dispensed. Feces were produced the following day, and he is now fully recovered.
Healing was smooth and with no complications. Figure 9 shows the happy patient two weeks post-surgery, strolling outside with a friend.
Ed Gilsleider, DVM, is a 1982 graduate of Kansas State University. He has been in Claremore, Okla., in his mixed animal practice since graduation. He has been married to Lisa for 41 years and has four adult children and eight grandchildren.
This Education Center article was underwritten by Aesculight of Bothell, Wash., manufacturer of the only American-made CO2 laser.
