An 11-year-old Trakehner gelding required 2 ventral midline celiotomies for correction of a large colon volvulus and a large colon displacement, respectively. Laparoscopic colopexy was performed 50 days following the 2nd celiotomy. Delayed laparoscopic colopexy is minimally invasive and does not disrupt the ventral midline incision following abdominal exploration.

An 11-year-old Trakehner gelding was presented to the Western College of Veterinary Medicine with a 2-hour history of abdominal pain. On presentation, the temperature, pulse, and respiration rate were within normal limits. Gastrointestinal sounds were reduced on auscultation. Transrectal palpation revealed a moderately distended large colon and an absence of manure in the rectum. A tentative diagnosis of large colon displacement was made and an abdominal exploration was recommended. The horse was immediately placed under general anesthesia and a ventral midline celiotomy was performed. Exploration of the abdomen revealed a 360° volvulus of the large colon at the sternal and diaphragmatic flexures. The colon was returned to its normal position. The serosal surface of the colon was pink and the wall was minimally edematous. There were no other abnormalities in the abdomen. The abdomen was closed and the horse recovered from anesthesia uneventfully. The horse remained comfortable following surgery and was discharged without complications.

Seven weeks following discharge, the horse was presented again with abdominal pain. The temperature, pulse, and respiration were within normal limits. Gastrointestinal sounds were absent. Transrectal palpation exam revealed a moderately distended large colon. A tentative diagnosis of large colon displacement was made and an abdominal exploration was recommended. The horse was anesthetized and a 2nd ventral midline celiotomy was performed. Abdominal exploration revealed severe gaseous distension of the large colon with the pelvic flexure positioned cranially and to the left. The colon was decompressed and the pelvic flexure repositioned. The serosal surface of the colon was pink and peristaltic movements were present; however, the wall of the left ventral colon was moderately edematous. Colopexy was considered, but because the left ventral colon was mildly compromised, it was postponed. The abdomen was closed and the horse recovered from anesthesia uneventfully.

The horse was rested in a box stall until a laparoscopic colopexy could be performed. During this time, the horse exhibited 2 episodes of colic at 46 d and 48 d following the 2nd surgery. Physical examination at the time of both episodes did not reveal any abnormalities. Both colic episodes responded to 1 treatment of flunixin meglumine (Banamine; Schering-Plough Animal Health, Pointe-Claire, Quebec), 1.1 mg/kg body weight (BW), IV.

A laparoscopic colopexy, as described by Trostle et al (1), was performed 50 d following the 2nd ventral midline celiotomy. In order to facilitate laparoscopic examination of the abdomen, feed was withheld for 48 h prior to the procedure for the gastrointestinal tract to empty (2). Preoperative antibiotics included sodium penicillin (Penicillin G Sodium; Novopharm, Toronto, Ontario), 22 000 IU/kg BW, IV, and gentamicin (Gentocin; Schering-Plough Animal Health), 6.6 mg/kg BW, IV. The horse was sedated with xylazine (Rompun; Bayer, Toronto, Ontario), 1 mg/kg BW, IV, and 5% guaifenesin (Glycerol guaiacolate; BDH, Toronto, Ontario) IV, given to effect. Anesthesia was induced with ketamine (Vetalar; Vetrepharm, London, Ontario), 2 mg/kg BW, IV, and maintained with halothane in oxygen. The horse was placed in dorsal recumbancy and the ventral abdomen was prepared for aseptic surgery.

A 10-mm skin incision was made immediately to the right of the umbilicus and a teat cannula was inserted into the abdominal cavity (Figure 1). The abdomen was insufflated (Electronic Endoflator Model 234305-20; Karl Storz, Goeleta, California, USA) with carbon dioxide, through the teat cannula, to a pressure of 15 mm Hg. The teat cannula was removed and a laparoscopic cannula (Instrument Cannula; Karl Storz) was placed into the abdomen. A 10-mm diameter, 30% forward viewing laparoscope (Karl Storz, Goleta) was inserted through the laparoscopic cannula. A cranial instrument portal was placed 8 cm caudal to the xiphoid process and 2 cm to the left of the midline. Two caudal instrument portals were placed 5 cm and 15 cm to the left of midline on a transverse plane centered between the umbilicus and the prepuce. Each instrument portal consisted of a 10-mm skin incision with a laparoscopic trocar inserted into the abdomen at each site.

An incision was made through the skin and subcutaneous tissue at a point 10 cm left of midline and 20 cm cranial to the umbilicus. This incision was extended caudally for 25 cm and remained parallel with the midline. Laparoscopic foreceps (Atraumatic Babcock Grasper; Ethicon Endo-Surgery, Cincinnati, Ohio, USA) were inserted through the cranial instrument portal perpendicular to the body wall and the lateral taenia of the left ventral colon was grasped and pulled towards the proposed colopexy site on the abdominal wall. The colopexy suture material consisted of 60 cm lengths of number 2 polypropylene (Surgilene; Tyco Healthcare Group LP, Norwalk, Conneticut, USA) swaged onto a 1/3 circle reverse cutting needle. The needle was manually modified into a 1/2 curve needle to facilitate placement through the sheath of the rectus abdominis muscle (rectus sheath). The needle was introduced into the abdomen through the rectus sheath at the cranial aspect of the skin incision. Laparoscopic needle drivers (In-line Needle Holder; Ethicon Endo-Surgery) placed through either of the 2 caudal portals were used to manipulate the needle within the abdomen. The needle was passed across the entire width of the lateral taenia perpendicular to the long axis of the colon. The needle was then passed back through the rectus sheath to exit the abdomen. The suture was pulled and tied off so that the lateral taenia was in contact with the abdominal wall. The colopexy was completed with a simple continuous pattern by repeatedly passing the needle through the rectus sheath, across the taenia, and out through the rectus sheath, with 2-cm tissue spacing between each suture bite. An assistant maintained enough suture tension so that the lateral taenia contacted the body wall throughout the length of the colopexy. Two packets of suture material were required, with the first packet tied midway through the colopexy. The second packet was started, as previously described, and tied off when the colopexy measured 15 cm in length. All knots were tied in the subcutaneous space. The subcutaneous tissue at the colopexy site was closed with 2-0 polydioxanone (PDS II; Ethicon, Somerville, New Jersey, USA), using a simple continuous pattern, and the skin was closed with staples (Appose ULC; Tyco Healthcare Group LP). The external fascia of the rectus abdominis muscle at the laparoscopic portals was closed with number 1 polyglyconate (Maxon; Tyco Healthcare Group LP), using a single cruciate suture. The subcutaneous tissue was closed with 2-0 polydioxanone, using cruciate sutures, and the skin was closed with staples.

Recovery from anesthesia was uneventful. After the horse had been returned to the stall, 1 dose of flunixin meglumine 1 mg/kg BW, IV, was administered. The diet was not changed in the postoperative period and consisted of free choice alfalfa grass mix hay. The horse was discharged from hospital without complications. Because body weight was maintained during the immediate postoperative period following the laparoscopic procedure, specific dietary recommendations at discharge were not deemed necessary. The horse was confined to a box stall for a total of 60 d following colopexy with daily hand walking for 10 min. After the 60-day rest period, the horse returned to it's previous use for pleasure riding. Follow-up was performed at 16 mo. The owner did not report any weight loss and further colic episodes have not been observed.

Large colon displacement and volvulus in horses are common causes of abdominal pain that require exploratory celiotomy. The recurrence rate for these conditions has been reported at 15% (3). Following surgical correction, performing either a colopexy or a large colon resection can prevent large colon displacement and volvulus. Colopexy involves suturing the lateral band (taenia) of the left ventral colon to the abdominal wall, so that volvulus at the base of the cecum is minimized and displacement of the large colon is prevented (3). Large colon resection involves surgical removal of 80% to 95% of the large colon as close to the cecocolic ligament as possible (4), preventing further occurrences of displacement or volvulus. Certain disadvantages are associated with each of these techniques; therefore, they are usually reserved for horses that have had a recurrence of large colon displacement or volvulus.

The main disadvantage with performing a colopexy at the time of surgical correction is that suture placement into compromised intestine may predispose the colon to rupture at the colopexy site, because the vasculature of the colon is often compromised following displacement or volvulus, and the colonic wall may be edematous with decreased ability to hold sutures (1). Evaluation of colonic viability must be undertaken before a colopexy is performed (3,5). Parameters used to evaluate viability include subjective assessment of seromuscular color and mural edema (5). Suturing a compromised colon to the abdominal wall may result in dehiscence of the colopexy site or colonic rupture (5). Colopexies should not be performed if the large colon is considered severely edematous and compromised (3). In cases with intestinal compromise, the colopexy should be delayed until the large colon has healed (3). In this case, the colon was moderately edematous and of questionable viability; therefore, a colopexy was recommended at a later date, after the colon had healed. The main disadvantage of performing a delayed colopexy is that an additional ventral midline celiotomy is required.

Large colon resection for prevention of large colon displacement and torsion is also accompanied with certain disadvantages. The most common complication associated with large colon resection is the development of postsurgical peritonitis with persistent endotoxemia (4). Removal of the majority of the large colon can also result in decreased phosphorous digestion, increased fecal water, and weight loss when poor quality grass hay is fed; however, these problems can be managed by feeding high quality alfalfa hay and providing free choice water (6). Large colon resection was not performed at the 2nd celiotomy because we felt that the risk of postsurgical peritonitis did not warrant justification of the procedure.

Weight loss has been reported for horses where a colopexy was performed between the left ventral and right ventral colon (7,8). In one report, feed consumption was reduced in a majority of the horses that had received a colopexy (8). These researchers theorized that the anorexia and associated weight loss might have been due to mild, subclinical abdominal pain (8). The horse in this case was not anorectic following the colopexy and did not show any signs of abdominal pain. Only 1 dose of analgesic was administered immediately following the colopexy. Weight loss was not observed at any time following the colopexy.

The frequency of colonic rupture following colopexy has been reported at 4.5% (3). These ruptures have occurred between 4 and 12 wk following surgery. Because there is a small risk of rupture in horses that have received colopexies, athletic pursuits could theoretically add to the risk. To the authors' knowledge, there is no information regarding the effects of colopexy on athletic performance. Enterocutaneous fistulas may also develop if the suture material enters the lumen of the bowel. Entry into the lumen can be avoided by placing the needle flat to the surface of the taenia (3) and by creating a “mucosal slip” when the wall of the colon is grasped with laparoscopic forceps (1).

Laparoscopy in horses has been used for cryptorchidectomy, ovariectomy, abdominal exploration, inguinal herniorrhaphy, and cystorraphy (9). Trostle et al (1) have described a successful laparoscopic technique for performing colopexy in experimental horses. Delayed laparoscopic colopexy is less invasive than a ventral midline celiotomy and reduces the risk of rupture at the colopexy site. For this reason, we elected to perform this technique by using a laparoscopic approach (1).

Extensive abdominal adhesions may develop during the convalescence time period prior to delayed laparoscopic colopexy. If adhesions form between a viscus and the abdominal wall at the proposed instrument portal sites, then the adhered viscus may be inadvertently punctured on placement of the laparoscopic cannula. Ultrasonographic evaluation of the abdomen at the proposed instrument portal sites, theoretically, could detect adhesions by evaluating mobility between the intestines and the body wall. To the authors' knowledge, this ultrasonographic technique has not been reported in horses. Inadvertent puncture may also be reduced by using the open laparoscopic technique, in which the laparoscopic trocar is bluntly inserted into the abdomen through a small incision through the body wall (10).

Colopexy is a viable alternative to large colon resection for the prevention of large colon displacement and volvulus. The laparoscopic colopexy technique is minimally invasive and does not disrupt the ventral midline incision following abdominal exploration. CVJ