Compendium April 2000
EMERGING TECHNOLOGY
Endoscopy in Small Animal
Medicine and Surgery
Elizabeth A. Carsten, DVM,
Diplomate, ACVIM, and
Stephen D. Gilson, DVM,
Diplomate, ACVS
Sonora Veterinary Specialists
Phoenix, Arizona
E
ndoscopy refers to fiberoptic,
video, and rigid endoscopy.
The principle of total internal
reflection in fiberoptics allows light
to be transmitted through a flexible
system for both illumination and vi-
sualization. A large number of very
fine, coated glass fibers are combined
to form a flexible bundle that is used
for image transmission and illumina-
tion. Video endoscopes replace the
image bundle with an electronic sig-
nal transmission system; the image is
“read” by a video chip and displayed
on a monitor. Special video cameras
(endocouplers) can also be attached
to fiberoptic endoscopes to produce a
combination system for video display
and recording. Flexible fiberoptic and
video instruments are used to evalu-
ate the respiratory, gastrointestinal
(GI), and urogenital tracts. Rigid en-
doscopes use a noncoherent fiber
light transmission bundle for illumi-
nation but a series of glass lenses for
optical transmission. Rigid endo-
scopes are used for rhinoscopy, arthros-
copy, cystoscopy, laparoscopy, and
thoracoscopy procedures.
History
Endoscopy was first described in
the early 1800s, but advances were
20TH ANNIVERSARY
V
not made in the discipline until the
late 1800s, when optical lenses were
incorporated into viewing devices and
incandescent bulbs were invented.1
Laparoscopy was pioneered by Kell-
ing in 1902 when he inserted a cysto-
scope into the abdomen of a dog.2
Thoracoscopy quickly followed in the
early 1900s when a cystoscope was
used in humans in an attempt to break
down adhesive tuberculosis lesions.3
In 1987, Mouret performed the first
laparoscopic cholecystectomy; an ex-
plosion of simultaneous work devel-
oping endless endoscopic surgical
techniques and equipment soon fol-
lowed.4
Uses
When using flexible endoscopes,
gastroduodenoscopy and colonoscopy
allow direct examination and mucosal
biopsy of the GI tract from these areas
and in many cases, retrieval of gastric
foreign bodies without the need for
invasive exploratory laparotomy. En-
doscopy is considered more reliable
than is barium series for diagnosing
esophagitis, chronic gastritis, GI ul-
ceration, gastric neoplasia, inflamma-
tory bowel disease, and colitis. Biopsy
samples obtained with endoscopy are
associated with less morbidity and
thus should be obtained regardless of
gross mucosal appearance. The most
significant limitation of GI endoscopy
is the inability to examine the entire
length of intestine (especially the je-
junum and ileum).
Flexible endoscopic bronchoscopy
is one of the best diagnostic tests for
evaluating canine and feline lower air-
Small Animal/Exotics
way disease. No other procedure al-
lows direct evaluation of both ana-
tomic and functional aspects of the air-
ways while simultaneously allowing
collection of samples. Before proceeding
with the bronchoscopy, thoracic ra-
diographs should be obtained to fully
evaluate all thoracic structures (heart,
pleural space, chest wall, lungs, air-
ways) and help identify areas of con-
cern to evaluate during the bronchos-
copy.
Similarly, rhinoscopy is a noninva-
sive technique that is considerably less
traumatic than surgical exploration
but allows direct visualization of and
sample collection from the nasal cavi-
ty, nasal turbinates, and nasopharynx.
Occasionally, the frontal sinuses can
be examined through the nasal cavity,
or they can be accessed directly by
trephining a hole in the outer table of
the frontal bone. Typically, a flexible
endoscope is used to evaluate the na-
sopharynx, and rigid endoscopes are
used to evaluate the rest of the nasal
cavity. Rhinoscopy is essential to diag-
nosing nasal disease but cannot always
be relied on to provide a diagnosis by
itself. Successful diagnosis of chronic
nasal disease is considerably enhanced
by taking a thorough and systematic
approach centered around effective
rhinoscopic examination.
Depending on the size and sex of
patients, both small flexible fiberoptic
and rigid endoscopes are used for cys-
toscopy and vaginoscopy. The advan-
tages of using cystoscopy instead of
other diagnostic techniques are many:
It provides minimally invasive direct
visualization of the vagina, urethral
Small Animal/Exotics
opening, urethra, bladder, and ureter-
al openings. Visualization of these
structures, even where accessible by
surgery, is superior with cystoscopy
because of the magnification provided
and elimination of distortion.
Arthroscopy is a minimally invasive
technique that evaluates soft tissue
structures and joint cartilage not visi-
ble on radiographs. In addition, some
structures can be visualized better
with arthroscopy than with surgery.
Decreased morbidity and shortened
recovery times are two advantages of
arthroscopy over arthrotomy. Thus
arthroscopy is rapidly becoming the
diagnostic tool of choice in evaluating
shoulder lameness. Disadvantages in-
clude its limitation during diagnostic
and corrective surgical procedures in
small patients.
Although all these procedures are
widely used in veterinary medicine, la-
paroscopic and thoracoscopic tech-
niques are more recent advances. La-
paroscopy is a minimally invasive
method for evaluating intraabdominal
structures. Organs that can be visually
inspected and/or biopsied include the
liver, gallbladder, spleen, kidneys, uri-
nary bladder, prostate, vas deferens,
ovaries, uterus, adrenal glands, stom-
ach, pancreas, small and large intestine,
lymph nodes, and peritoneal surfaces.
At this time, laparoscopy is used most
frequently in veterinary medicine to
obtain hepatic and renal biopsy sam-
ples. The greatest advantage of lapa-
roscopy compared with exploratory la-
parotomy is the lower morbidity and
mortality because trauma to the pa-
tient is minimized. However, the po-
tential benefits for veterinary patients
are only beginning to be explored.
Many laparoscopic techniques current-
ly being used in human medicine (i.e.,
cholecystectomy, intestinal biopsy, gas-
trotomy/enterotomy, GI resection and
anastomosis, gastrostomy/enterostomy
tube placement, gastropexy) are being
evaluated for their applicability in vet-
erinary patients. The main disadvan-
tage of laparoscopy may be the inabili-
ty of veterinarians to evaluate deeper
parenchymal lesions.
With expanded efforts to explore
minimally invasive surgical tech-
niques, thoracoscopy has stimulated
renewed interest in human thoracic
medicine and surgery. The use of tho-
racoscopy has been limited to a few
veterinarians and referral centers, with
only a few reports of thoracoscopy in
the veterinary literature. The tech-
nique is considerably less invasive
than is traditional thoracotomy and
has much lower morbidity and mor-
tality. The view obtained with thora-
coscopy is often better than that ob-
tained with traditional thoracotomy
because any structure within the tho-
rax can be visualized and is magnified
by the endoscope. In veterinary medi-
cine, thoracoscopy has been used to
diagnose intrathoracic pathology (es-
pecially hilar and mediastinal masses),
evaluate fluid loculation versus solid
masses, and treat malignant pleural
effusions and pericardial diseases.1 In
human medicine, thoracoscopy has
also been used for general thoraco-
scopic exploration, staging of neopla-
sia, assessment of lesion resectability,
implantation of pacemaker lead wires,
and correction of vascular anomalies.3
Currently, endoscopy is most wide-
ly applied for diagnostic procedures in
veterinary medicine, and the limita-
tions are being reached. The future of
endoscopy in veterinary medicine
centers around therapeutic and inter-
ventional procedures. Therapeutic en-
doscopy is only limited by the inno-
vation and skill of endoscopists.
Equipment
The type of flexible fiberoptic or
video endoscope purchased (see Com-
mon Equipment Manufacturers) de-
pends on personal preference. Because
the image is displayed on a screen,
video endoscopes are advantageous
for sterile applications during surgery
and as a teaching tool, with examina-
tions recorded onto a standard video-
tape for further review. However,
Compendium April 2000
Common Endoscopy
Manufacturersa
Karl Storz Veterinary
Endoscopy
175 Cremona Drive
Goleta, CA 93117
800-968-7776
www.karlstorz.com
Pentax Precision
Instrumentation Corp.
30 Ramland Road
Orangeburg, NY 10962-2699
800-431-5880
www.pentaxmedical.com
Olympus America Inc.
2 Corporate Center Drive
Melville, NY 11747-3157
516-844-5000
www.olympus.com
aIn addition to these major manu-
facturers of endoscopic equipment,
numerous dealers also sell the equip-
ment.
video capability is not required for the
procedure. In addition, if a flexible fi-
beroptic endoscope is initially pur-
chased, a video camera can be pur-
chased later. Flexible endoscopes are
available in various diameters and
lengths (Figure 1). The flexibility of
endoscopes varies between two- and
four-way directional bending.
Four-way bending allows greater ma-
nipulation of the endoscope tip, thus
providing endoscopists with a better
view of the area being examined; how-
ever, this feature costs more. The size
of the biopsy port should also be con-
sidered, especially if multiple endo-
scopes are being purchased, because
one set of instruments can be used in
multiple flexible endoscopes if the di-
ameter of the biopsy port is the same
on all of them.
Rigid endoscopes (Figure 2) are
available in various diameters, ranging
from 1.9 to 10 mm. Larger-diameter
rigid endoscopes provide more light
for better visualization and photo-
Compendium April 2000
Figure 1—Flexible endoscope with
7.9-mm outer diameter, 2-mm chan-
nel, 100˚ field of view, 210˚ up angu-
lation, 90˚ down angulation, and 100˚
right and left angulation.
graphic results and thus serve as a bet-
ter teaching tool. Smaller-sized endo-
scopes facilitate applications in small
patients but have less field of view and
transmit less light. Although tradi-
tional thoracoscopic instrumentation
is shorter than that commonly used in
laparoscopy, laparoscopic instruments
can easily be substituted in veterinary
patients, which markedly decreases
the cost of obtaining specific thoracic
instrumentation in practices that al-
ready perform laparoscopy. In addi-
tion, for such procedures as rhinos-
copy, cystoscopy, and arthroscopy,
rigid endoscopes can be used instead
Common Endoscopic
Accessories
Aspiration tubes
Biopsy forceps and needles
Bougies for stricture dilation
Cryosurgery probes
Curettes
Cytology brushes
Dissectors
Electrocoagulation forceps and
snares
Exploration probes
Forceps and baskets for
removing foreign bodies
Forceps for removing sutures
Gastrointestinal staplers
Hemostatic clip applicators
Needle holders
Power-driven cartilage shavers
Rongeurs
Scissors
Special suture material
Tissue graspers
Figure 2—Arthroscope with 2.8-mm
diameter and 30˚ angle.
of small flexible endoscopes, which are
more expensive. Accessory equipment
(e.g., sleeves, bridges) is needed to use
rigid endoscopes for diagnostic and
therapeutic procedures (e.g., guided
biopsies, foreign body retrieval).
The gastroscope (Figure 1) and 2.8-
mm diameter 30˚ arthroscope (Figure
2) are the workhorse endoscopes in
veterinary practices. The gastroscope
can be used for all GI procedures and
bronchoscopy in medium- and large-
breed dogs. The arthroscope can be
used for rhinoscopy, sinoscopy, and
bronchoscopy in small dogs and cats,
laparoscopy, cystoscopy, vaginoscopy,
prepuceoscopy, otoscopy, and arthros-
copy. Additional endoscopes depend
on the demands of each practice but
might include a 4-mm diameter rigid
cystoscope and 5-mm diameter flexi-
ble endoscope.
TABLE ONE
Endoscopic Equipmenta
Equipment
Flexible fiberoptic endoscope
Endocoupler
Video endoscope light source
Rigid endoscope
Light cable
Tungsten light source
Xenon light source
Monitor, printer, and video recorder
Insufflator
Flexible endoscopic accessories
Rigid endoscopic accessories
aAnnual maintenance costs approximately $1000 to $2000 per endoscope, and the
average lifetime of endoscopes is about 10+ years with good maintenance.
Small Animal/Exotics
The light source for endoscopy is
remote from the area of examination
to allow a much brighter light to be
used and avoid the problems of inade-
quate lighting and heat damage to tis-
sue. The term cold light source evolved
because light is transmitted by the
fiberoptic bundle but heat is not. Al-
though a 150-watt tungsten light
source is less expensive, it may not be
adequate in some situations. Greater
illumination can be produced by a
300-watt xenon source, but many of
today’s more sensitive cameras do not
require excess lighting.
In addition to the endoscope and
light source, accessory instrumenta-
tion (see Common Endoscopic Acces-
sories) is needed to collect samples,
perform certain surgical procedures,
and remove foreign bodies. Although
accessories are relatively expensive,
they are not cost prohibitive. Mainte-
nance costs are minimal if accessories
are cared for properly (Table One).
Space Considerations
The amount of space devoted to en-
doscopy depends on the goals of the
practice. Flexible endoscopes and ac-
cessory instruments should be stored
hanging vertically, with care to protect
Estimated Cost (New)
$8000–$16,000+
$700–$900
$6500
$1800–$3000
$200
$400–$750
$3500
$700–$3500
$4000–$5000
$200–$500+
$200–$500+
Small Animal/Exotics
the camera at the distal end. Thus a storage closet should be
included in the purchasing plans. Except for rigid endo-
scopes, endoscope cases should only be used for transporting
the endoscope and not for routine storage. Rigid endoscopes
can be stored in their case or a padded drawer. A standard
cart can be lined with foam for storing most rigid endoscopic
equipment, with the light source and video equipment on
top. No additional surgical space is needed to perform endo-
scopic procedures.
Cleaning and Sterilization
In general, manufacturers will instruct veterinarians and
their staff on appropriate cleaning and care of endoscopic
equipment. After each procedure has been completed, endo-
scopes and accessories should be cleaned according to the
manufacturer’s instructions. Most rigid endoscopes can be
routinely sterilized for such procedures as arthroscopy, cys-
toscopy, laparoscopy, and thoracoscopy. Flexible endoscopes
used for sterile procedures need to be chemically or gas ster-
ilized according to the manufacturer’s instructions.
Compendium April 2000
Training and Education
Endoscopy must be learned hands-on. Many universities
and national meetings now offer courses in endoscopy, com-
plete with wet labs to familiarize veterinarians with tech-
niques and applications of a variety of equipment. For the
novice endoscopist, learning proper technique for endoscop-
ic procedures will initially be slow and cumbersome. Hands-
on completion of multiple procedures is usually needed be-
fore manipulation of the endoscope becomes familiar and
the endoscopist becomes more adept and efficient.
References
1. Bailey JE, Freeman LJ, Hardie RJ: Endosurgery, in Bojrab MJ, Elli-
son GW, Slocum B (eds): Current Techniques in Small Animal
Surgery, ed 4. Baltimore, Williams & Wilkins, 1998, pp 729–746.
2. Kelling G: Ueber oesophagoskopie, gastroskopie und kölioskopie.
Munch Med Wochenschr 49:21–24, 1902.
3. Walton RS: Diagnostic video-assisted thoracoscopy. Sixth Annu
ACVS Symp Small Anim Proc:393–396, 1996.
4. Cushieri A, Dubois F, Mouiel J: The European experience with la-
paroscopic cholecystectomy. Am J Surg 161:385–387, 1991.