RESEARCH ARTICLE 
J Res Vet Med. 2020: 39 (1) 15-20 
DOI:10.30782/jrvm.576554
Ultrasound Follow-up of Adhesions After one-Step Laparoscopic 
Abomasopexy for Correction of Left Displaced Abomasum in Cattle
 Göksen Çeçen Ayalp1,  İsmail Altuğ Şen1,
  nihal Yaşar Gül Satar1,   Sibel Tokoğlu Sert1
1Uludag University, Faculty of Veterinary Medicine, Department of Surgery, Bursa, Turkey
Received 2019-06-13  Accepted 2019-11-11
Abstract
The objective of this study was to evaluate the use of ultrasonography on the determination of the thickness of adhesion formation at the 
abomasopexy site in cows which had undergone one-step laparoscopic abomasopexy. Ten Holstein cows with left displaced abomasum (LDA) 
were included in the study. Animals were treated with one-step laparoscopic abomasopexy whilst standing. Postoperative ultrasonographic 
examinations were carried out starting immediately after surgery (day 0), and on days 28, 90 and 120 by using a 5 MHz linear transducer. The 
thickness of the adhesion formation was measured between the abdominal wall and the abomasum. Ultrasonographic image revealed the 
area of fixation on day 0 as a mild distorted subcutaneous tissue. A heterogeneous hypoechoic irregular-shaped mass (adhesion) was observed 
between the abomasum and abdominal wall on days 28, 90 and 120. Average thickness significantly (p <0.05) increased from day 0 to day 28, 
but tended to decrease afterwards. The average thickness at the abomasopexy site was recorded as 20.47, 22.82, 22.34
and 21.92mm on days 0, 28, 90 and 120, respectively.
Ultrasonographic examination can diagnose and measure adhesions between the abomasum and the abdominal wall. During the study peri-
od, adhesion formation was followed up to the 120th day, and in this period the thickness of the adhesion tended to decrease. Long follow-up 
studies are thought to be beneficial to determine the difference in adhesion thickness.
Keywords: LDA, one-step laparoscopic abomasopexy, ultrasound, adhesions, cattle
Introduction abdominal wall with the animal positioned in dorsal 
recumbency.2,13 
In recent years, laparoscopic abomasopexy (LA) tech-
niques have gained an acceptance for correction of left The advantages of one-step LA technique include confir-
displacement of the abomasum (LDA). The LA technique mation of the LDA and the ability to evaluate adhesions 
combines the minimal invasiveness and visual control between the abomasum and the left body wall or rumen. 
for abomasal positioning and fixation offered by  Furthermore, this technique can also be performed 
laparoscopy.4,11 Janowitz (1998), described a two-step completely in a standing cow, is procedurally simpler, 
laparoscopically guided toggle pin (TP) fixation and requires less time compared with the two-step LA 
technique for LDA. The one-step procedure developed procedure.14
by Christiansen (2004) and Barisani (2004) involves 
placement of the TP suture within the abomasal lumen The success of these techniques depends on developing 
under laparoscopic guidance via the left paralumbar inflammatory adhesions in the abomasal fi xa ti on  re gi on
area in a standing cow. The other one-step and these adhesions prevent recurrence of AD during the 
procedures are performed via the ventral 
* Corresponding author: Göksen Çeçen Ayalp, Adress: Uludag University, Faculty of Veterinary Medicine, Department of Surgery,
16059 Nilüfer, Bursa, Turkey. Telephone number: +90 224 294 08 40  E-mail: goksenc@uludag.edu.tr
15
Cecen Ayalp et al. 2020
current and the subsequent lactation.3,9 The degree and masopexy. In the preoperative period, the cows received 
persistence of adhesions formed after correction of LDA a single dose of flunixin meglumine (Finadyne®, Intervet 
using the laparoscopic TP suture techniques and espe- Co., 2.2 mg/kg bodyweight, intramuscularly). The surgical 
cially traditional laparotomy techniques are poorly site of the animal was aseptically prepared, and 2% solution 
characterized.14 The strength and size of adhesions required of prilocaine hydrochloride (Citanest®, Astra Zeneca PLC) 
to prevent recurrence after LA is unknown and further was infiltrated locally at the points of entry for the trocar/
research is required to address this issue.3,14 A few cannula units. 
authors have reported follow-up data for the assessment of 
adhesions of the abomasum to the body wall after Surgery was performed in the standing animal. Standard 
laparoscopic abomasopexy.1,3,18 The presence or absence of equipment was used (Dr. Fritz GmbH, Germany). The first 
adhesions, as well as their appearance at the site of the incision was made in the left paralumbar fossa behind the 
abomasopexy, were confirmed by laparoscopic visualization ribs and beneath the transverse processes and a trocar was 
or necropsy findings.3,18 The au thors ha ve  re ported re peat inserted into the abdominal cavity (portal site 1). Pneumo-
laparoscopy 90 days after surgery found strong adhesions peritoneum was obtained and the abdominal cavity was 
between the abomasum and body wall in all ten cows explored. For the second portal, the incision was made 
positioning the cow in dorsal recumbency. on the dorsal part of the 11th intercostal space. Next a tro-
Furthermore, strong adhesions were observed in four car-cannula unit was inserted in the 11th intercostal space 
cows that underwent repeat laparotomy 1 year after LA.3 under laparoscopic guidance. The long trocar was used for 
the placement of the toggle and for emptying the air from 
Ultrasonography, as a diagnostic imaging technique, the abomasum. A stainless steel toggle pin with 2 lengths 
provides reliable information concerning the abomasum of polyamide suture (synthetic pseudo-monofilament 
and its contents, and the condition of its wall enables non-absorbable suture; Kruuse Supramid, USP 3+4) at-
identi-fication and assessment of any changes in adjacent tached at its midpoint was inserted via the cannula into the 
structures.5,15 It is possible to measure the size of fibrinous abomasal lumen while the excess suture material remained 
adhesions between the abomasum and the abdominal exterior to the abdomen. The abomasum was deflated, and 
wall via ultrasonographic examination.1 In only one study, the excess suture material through with a long spieker were 
ul-trasonography was performed for the follow-up of pushed down into the abdominal cavity and the needle was 
adhe-sions in the postoperative period of two-step LA.1 To passed through the ventral aspect of the right abdominal 
our knowledge, there is no other study in the literature wall and the threads were pulled. The t w o t h reads w e re 
about ultrasound follow-up of adhesions after one-step passed through a rubber bottle cap and then knotted to-
LA for correction of LDA. gether. The abdomen was deflated and the incisions on the 
left abdomen were closed by polydioxanone suture (Mono-
The goal of this study was to evaluate adhesion plus, USP 2, Braun Aesculap, Tuttlingen) material.
formation and measure adhesion thickness at the fixation 
area by using ultrasonography in a 4-month follow-up In the postoperative period, the cows received ceftiofur 
after one-step LA procedure for correction of LDA in the hydrochloride (Excenel®, Zoetis Inc., 1.1 mg/kg 
standing cow. bodyweight) intramuscularly once a day for 3 days. 
After laparoscopic abomasopexy, the animals were 
Materials and Methods discharged on the day of surgery and allowed to mix 
This study plan was approved by Local Ethics with other cows. However, their feeding was kept under 
Committee of Uludag University (Decision no: control the day after surgery. All cows were fed with half 
2014-13/03). Ten Holstein cows with LDA were used for rations for the first three post-operative days and the 
this study. Each animal was subjected to a general physical following days were gradually increased. Full ration 
examination and special examination of the was started 7 days after surgery. Clinical follow-up of 
gastrointestinal system. The day prior to surgery, cows the animals was done on days 0, 28, 90, and 120. Skin 
were examined transabdominally with ultrasound on sutures on the left abdomen were removed on day 14. 
the left side of the abdomen and was mainly focused on Fixation sutures were not removed.
the examination of abomasal position and for the For the postoperative ultrasonographic examination, 
presence of adhesions. Ultrasonographic examinations the abomasum fixation area was investigated in 
were performed on non-sedated, standing cows using a transverse and longitudinal directions by using a 5 MHz 
5.0 MHz linear transducer (Mindray Z6 Vet, Turkey). linear probe (Mindray Z6 Vet, Turkey) in each case on 
Animals were treated with one-step laparoscopic abo- days 0, 28, 90, 
16
Cecen Ayalp et al. 2020
and 120. The abomasum, its contents and the condition of The macroscopic appearance of the site of fixation (the tis-
its wall and the adhesion formation were evaluated and the sue under and around the rubber bottle cap) in all cows 
thickness of the adhesion was measured between the ab- showed swelling with mild pain (inflammation) on day 28. 
dominal wall and the abomasal wall. The swelling noticeably decreased on successive examina-
tion days and was replaced by scar tissue. There was no 
Statistical Analysis: Data were analyzed by the GLM proce- suture material at the fixation site examined on day 90.
dure. Model was specified as full factorial and polynomial. 
Post Hoc Multiple Comparison was chosen by Tukey HSD Ultrasonographic findings: The abomasal wall appeared as 
Test. Bonferroni was chosen as certainty at interval adjust- an echoic line. The ingesta were mostly homogeneous in all 
ment. Differences were considered significant at a proba- cows. In 9 of the 10 cows, abomasal contractions were nor-
bility level of p<0.05 in all analyses. All statistical analysis mal (passive and slow movement) but an active movement 
was performed with SPSS software (version 23.0, SPSS Inc, of the abomasum was noticed in one case. A heterogeneous 
USA) statistical program. The continuous values were giv- hypoechoic irregular-shaped mass (adhesion formation) 
en as mean ± standard deviation (SD). was located between the abomasum and abdominal wall in 
all examinations (on day 28, 90 and 120).
Results
The cows with LDA had a mean age of 38.7 ± 21.9 (SD) On examination day 0, the area of fixation was observed as 
months ranging from 24 to 96 months. The mean weight a mild distorted subcutaneous tissue. The location of the 
was 497.5 ± 65.5 kg (SD) with a range of 425 to 600 kg. The toggle-pin was found at a central position within the abo-
duration of illness ranged from 1 to 7 days with a mean masum in relation to the fixation area with the presence 
of 3.9 ± 2.13 days (SD). All LDA cases were diagnosed af- of a comet-tail artifact. In this area, the thickness values 
ter hearing classical resonant sounds (pings) on simulta- varied from 14.29 to 27.39 mm; the average being 20.38 ± 
neous auscultation and percussion of the left flank, espe- 3.86 mm (mean ± SD).
cially over the last three ribs during clinical examination. 
In cows the abomasum was imaged with transabdominal On examination day 28, the toggle was visible in all cows 
ultrasonography over the left middle to upper third of the as a hyperechoic object with a comet-tail artifact but the 
abdomen especially at the 11—12th intercostal space and location was different. The toggle-pin position changed 
no adhesions were detected. cranially or caudally from the fixation area. The thickness 
values were 16.90 to 30.10 mm; the average being 22.68 ± 
One-step laparoscopic abomasopexy was successfully per- 3.75 mm (mean ± SD) (Figure 1). 
formed in all 10 cows. No abdominal organs were acci- Figure 1. A transverse (medial-lateral) ultrasound image on day 
dentally perforated during the entrance of the trocar and 28 postoperatively (case 6). The toggle-pin ( ↘ ) presenting the 
no major complications were encountered during surgery. characteristic feature of a comet-tail shadowing artifact (↙) . 
During exploration of the abdominal cavity, the distended (D): the distance between the abdominal wall and the toggle-pin,
abomasum was observed between the rumen and the ab- ( I) : Abomasum wall.
dominal wall on the left side. No other pathological find-
ings such as free fluid, adhesion or lesions were recorded. 
The median operation time, which was defined as the time 
required to insert the trocar and close the wound, was 46 
minutes (range, 29 to 76 min). The suture material was cut 
in some cases (cows 2, 4, and 8) by the lancet contained 
within the spieker during the placement of the suture in 
the right paramedian area. In these cases, this phase of the 
operation was repeated. This caused a prolongation of the 
operation time (mean 35 min).
In the postoperative period, gastrointestinal motility was 
restored within hours after surgery. The demand for water 
and hay increased in the postoperative period. Only in one 
case (case no. 9) recurrence of LDA was observed on day 
129. The animal was re-operated.
17
Cecen Ayalp et al. 2020
Figure 2. A longitudinal (cranial-caudal) ultrasound picture on wound complications. Similar results have been reported 
day 120 postoperatively (case 10) presenting irregular shaped in the literature.6,12,13,16 The average surgical time in our 
adhesion site (↙) which a hypoechoic area with small hypere- study was higher than that reported in the literature (46 
choic spots ( ↘), the abomasum wall (I). min).4,6,16 This difference c an be  tar ib uted to  h te nu mb er  
of cases in which the suture material was cut by the lan-
cet contained within the spieker during the withdrawal of 
the spieker from the abdominal wall in this study (30%), 
which increased the surgical time. The lower experience of 
the surgeons in this study could also have contributed to 
the increased surgical time. Similarly, Perotta et al. (2017) 
reported that the toggle thread was cut off by the trocar tip 
in one cow (4.76%).
The rates of recurrence after one-step laparoscopic 
abomasopexy were reported between 1.97% and 
9.52%.6,16 In this study, one cow showed recurrence 
(10%) of displacement on day 129 after surgery because 
of a lack of adhesion. The animal was re-operated. 
However, recurrence was not observed in other cows 
during the subsequent lactation period.
On examination day 90, the toggle-pin was not evident in The success of any operation to correct a displaced aboma-
ultrasound images in all cattle. The thickness values de- sum depends on the formation of an adhesion to hold the 
creased in comparison with the earlier period and were abomasum in position.7 Abomasopexy and manipulations 
measured as 12.63-27.87 mm, the average being 21.85 ± in the abdominal cavity cause adhesion formation at the 
4.23 mm (mean ± SD). site of operation.19 Only a few authors reported follow-up 
data for the assessment of adhesions of the abomasum 
On examination day 120, the thickness values varied from to the body wall after laparoscopic abomasopexy.1,3,18 I n  
19.91 to 27.70 mm; the average was 21.91 ± 2.54 mm (mean these studies, the presence or absence of adhesions, as well 
± SD). On the ultrasound image, there was a hypoechoic as their appearance at the site of the abomasopexy, were 
area with small hyperechoic spots (Figure 2). confirmed by laparoscopic visualization or necropsy fi nd -
A significant increase (p<0.05) was observed regarding the ings.3,18 In only one study, ultrasonography was performed 
adhesion thickness from day 0 and 28, and tended to de- for the follow-up of adhesions in the postoperative period 
crease afterwards (p>0.05) (Table 1). of two-step laparoscopic abomasopexy.1 To our knowledge, 
there is no other study in the literature about ultrasound 
Table 1. Ultrasonographic measurement values taken on differ- follow-up of adhesions after one-step laparoscopic abo-
ent days of examination masopexy for the correction of LDA.
Ultrasonography provides reliable information 
concerning the abomasum, its contents and the 
condition of its wall and various developments of 
p value:  0-90: p<0.080; 28-120: p<0.057; 90-120: p<0.066 adhesion-fibrous tissue formation in adjacent 
structures.1,15 The adhesion-fibrous tissue area can be 
Discussion and Conclusion characterized and manifested as echogenic deposits and 
One-step LA has been considered an advancement of the also as echogenic constricting bands or high-level 
two-step laparoscopic technique, and is charecterized by echoes, as suggested by researchers.17 Ultra-sonographic 
the ventral fixation of a toggle suture by using a spieker.16 images of the toggle-pin show typical artefacts (comet-
Our results show that one-step laparoscopic abomasopexy tail artifact) because of its metal structural nature.10 In 
technique is advantageous in many ways, with shorter this study, ultrasonographic examination was performed 
surgery time and faster postoperative recovery and char- in standing position by a 5 MHz linear transducer as 
acterized by higher food intake and lower incidence of suggested by other researchers.1,5,15 The abdominal wall, 
abomasum content and wall of the abomasum, and 
18
Cecen Ayalp et al. 2020
toggle pin were easily examined in this way. The authors would like to thank Hakan UZUN  School of 
Foreign Languages, and İ. Taci CANGUL from Uludag 
Al-Bayati (2011) was able to detect the toggle-pin in University, Faculty of Veterinary Medicine, Pathology 
ultrasonographic controls even on the 180th and 270th Department for linguistic reading of this manuscript.
days after o peration and also identified oval; round-
shaped hypoechoic adhesions between abomasal and Conflict of Interest Statement
abdominal walls. In our study, the toggle-pin was The authors declared that they had no conflict of interest.
detectable ultrasonographically on days 0 and 28, but References
could not be determined in any case on day 90. On the 1. Al-Bayati A. Development of abdominal adhesions af-
90th day of the cases, there was no suture material on ter laparoscopic abomasopexy. (PhD Thesis) College
the fixation line. It was considered that the suture of Veterinary Medicine, Justus-Liebig University Gies-
material had been continuously in contact with the sen, 2011:38-82.
abomasal content and therefore its strength was reduced 2. Babkine M, Desrochers A. Laparoscopic Surgery in
and the threads were broken by organ movements. Adult Cattle. Vet Clin Food Anim. 2005;21:251–279.
Ultrasonographically, the adhesion area showed a 3. Babkine M, Desrochers A, Bouré L, Hélie P. Ventral
heterogeneous hypoechoic irregular-shaped mass laparoscopic abomasopexy on adult cows. Can Vet
between the abomasum and abdominal wall on Journal. 2006;47:343–348.
examinations on day 28, 90 and 120. The adhesion 4. Barisani C. Evoluzione della tecnica di Janowitz per la
thickness tended to decrease from day 28 to day 120. risoluzione della dislocazione abomasale sinistra sec-
Similarly, in the study of Al-Bayati (2011), highest ondo Barisani. Summa 2004;5:35-39.
adhesion values were seen four weeks postoperatively 5. Braun U. Ultrasonography in gastrointestinal disease
and then decreased over time. in cattle. Vet Journal. 2003;166:112–124.
6. Christiansen K. Laparoskopisch kontrollierte Oper-
The localized inflammation at the site of fixation which ation des nach links verlagerten Labmagens (Janow-
was seen one month postoperatively may be due to the itz-Operation) ohne Ablegen des Patienten. Tierarztl
leakage of abomasal content into the wound area1 or as a Prax. 2004;32:118-121.
result of the normal defense mechanism against 7. Connell J. Four Methods of Surgical Correction of
the suture material.8 In our study, the swelling at the Abomasal Displacement in the Cow. Iowa State Uni-
fixation site noticeably decreased on day 90 and was versity Vet. 1976;38:21-24.
replaced by scar tissue. This decrease in tissue 8. Fecteau G. Peritonitis in the Ruminant. In: Large Ani-
reaction could be interpreted by the absence of suture mal Internal Medicine. 4th ed. Mosby, Elsevier, St Lou-
material. is, 2008:850-855.
9. Freick M, Sieber I, Endtmann A, Passarge U, Passarge
Although laparoscopic techniques have been widely O. Laparoscopic reposition of the displaced abomasum 
accepted in clinical practice for treatment of LDA, in a dairy herd in Saxony (Germany) - a case series
information about the strength and size of adhesions (Article in German). Tierärztliche Umschau. 2013;68:
required to prevent recurrence after LA is still 311 – 321.
inadequate and further research is required. To the best 10. Grechenig W, Clement HG, Fellinger M, Schleifer
of our knowledge, this is the first report describing P, Tesch PN. Ultrasound imaging and localization
ultrasonographic follow-up of adhesions after one-step of metal implants. A clinical study. Unfallchirurg.
laparoscopic abomasopexy for correction of LDA. 1996;22:117-123.
According to our findings, ultrasono-graphic 11. Janowitz H. Laparoscopic reposition and fixation of
examination provides useful information regarding the left displaced abomasum in cattle. Tierarztl Prax
adhesion formation at the abomasopexy site. Long Ausg G Grosstiere Nutztiere. 1998;26(6):308–313.
follow-up studies are thought to be necessary for the 12. Mulon PY, Babkine M, Desrochers A. Ventral laparo-
evaluation of the size, thickness and quality of the scopic abomasopexy in 18 cattle with displaced abo-
adhesion formation in the postoperative period. masum. Vet Surg. 2006;33:347-355.
13. Newman KD, Anderson DE, Silveira F. One-step lapa-
Acknowledgements roscopic abomasopexy for correction of left-sided dis-
This study was financially supported by the Scientific placement of the abomasum in dairy cows. J Am Vet
Re-search Projects Unit of Uludag University by the Med Assoc. 2005;227:1142-1147.
project number KUAP(V)-2014/8.
19
Cecen Ayalp et al. 2020
14. Newman KD, Harvey D, Roy JP. Minimally inva-
sive field abomasopexy techniques for correction
and fixation of left displacement of the abomasum
in dairy cows. Vet Clin N Am-Food A. Philadelphia,
2008;24(2):359-382.
15. Ok M, Arıcan M, Turgut K. Ultrasonographic findings
in cows with left and right displacement of abomasum.
Revue Méd Vét. 2002;15:15-18.
16. Perotta JH, Ollhoff RD, Naylor Lisboa JA, de Barros
Filho IR. One-step laparoscopy for the correction of
left abomasal displacement in high-yielding Holstein
dairy cows. Semina: Ciências Agrárias. 2017;38:1313-
1322.
17. Schmidt G. Thieme Clinical Companions: Ultrasound.
3rd ed. Stuttgart, New York, Georg Thieme Verlag;
2007.
18. Thomas KL, Wilson DG, Bracamonte Jl, Carmalt JL,
Luby CD. Quality of Adhesions After Sutured Para-
median vs. Laparoscopic Toggle Abomasopexy in an
Ovine Model. Vet Surg. 2016;45:488–493.
19. Zografos GC, Simeonidis KM, Messaris EG, Parasi
AS, Sotiriou HG, Dontas IA. Adhesion formation and
intraperitoneal catheters: histologic findings in a rat
model. Fertil Steril. 2005;83:516-518.
20