Laparoscopic correction of experimentally induced diaphragmatic rupture in dogs1 1 Research performed at Veterinary Hospital, Universidade Estadual do Norte Fluminense Darcy Ribeiro (UENF), Campos dos Goytacazes-RJ, Brazil.

Diogo Benchimol de Souza Carlos Magno Anselmo Mariano Paulo Sérgio Cruz de Andrade Jr. Gabriela Correa Coelho Edmundo Jorge Abílio About the authors

Abstract

PURPOSE:

To describe the dog as a model for studying laparoscopic correction of experimental diaphragmatic ruptures.

METHODS:

Five male dogs were used in this study. Under laparoscopic approach, a defect of 7cm was created on the left ventral insertion of the diaphragm. Fourteen days after this procedure, the abdomen was explored using laparoscopic access and the diaphragmatic defect was corrected with intracorporeal suture. The dislocated organs, surgical time, and suturing time were recorded. Analgesia and clinical condition were monitored during the postoperative period.

RESULTS:

All animals recovered well from the diaphragmatic rupture creation. After 14 days, abdominal organs (liver, spleen, omentum and/or intestine) were found inside the thoracic cavity in all animals. It was possible to reposition the organs and suture the defect by laparoscopic access in three animals. These animals showed excellent postoperative recovery. It was not possible to reposition the liver safely when it was friable.

CONCLUSIONS:

Laparoscopic creation of diaphragmatic rupture in dogs is feasible. Dogs are a good model for training and studying the correction of experimentally created diaphragmatic rupture by the laparoscopic approach. A friable liver is a complicating factor that should be taken into account. Animals submitted to laparoscopic correction showed excellent postoperative recovery.

Diaphragm; Rupture; Laparoscopy; Models, Animal; Dogs


Introduction

Traumatic diaphragmatic rupture is a medical condition that allows abdominal organs to migrate into the thoracic cavity. Treatment commonly requires the replacement of dislocated organs and suture of the diaphragmatic defect, usually by open laparotomy or thoracotomy11. Morgan BS, Watcyn-Jones T, Garner JP. Traumatic diaphragmatic injury. J R Army Med Corps. 2010 Sep;156(3):139-44. doi: 10.1136/jramc-156-03-02.
https://doi.org/10.1136/jramc-156-03-02...
.

The use of laparoscopy to diagnose diaphragmatic rupture was first described in 198422. Adamthwaite DN. Traumatic diaphragmatic hernia: a new indication for laparoscopy. Br J Surg. 1984 Apr;71(4):315. PMID: 6231076., but the first laparoscopic correction of this disease was reported only in 199433. Frantzides CT, Carlson MA. Laparoscopic repair of a penetrating injury to the diaphragm: a case report. J Laparoendosc Surg. 1994 Apr;4(2):153-6. PMID: 8043925.. Since then, several authors have reported the early recovery and low incidence of postoperative complications in patients submitted to this minimally invasive approach44. Cueto J, Vazquez-Frias JA, Nevarez R, Poggi L, Zundel N. Laparoscopic repair of traumatic diaphragmatic hernia. Surg Laparosc Endosc Percutan Tech. 2001 Jun;11(3):209-12. PMID: 11444756.

5. Domene CE, Volpe P, Santo MA, Onari P, Szachnowicz S, Pinotti HW. Laparoscopic treatment of traumatic diaphragmatic hernia. J Laparoendosc Adv Surg Tech A. 1998 Aug;8(4):225-9. PMID: 9755915.

6. Horstmann O, Neufang T, Post S, Stephan H, Becker H. Laparoscopic diagnosis and therapy of closed traumatic diaphragmatic rupture. Chirurg. 1996 Jul;67(7):744-7. PMID: 8925702.

7. Meyer G, Huttl TP, Hatz RA, Schildberg FW. Laparoscopic repair of traumatic diaphragmatic hernias. Surg Endosc. 2000 Nov;14(11):1010-4. doi: 10.1007/s004640000206.
https://doi.org/10.1007/s004640000206...

8. Pojarliev T, Tzvetkov I, Blagov J, Radionov M. Laparoscopic repair of traumatic rupture of the left diaphragm cupola with prosthetic mesh. Surg Endosc. 2003 Apr;17(4):660. doi: 10.1007/s00464-002-4216-3.
https://doi.org/10.1007/s00464-002-4216-...

9. Rasiah KK, Crowe PJ. Laparoscopic repair of a traumatic diaphragmatic hernia. J Laparoendosc Surg. 1995 Dec;5(6):405-7. PMID: 8746994.

10. Rossetti G, Brusciano L, Maffettone V, Napolitano V, Sciaudone G, Del Genio G, Russo G, Del Genio A. Giant right post-traumatic diaphragmatic hernia: laparoscopic repair without a mesh. Chir Ital. 2005 Mar-Apr;57(2):243-6. PMID: 15916154.

11. Xenaki S, Lasithiotakis K, Andreou A, Chrysos E, Chalkiadakis G. Laparoscopic repair of posttraumatic diaphragmatic rupture. Report of three cases. Int J Surg Case Rep. 2014; 5(9):601-4. doi: 10.1016/j.ijscr.2014.07.007.
https://doi.org/10.1016/j.ijscr.2014.07....

12. Zarzavadjian Le Bian A, Costi R, Smadja C. Delayed right-sided diaphragmatic rupture and laparoscopic repair with mesh fixation. Ann Thorac Cardiovasc Surg. 2014;20(Suppl):550-3. doi: 10.5761/atcs.cr.12.02065.
https://doi.org/10.5761/atcs.cr.12.02065...
- 1313. Baldwin M, Dagens A, Sgromo B. Laparoscopic management of a delayed traumatic diaphragmatic rupture complicated by bowel strangulation. J Surg Case Rep. 2014 Jul 16;2014(7). doi: 10.1093/jscr/rju073.
https://doi.org/10.1093/jscr/rju073...
.

The development of an animal model for experimental and/or training purposes regarding laparoscopic correction of diaphragmatic rupture is of interest, but has not been reported yet. Thus, the objective of the present study is to describe the dog as a model for diaphragmatic rupture development and correction, both by minimally invasive approaches.

Methods

All experiments were performed in accordance with Brazilian laws on scientific use of animals, and the project was approved by the institutional ethics committee (CEUA-012-06).

Five healthy male mongrel dogs weighing 15-25 Kg were used in the study. Clinical examinations were performed, and the animals were observed for at least 15 days before the experiment.

Dogs were housed together in an area with space of 5 m2/dog. There was free access to water and the animals were fed with commercial dog food, twice a day. The dogs were allowed to walk and play in a ~5,000 m2 outdoor area twice /day.

Creation of diaphragmatic rupture

Animals were premedicated with acepromazine (0.05 mg/Kg, IM) and fentanyl (0.003 mg/Kg, IM). The anesthesia was induced with propofol (3mg/kg, IV) followed by Atracurium (0.5 mg/Kg, IV) and maintained with isoflurane in oxygen. The whole abdomen, from the xiphoid to the pubis, was prepared for aseptic surgery.

Pneumoperitoneum of 12 mmHg was created with a Veres needle and then a first 10mm trocar was introduced on the umbilical scar in order to insert the laparoscope (30o). After initial inspection, a 10 mm trocar and a 5 mm trocar were placed in the right and left cranial abdominal quadrants. The table was tilted to a 15o Fowler position, intra-abdominal pressure was reduced to 6 mmHg and the diaphragm was incised on the left ventral insertion with scissors and hook, applying monopolar energy. Hemorrhagic points were coagulated with bipolar energy. The defect created was measured with a piece of polypropylene tube from a butterfly needle, previously cut to 7 cm. This tube was introduced from a reducer and stretched with two forceps (Figure 1a). The cavity was desuflated, the 10 mm port incisions and skin were closed. Needle thoracocentesis was performed for drainage of residual CO2.

Figure 1.
Laparoscopic images. a) Polypropylene tube (arrows) stretched with two forceps used to measure the diaphragmatic defect. A, abdominal wall; D, diaphragm. b) Congested and friable liver (L) inside the thoracic cavity with effusion (E). c) Intracorporeal suturing for correction of diaphragm rupture. Needle (arrow) being inserted in the diaphragm. d) Final aspect of the sutured diaphragmatic defected.

Correction of diaphragmatic rupture

Fourteen days after the creation of the diaphragmatic rupture, dogs were anaesthetized with the same protocol and prepared for laparoscopy. Pneumoperitoneum of 6mmHg was created by Hasson technique with introduction of the first trocar 2 cm caudal to the umbilicus. Other trocars (10 mm and 5 mm) were inserted at the right and left side just caudal to the first surgery's scars. After complete inspection of the cavity with special attention to the diaphragm, the table was tilted to a 15o Fowler position, dislocated organs were replaced into the abdominal cavity and intracorporeal simple continuous suture was placed on the defect using 2-0 polyglactin 910. The cavity was desuflated and the 10 mm port incisions and skin were closed. Needle thoracocentesis was performed for drainage of residual CO2.

Postoperative evaluation and analgesia

The animals were individually monitored during the first seven days following surgery. Rectal temperature, general state, behavior, dyspnea, food and water consumption, production of feces and urine, wound state and any other abnormal findings were evaluated.

Cetoprofen was administered just after the anesthetic induction (1 mg/Kg, IV) and during the following three days (1 mg/Kg, PO, q 24h). Tramadol (2 mg/Kg ,IM) was administered in case of a score higher than 8 based on the University of Melbourne Pain Scale1414. Firth AM, Haldane SL. Development of a scale to evaluate postoperative pain in dogs. J Am Vet Med Assoc. 1999 Mar 1;214(5):651-9. PMID: 10088012.. This postoperative protocol was used for the surgeries to create and correct of the diaphragmatic rupture.

Results

Creation of diaphragmatic rupture

The use of scissors and hook with monopolar energy was successful in promoting the diaphragmatic defect. Some small hemorrhagic points were promptly cauterized with bipolar forceps.

The insertion of a piece of polypropylene tube was an easy and useful maneuver to measure the created defect.

After the first incision on the diaphragm, the passage of gas from the abdominal to the thoracic cavity was observed, even after the reduced insufflation pressure of 6 mmHg. This procedure left the thorax in a barrel shape. This insufflation pressure was enough to perform all maneuvers. No abdominal organ was found displaced through the thoracic cavity at the end of this surgery. The mean surgical time was 47.5 minutes.

Correction of diaphragmatic rupture

In all animals studied, both the diaphragmatic defect and dislocated organs were promptly visualized during laparoscopy. The liver was the most frequently dislocated organ (60%) and in two animals (40%) it was seen congested and very friable. Pleural effusion was present in those two animals (Figure 1b). The omentum (40%), spleen (20%), and small intestine (20%) were the other organs found in the thorax. It was possible to notice in some animals adherences among the falciform ligament, omentum and the edge of the diaphragmatic defect.

The major difficulty observed in the surgeries was repositioning the dislocated friable liver. The traction of the organ with laparoscopic instruments was not a practical method, since in one of the animals it provoked parenchymal lesions. As a consequence, bleeding was observed after repositioning of the organ into the abdomen, requiring conversion to open surgery. In the other animal with friable dislocated liver, conversion to open surgery was performed after unsuccessful attempts of repositioning the organ into abdominal cavity.

All other dislocated organs, including the liver without congestion, were easily replaced by traction with Babcock forceps. The adherences here observed were promptly dissected with Hook or Maryland forceps.

Intracorporeal diaphragmatic suture was successfully performed in three dogs in an average time of 54 minutes, from the introduction to the removal of the needle from the cavity (Figures 1c and d). The mean surgical time in the animals that were submitted to intracorporeal suture was 106 minutes.

Postoperative evaluation and analgesia

The animals submitted to laparoscopy showed excellent recovery after anesthesia. They promptly accepted food less then 30 minutes after extubation. No changes in rectal temperature, food and water intake, production of feces and urine and behavior were noted. Surgical wounds did not show any sign of infection, healing uneventfully. Dyspnea was also absent in all animals. None of these animals needed administration of tramadol.

The dogs that underwent laparotomy for correction of the diaphragmatic defect showed inapetence and apathy in the early postoperative period, with slower anesthetic recovery. After 24 hours, food and water were accepted, but the animals general state was not good, and higher rectal temperature (39.7oC), behavior changes and dyspnea were observed. Analgesic evaluation showed scores of 9 and 10, thus requiring administration of tramadol. An improvement in the general state, return to normal behavior as well a reduction of dyspnea were observed by the third and fourth postoperative day.

Discussion

In our study it was possible to correct with laparoscopy diaphragmatic rupture experimentally induced in dogs when the liver was not friable. The major difficulty concerned the proper replacement of this organ, since it could not be securely grasped with laparoscopic instruments. The repositioning of the liver dislocated to thoracic cavity was previously reported1515. Fiscon V, Portale G, Migliorini G, Frigo F. Laparoscopic repair of intrathoracic liver herniation after traumatic rupture of the diaphragm. Surg Endosc. 2011 Oct;25(10):3423-5. doi: 10.1007/s00464-011-1721-2.
https://doi.org/10.1007/s00464-011-1721-...
, but the authors did not find the organ friable as in the present experiment.

It is well known that when excessive hepatic manipulation is needed during laparoscopic surgery, a hand-assisted approach may be indicated, in order to avoid parenchymal injuries by the laparoscopic instruments, allowing fast manual compression of hemorrhagic points and preserving tactile sensation of the organ1616. Kooby DA, Fong Y. Laparoscopic liver surgery. In: Soper NJ, Swanstrom LL, Eubanks WS, (eds). Mastery of endoscopic and laparoscopic surgery. 2ed. Philadelphia: Lippincott Willians & Wilkins; 2005. p.342-54.. Therefore the hand-assisted approach may be of benefit when a friable liver is found during laparoscopic correction of diaphragmatic rupture.

Intracorporeal suturing is considered an advanced minimally invasive skill that demands a long learning curve1717. Madan AK, Frantzides CT, Tebbit CL, Park WC, Kumari NV, Shervin N. Evaluation of specialized laparoscopic suturing and tying devices. JSLS. 2004 Apr-Jun;8(2):191-3. PMID: 15119669.

18. Nguyen NT, Mayer KL, Bold RJ, Larson M, Foster S, Ho HS, Wolfe BM. Laparoscopic suturing evaluation among surgical residents. J Surg Res. 2000 Sep;93(1):133-6. doi: 10.1006/jsre.2000.5969.
https://doi.org/10.1006/jsre.2000.5969...
- 1919. Tan A, Razvi H. Evaluation of a novel modified suture material designed to facilitate intracorporeal knot tying during laparoscopic surgery. J Endourol. 2005 Nov;19(9):1104-8. doi: 10.1089/end.2005.19.1104.
https://doi.org/10.1089/end.2005.19.1104...
. Suturing is considered difficult because of the absence of tactile sensation, lack of depth perception, magnification of all movements and limitations of instrument mobility2020. Adams JB, Schulam PG, Moore RG, Partin AW, Kavoussi LR. New laparoscopic suturing device: initial clinical experience. Urology. 1995 Aug;46(2):242-5. doi: 10.1016/S0090-4295(99)80200-3.
https://doi.org/10.1016/S0090-4295(99)80...
. In our study, intracorporeal suturing was a very time-consuming phase, but did not hamper the use of the minimally invasive technique for correcting the diaphragmatic defect.

The introduction of automatic suturing devices in laparoscopic surgery reduces suturing and operative times1818. Nguyen NT, Mayer KL, Bold RJ, Larson M, Foster S, Ho HS, Wolfe BM. Laparoscopic suturing evaluation among surgical residents. J Surg Res. 2000 Sep;93(1):133-6. doi: 10.1006/jsre.2000.5969.
https://doi.org/10.1006/jsre.2000.5969...
, 2020. Adams JB, Schulam PG, Moore RG, Partin AW, Kavoussi LR. New laparoscopic suturing device: initial clinical experience. Urology. 1995 Aug;46(2):242-5. doi: 10.1016/S0090-4295(99)80200-3.
https://doi.org/10.1016/S0090-4295(99)80...
. However, the use of these devices can also reduce time for correction of diaphragmatic ruptures, although the unavailability did not preclude the procedure.

Laparoscopic correction of diaphragmatic rupture in clinical settings has been reported by many authors and it is always associated with shorter hospital stay, faster return to normal activities and minimal postoperative complications44. Cueto J, Vazquez-Frias JA, Nevarez R, Poggi L, Zundel N. Laparoscopic repair of traumatic diaphragmatic hernia. Surg Laparosc Endosc Percutan Tech. 2001 Jun;11(3):209-12. PMID: 11444756.

5. Domene CE, Volpe P, Santo MA, Onari P, Szachnowicz S, Pinotti HW. Laparoscopic treatment of traumatic diaphragmatic hernia. J Laparoendosc Adv Surg Tech A. 1998 Aug;8(4):225-9. PMID: 9755915.

6. Horstmann O, Neufang T, Post S, Stephan H, Becker H. Laparoscopic diagnosis and therapy of closed traumatic diaphragmatic rupture. Chirurg. 1996 Jul;67(7):744-7. PMID: 8925702.

7. Meyer G, Huttl TP, Hatz RA, Schildberg FW. Laparoscopic repair of traumatic diaphragmatic hernias. Surg Endosc. 2000 Nov;14(11):1010-4. doi: 10.1007/s004640000206.
https://doi.org/10.1007/s004640000206...

8. Pojarliev T, Tzvetkov I, Blagov J, Radionov M. Laparoscopic repair of traumatic rupture of the left diaphragm cupola with prosthetic mesh. Surg Endosc. 2003 Apr;17(4):660. doi: 10.1007/s00464-002-4216-3.
https://doi.org/10.1007/s00464-002-4216-...

9. Rasiah KK, Crowe PJ. Laparoscopic repair of a traumatic diaphragmatic hernia. J Laparoendosc Surg. 1995 Dec;5(6):405-7. PMID: 8746994.

10. Rossetti G, Brusciano L, Maffettone V, Napolitano V, Sciaudone G, Del Genio G, Russo G, Del Genio A. Giant right post-traumatic diaphragmatic hernia: laparoscopic repair without a mesh. Chir Ital. 2005 Mar-Apr;57(2):243-6. PMID: 15916154.

11. Xenaki S, Lasithiotakis K, Andreou A, Chrysos E, Chalkiadakis G. Laparoscopic repair of posttraumatic diaphragmatic rupture. Report of three cases. Int J Surg Case Rep. 2014; 5(9):601-4. doi: 10.1016/j.ijscr.2014.07.007.
https://doi.org/10.1016/j.ijscr.2014.07....

12. Zarzavadjian Le Bian A, Costi R, Smadja C. Delayed right-sided diaphragmatic rupture and laparoscopic repair with mesh fixation. Ann Thorac Cardiovasc Surg. 2014;20(Suppl):550-3. doi: 10.5761/atcs.cr.12.02065.
https://doi.org/10.5761/atcs.cr.12.02065...
- 1313. Baldwin M, Dagens A, Sgromo B. Laparoscopic management of a delayed traumatic diaphragmatic rupture complicated by bowel strangulation. J Surg Case Rep. 2014 Jul 16;2014(7). doi: 10.1093/jscr/rju073.
https://doi.org/10.1093/jscr/rju073...
. The present study reports comparable postoperative results in experimental animals, which may be another advantage of this technique. Thus, the use of this model can be considered for both training and research purposes. In a previous study, pigs were used to create and immediately correct small diaphragmatic tears2121. Kozar RA, Kaplan LJ, Cipolla J, Meija J, Haber MM. Laparoscopic repair of traumatic diaphragmatic injuries. J Surg Res. 2001 May 15;97(2):164-71. doi: 10.1006/jsre.2001.6131.
https://doi.org/10.1006/jsre.2001.6131...
.

It has been demonstrated that thoracic insufflation with carbon dioxide with or without associated abdominal insufflation causes cardiopulmonary effects such as decrease in oxygen saturation, arterial blood pressure and cardiac output, and increases in peak inspiratory and central venous pressure2222. Daly CM, Swalec-Tobias K, Tobias AH, Ehrhart N. Cardiopulmonary effects of intrathoracic insufflation in dogs. J Am Anim Hosp Assoc. 2002 Nov-Dec;38(6):515-20. doi: 10.5326/0380515.
https://doi.org/10.5326/0380515...
, 2323. Marcus DR, Lau WM, Swanstrom LL. Carbon dioxide pneumothorax in laparoscopic surgery. Am J Surg. 1996 May;171(5):464-6. doi: 10.1016/S0002-9610(96)00009-8.
https://doi.org/10.1016/S0002-9610(96)00...
. One study that mentions insufflation pressure for correction of diafragmatic rupture in clinical conditions used 10 mmHg. In that study, the authors postulated that low pressure should be used to avoid CO2 passage through the mediastinum with potential complications2424. Slim K, Bousquet J, Chipponi J. Laparoscopic repair of missed blunt diaphragmatic rupture using a prosthesis. Surg Endosc. 1998 Nov;12(11):1358-60. PMID: 9788863.. In our study, using 6 mmHg insufflation, it was possible to observe CO2 passage to both hemithoraxes, leaving the chest in a barrel shape. We believe that experimental hemodynamic studies of animals submitted to different abdominal insufflation pressures in the presence of diaphragmatic rupture may be important to define safe insufflation pressures.

Conclusions

Dogs can be used as a model for laparoscopic creation of diaphragmatic rupture for research and education purposes. Laparoscopic correction of experimentally created diaphragmatic rupture in dogs is feasible with intra-corporeal suturing. The possibility of a friable liver is a complicating factor that should be taken into account. All animals had the major advantage of excellent postoperative recovery.

References

  • 1
    Morgan BS, Watcyn-Jones T, Garner JP. Traumatic diaphragmatic injury. J R Army Med Corps. 2010 Sep;156(3):139-44. doi: 10.1136/jramc-156-03-02.
    » https://doi.org/10.1136/jramc-156-03-02
  • 2
    Adamthwaite DN. Traumatic diaphragmatic hernia: a new indication for laparoscopy. Br J Surg. 1984 Apr;71(4):315. PMID: 6231076.
  • 3
    Frantzides CT, Carlson MA. Laparoscopic repair of a penetrating injury to the diaphragm: a case report. J Laparoendosc Surg. 1994 Apr;4(2):153-6. PMID: 8043925.
  • 4
    Cueto J, Vazquez-Frias JA, Nevarez R, Poggi L, Zundel N. Laparoscopic repair of traumatic diaphragmatic hernia. Surg Laparosc Endosc Percutan Tech. 2001 Jun;11(3):209-12. PMID: 11444756.
  • 5
    Domene CE, Volpe P, Santo MA, Onari P, Szachnowicz S, Pinotti HW. Laparoscopic treatment of traumatic diaphragmatic hernia. J Laparoendosc Adv Surg Tech A. 1998 Aug;8(4):225-9. PMID: 9755915.
  • 6
    Horstmann O, Neufang T, Post S, Stephan H, Becker H. Laparoscopic diagnosis and therapy of closed traumatic diaphragmatic rupture. Chirurg. 1996 Jul;67(7):744-7. PMID: 8925702.
  • 7
    Meyer G, Huttl TP, Hatz RA, Schildberg FW. Laparoscopic repair of traumatic diaphragmatic hernias. Surg Endosc. 2000 Nov;14(11):1010-4. doi: 10.1007/s004640000206.
    » https://doi.org/10.1007/s004640000206
  • 8
    Pojarliev T, Tzvetkov I, Blagov J, Radionov M. Laparoscopic repair of traumatic rupture of the left diaphragm cupola with prosthetic mesh. Surg Endosc. 2003 Apr;17(4):660. doi: 10.1007/s00464-002-4216-3.
    » https://doi.org/10.1007/s00464-002-4216-3
  • 9
    Rasiah KK, Crowe PJ. Laparoscopic repair of a traumatic diaphragmatic hernia. J Laparoendosc Surg. 1995 Dec;5(6):405-7. PMID: 8746994.
  • 10
    Rossetti G, Brusciano L, Maffettone V, Napolitano V, Sciaudone G, Del Genio G, Russo G, Del Genio A. Giant right post-traumatic diaphragmatic hernia: laparoscopic repair without a mesh. Chir Ital. 2005 Mar-Apr;57(2):243-6. PMID: 15916154.
  • 11
    Xenaki S, Lasithiotakis K, Andreou A, Chrysos E, Chalkiadakis G. Laparoscopic repair of posttraumatic diaphragmatic rupture. Report of three cases. Int J Surg Case Rep. 2014; 5(9):601-4. doi: 10.1016/j.ijscr.2014.07.007.
    » https://doi.org/10.1016/j.ijscr.2014.07.007
  • 12
    Zarzavadjian Le Bian A, Costi R, Smadja C. Delayed right-sided diaphragmatic rupture and laparoscopic repair with mesh fixation. Ann Thorac Cardiovasc Surg. 2014;20(Suppl):550-3. doi: 10.5761/atcs.cr.12.02065.
    » https://doi.org/10.5761/atcs.cr.12.02065
  • 13
    Baldwin M, Dagens A, Sgromo B. Laparoscopic management of a delayed traumatic diaphragmatic rupture complicated by bowel strangulation. J Surg Case Rep. 2014 Jul 16;2014(7). doi: 10.1093/jscr/rju073.
    » https://doi.org/10.1093/jscr/rju073
  • 14
    Firth AM, Haldane SL. Development of a scale to evaluate postoperative pain in dogs. J Am Vet Med Assoc. 1999 Mar 1;214(5):651-9. PMID: 10088012.
  • 15
    Fiscon V, Portale G, Migliorini G, Frigo F. Laparoscopic repair of intrathoracic liver herniation after traumatic rupture of the diaphragm. Surg Endosc. 2011 Oct;25(10):3423-5. doi: 10.1007/s00464-011-1721-2.
    » https://doi.org/10.1007/s00464-011-1721-2
  • 16
    Kooby DA, Fong Y. Laparoscopic liver surgery. In: Soper NJ, Swanstrom LL, Eubanks WS, (eds). Mastery of endoscopic and laparoscopic surgery. 2ed. Philadelphia: Lippincott Willians & Wilkins; 2005. p.342-54.
  • 17
    Madan AK, Frantzides CT, Tebbit CL, Park WC, Kumari NV, Shervin N. Evaluation of specialized laparoscopic suturing and tying devices. JSLS. 2004 Apr-Jun;8(2):191-3. PMID: 15119669.
  • 18
    Nguyen NT, Mayer KL, Bold RJ, Larson M, Foster S, Ho HS, Wolfe BM. Laparoscopic suturing evaluation among surgical residents. J Surg Res. 2000 Sep;93(1):133-6. doi: 10.1006/jsre.2000.5969.
    » https://doi.org/10.1006/jsre.2000.5969
  • 19
    Tan A, Razvi H. Evaluation of a novel modified suture material designed to facilitate intracorporeal knot tying during laparoscopic surgery. J Endourol. 2005 Nov;19(9):1104-8. doi: 10.1089/end.2005.19.1104.
    » https://doi.org/10.1089/end.2005.19.1104
  • 20
    Adams JB, Schulam PG, Moore RG, Partin AW, Kavoussi LR. New laparoscopic suturing device: initial clinical experience. Urology. 1995 Aug;46(2):242-5. doi: 10.1016/S0090-4295(99)80200-3.
    » https://doi.org/10.1016/S0090-4295(99)80200-3
  • 21
    Kozar RA, Kaplan LJ, Cipolla J, Meija J, Haber MM. Laparoscopic repair of traumatic diaphragmatic injuries. J Surg Res. 2001 May 15;97(2):164-71. doi: 10.1006/jsre.2001.6131.
    » https://doi.org/10.1006/jsre.2001.6131
  • 22
    Daly CM, Swalec-Tobias K, Tobias AH, Ehrhart N. Cardiopulmonary effects of intrathoracic insufflation in dogs. J Am Anim Hosp Assoc. 2002 Nov-Dec;38(6):515-20. doi: 10.5326/0380515.
    » https://doi.org/10.5326/0380515
  • 23
    Marcus DR, Lau WM, Swanstrom LL. Carbon dioxide pneumothorax in laparoscopic surgery. Am J Surg. 1996 May;171(5):464-6. doi: 10.1016/S0002-9610(96)00009-8.
    » https://doi.org/10.1016/S0002-9610(96)00009-8
  • 24
    Slim K, Bousquet J, Chipponi J. Laparoscopic repair of missed blunt diaphragmatic rupture using a prosthesis. Surg Endosc. 1998 Nov;12(11):1358-60. PMID: 9788863.

  • Financial source: FAPERJ
  • 1
    Research performed at Veterinary Hospital, Universidade Estadual do Norte Fluminense Darcy Ribeiro (UENF), Campos dos Goytacazes-RJ, Brazil.

Publication Dates

  • Publication in this collection
    Aug 2015

History

  • Received
    06 Apr 2015
  • Reviewed
    11 June 2015
  • Accepted
    15 July 2015
Sociedade Brasileira para o Desenvolvimento da Pesquisa em Cirurgia Al. Rio Claro, 179/141, 01332-010 São Paulo SP Brazil, Tel./Fax: +55 11 3287-8814 - São Paulo - SP - Brazil
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