Case study: Robotic gastropexy to prevent Gastric Dilatation Volvulus

Dr Charles Kuntz performing what is likely to be the world-first FlexDex gastropexy on a dog.

Alfie is a one-year-old Burnese mountain dog. He was a cute, boisterous puppy, who came into the practice completely healthy and happy. He was the second Burnese in his family—his predecessor had passed away a couple of years before as the result of a Gastric volvulus. Alfie’s owners were obviously upset by that but had responded to a call we had put out to our referring vets for pets that may be of risk of Gastric Dilatation Volvulus (GDV) to find patients who may benefit from a new robotic surgery system called FlexDex.

GDV affects up to 45 per cent of some breeds at some point in their life. The breed that’s most likely to be affected is the Great Dane. Between 40 and 45 per cent of Great Danes at some time in their life are going to have a Gastric Dilatation-Volvulus. And if it’s untreated it can be fatal and even if treated, 30-40 per cent of dogs can still die.

The risk is highest in the larger and giant breed dogs that have a high ratio between the depth of the chest and the width of the chest—Irish wolfhounds, Great Danes, and greyhounds are most at risk. Burnese mountain dogs, Rottweilers, German shepherds, golden retrievers, labradors, and Doberman pinschers are also at risk. 

A recent study looked at the financial cost of the surgery versus the cost of treatment for GDV, and the risk for the proportion of dogs that have the surgery compared to dogs that don’t have the surgery and that have the GDV. It was shown that in any of the large breed dogs that financially, it’s worthwhile doing the gastropexy. When you also consider the fact that 30 to 45 per cent of these dogs are going to die, you have a huge emotional component as well. The preventative surgery is fairly innocuous and minimally invasive, and offers a virtual guarantee that volvulus won’t occur.

The progression of gastric torsion is rapid—between half an hour and two hours. The most typical progression is that suddenly the dog becomes very distressed and tries to vomit non-productively, the abdomen gets descended, the stomach flips and they go into shock. So preventative treatment is highly attractive to owners of these breeds.

Nonetheless, for most patients that have this surgery, it is done in combination with another abdominal surgery. A female dog getting spayed may have this as an additional procedure because they’re under anaesthetic and the abdomen has been opened. Gastropexy normally involves a 15 to 20cm incision in the abdomen. The stomach is identified, pulled to the side and sutured in place. There are some less invasive options—you can do a mini laparotomy under laparoscopic guidance— but you’re still looking at a five centimetre incision plus the scope incisions.

When the patient Alfie woke up post operation, he felt perfectly normal.

Doing it through the incision in the side of the body wall is much quicker but the disadvantage is that if any of suture bites enter the stomach, you can get an abscess in that area. The alternative now available is the FlexDex system, which allows robotic functionality without the expense of a $3,000,000 robotic surgery system. The entire surgery is performed through a couple of keyhole incisions with techniques such as suturing within the abdomen made quick, natural and intuitive, resulting in vastly reduced procedure times, less postoperative pain and fewer complications.

I became aware of the FlexDex system three years ago. I’ve been trying to get one shipped over from the US to Australia for two years, but it wasn’t approved by the TGA so it wasn’t possible. About three months ago I found out that there was a distributor for FlexDex in Australia. I contacted him and immediately got on the training program. I brought a unit home with a laparoscopic trainer so that I could practise and I got very confident and comfortable with doing the surgery. When we anaesthetised Alfie for the procedure everything went pretty much as clockwork.

I’ve been a surgeon for 25 years and this is one of the first times in a long time that I have had to learn a completely new skill. The FlexDex surgery system quickly becomes intuitive, but initially, the learning curve is steep. According to the distributor, some surgeons give up, becoming quickly frustrated with the feeling of incompetence and lack of mastery. Perseverance pays off with big gains in skill achieved within a few hours of practice.  

With traditional abdominal exploratory surgery you have a 20cm incision, and if the dog is too active after surgery they could burst their sutures and eviscerate out on the floor. Using the FlexDex system, because the incisions are only five to 10mm, even if those broke down there’s nothing that’s going to be able to get through there that’s of any importance and so the risk is significantly lower.

If I had done a full abdominal gastropexy Alfie would’ve been kept overnight and he would’ve been quite sore and sorry for himself the next day. As it was, using three little keyhole incisions between five and 10mm across, when he woke up, he felt completely normal. He was sent home the same day and his owner said he was a hundred per cent back to normal the next day.

A video of Dr Kuntz’s surgery is available at:

Dr Charles Kuntz, Specialist Surgeon

Dr Charles Kuntz

DVM, MS, MACVSc, Diplomate of the American College of Veterinary Surgeons, Registered Specialist of Small Animal Surgery, Fellow of Surgical Oncology.

Southpaws founder and director, Dr Charles Kuntz, graduated from the University of Florida College of Veterinary Medicine in 1990. He did an internship at the Animal Medical Center in New York City and completed a residency and master’s degree in surgery at Virginia Tech in 1994. He achieved specialty board certification in surgery in 1996. 

Dr Kuntz then did a one-year fellowship in cardiovascular research and surgery. He completed a fellowship in surgical oncology at Colorado State University and was later a Professor of Orthopedic Surgery there before moving to northern Virginia and starting one of the busiest surgical referral practices in the Washington DC area. He was the program chair and a member of the Board of Directors of the District of Columbia Academy of Veterinary Medicine. 

Dr Kuntz moved to Australia in 2004 and is the founding director and co-owner of Southpaws Specialty Surgery for Animals. 


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