Evaluation of the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy to a small animal general practice

• Autores: Kelly Jones, Joseph Brad Case, Brian Evans, Eric Monnet
• Localización: JAVMA: Journal of the American Veterinary Medical Association, ISSN-e 0003-1488, Vol. 250, Nº. 7, 2017, págs. 795-800
• Idioma: inglés
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• Resumen

  • OBJECTIVE To evaluate the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy to a small animal general practice.

    DESIGN Prospective study.

    SAMPLE A single 2-veterinarian small animal practice in southern California.

    PROCEDURES In early 2012, endoscopic equipment was purchased, and both veterinarians in the practice undertook training in rigid endoscopic and laparoscopic procedures. Subsequently, information for client-owned animals that underwent endoscopic and laparoscopic procedures during a 12-month period (2012 to 2013) was collected. Cost of equipment and training, revenue generated, specific procedures performed, surgery time, complications, and client satisfaction were evaluated.

    RESULTS 78 endoscopic procedures were performed in 73 patients, including 71 dogs, 1 cat, and 1 rabbit. Cost of endoscopic and laparoscopic equipment and training in the first year was $14,809.71; most equipment was financed through a 5-year lease at a total cost of $57,507.70 ($ 10,675.20/y). Total revenue generated in the first year was $50,423.63. The most common procedures performed were ovariectomy (OVE; n = 49), prophylactic gastropexy (6), and video otoscopy (12). Mean ± SD surgery times for OVE (n = 44) and for OVE with gastropexy (5) were 63.7 ± 19.7 minutes and 73.0 ± 33.5 minutes; respectively. Twelve of 54 patients undergoing laparoscopic procedures experienced minor intraoperative complications. Conversion to laparotomy was not required in any patient. There were no major complications. All 49 clients available for follow-up were satisfied.

    CONCLUSIONS AND CLINICAL RELEVANCE With appropriate training and equipment, incorporation of basic rigid endoscopy and laparoscopy may be feasible in small animal general practice. However, results of the present study are not applicable to all veterinarians and practice settings, and patient safety considerations should always be paramount.

    Endoscopic surgery, including a large variety of thoracoscope and laparoscopic techniques, has become common in human medicine. For example, laparoscopic cholecystectomy has replaced open cholecystectomy as the gold standard for treatment of patients with uncomplicated gallbladder disease.1 In veterinary patients, laparoscopic surgery is becoming increasingly common but is typically restricted to specialty practices and teaching hospitals because of the specialty training and knowledge required to perform the procedures safely and the associated equipment costs. Nonetheless, in part because of client demand, many veterinarians in general practice are currently performing basic laparoscopic procedures in small animals (eg, OVE and prophylactic gastropexy). Several studies2–4 suggest that patients undergoing laparoscopic procedures may experience decreased signs of pain, fewer surgical site infections, and less soft tissue trauma, compared with traditional open surgeries, which is appealing to veterinarians and clients. However, as for endoscopic surgery in general, laparoscopic surgery has a relatively steep learning curve, which may increase surgery time, cost, and the risk of complications when performed by inexperienced practitioners. These factors may dissuade some veterinarians from performing these procedures.

    Multiple studies in human surgery have demonstrated that adequate training and experience is critical to the safety of patients undergoing laparoscopic procedures. Laparoscopic surgery presents specific technical challenges, including the fulcrum effect created by the requirement for insertion of instruments through small portals in the body wall, the necessity of viewing the 3-D surgical field on a 2-D screen, and the need for the camera to be under an assistant's control. In particular, the unique surgical situation created by the absence of 3-D visualization can cause a loss of depth perception and alter hand-eye coordination.5 In human surgery, residents initially train via simulation on box trainers and by means of virtual reality, with various requirements to complete skills curricula as they progress to assisting in the operating room.6 In 1 study,7 second-year medical students showed significant improvement with use of a virtual reality trainer for minimally invasive surgical skills; however, their skill plateau was not reached until 21 to 29 repetitions and in some cases > 30 repetitions. For residents in human surgical residency training programs to be eligible for the general surgery board examination, they are required to complete the Fundamentals of Laparoscopic Surgery skills curriculum, which is a comprehensive laparoscopic training program with a certifying test at completion.8 Similar application of simulation-based skills training curricula is being investigated and developed in veterinary surgery.9,10 Fransson et al,9 for example, reported similar results when evaluating skill acquisition by veterinary students, residents, and board-certified surgeons using a low-fidelity laparoscopic trainer.

    It has previously been reported that abdominal access is associated with a high rate of complications when performing laparoscopic surgery in human patients. In a study11 of 103,852 procedures, for instance, 82% of vascular injuries and 75% of visceral injuries occurred at the time of the first trocar insertion. In a recent retrospective study12 of 618 dogs undergoing laparoscopic OVE, splenic lacerations reportedly occurred in 6 (1%) patients. The same authors reported postoperative complications in 99 (16%) dogs, including incisional inflammation and infection requiring antimicrobial treatment, incisional seroma formation, and incisional herniation.12 Multiple studies in human patients have reported that the rate of complications in patients undergoing laparoscopic procedures is inversely correlated with surgeon experience.13–15 In a recent study14 evaluating the learning curve for a single surgeon performing urologic laparoscopic surgery, the complication rate plateaued after 601 procedures performed over 3 years.

    In addition to technical challenges, the success of incorporating rigid endoscopy and laparoscopy in a general practice is contingent on economic viability.16 In veterinary medicine, there is an absence of economic and clinical data relevant to the implementation of endoscopy and laparoscopy in general practice; however, surgical training laboratories are taught at many professional conferences. Thus, reports on the basic training required for minimally acceptable proficiency, associated equipment and training costs, and acceptable surgery times and complications are needed. As such, the purpose of the study reported here was to evaluate the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy to a single small animal general practice. Specifically, we wanted to compare investment costs with revenue generated during the first 12 months after introduction of rigid endoscopy and laparoscopy to the practice, to identify the training acquired by staff veterinarians and the procedures performed during those first 12 months, to record times for laparoscopic OVE and laparoscopic gastropexy and document any complications associated with these procedures, and to determine client satisfaction with endoscopic and laparoscopic procedures. Our hypotheses were that the introduction of basic rigid endoscopy and laparoscopy in this small animal general practice would be economically and clinically feasible and that client responses would be favorable.